Saturday, 18 August 2007

A chilling fight with psychosis

This is why I'm so blocked up without my cold medication ... f**kin' druggies ...

A chilling fight with psychosis

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A chilling fight with psychosis
July 10 2007

Hospital emergency rooms and ambulance crews had to develop new ways to battle the effects of ice, writes Malcolm Knox.

They used to park near Tim Logan's pharmacy in carloads of five. One by one they would come to the counter and ask for a packet of Sudafed, or Sinutab, or some other over-the-counter medication containing pseudoephedrine. Then they'd ask for a second packet, or a third.

"It was always the same story," says Logan. "They're going on a boat trip, or they're going overseas, and they need to take a few boxes for their sinus problem. Then a few minutes later another one would come in with the same story."

Logan's pharmacy, in Nambour on the Sunshine Coast, was on what he calls a "J-curve" followed by "pseud runners" from Cairns down the east coast through Brisbane and Sydney to Melbourne, then up to Canberra.

"They'd pick up a box here, a box there, until they had huge amounts," he says. "Sometimes they'd even recruit old ladies coming out of the RSL. They'd give them $20 for coming across the road to buy a pack of cold and flu tablets."

Pseudoephedrine is a crucial precursor chemical for the manufacture of methamphetamine. Pseud runners were paid by manufacturers to drive immense distances gathering enough pseudoephedrine for a commercial "cook" of meth or ice.

But they hit a roadblock in October 2005 when Queensland pharmacists launched Project STOP, a database letting chemists share instantaneous records of who is buying pseudoephedrine. Queensland, traditionally the national capital for clandestine meth labs, has since seen a 23per cent drop in lab detections, while numbers have risen in the rest of Australia.

As a result of the Queensland experience, Project STOP is rolling out into NSW and across the country this month.

Denis Leahy, who owns a pharmacy in Stanmore in Sydney's inner west, says the demand for pseudoephedrine has surprised pharmacists. "We've had dexamphetamine around for donkey's years, but the quick onset of the ice drug was dynamite."

Pharmacists are among several professions whose work practices have been changed by methamphetamine in the past five years. Some hospital emergency departments have instituted new protections against patients suffering violent meth psychoses. Ambulance and first-aid workers have new protocols for treating psychotic cases. Counsellors, police, mental health workers and legal officers have had to adapt their work practices to the unique challenge posed by psychotic individuals.

Buck Reed, the chief executive of the first-aid organisation UniMed, says the psychotic meth user has forced first-aiders to develop new procedures.

"If they're already breaking things, we get police back-up," Reed says. "If it's a clear-cut case, we get a whole lot of police to come in, and sedate them." Subduing the individual can take as many as eight paramedics and police. "Capsicum spray doesn't work on methamphetamine users. They become half-blinded and angry, as opposed to just angry. A person going through a meth psychosis doesn't care much for your safety, either."

More than the clear-cut cases, Reed says, it's "the in-between ones who are the challenge … the guy with a racing pulse, skyrocketing blood pressure, who will sit peacefully - but if the police come or even if he thinks the police are coming, he'll kill everyone".

There have been "many instances" of paramedics getting injured, he says. Meth frightens paramedics, it frightens police, it frightens the community. Cannabis, on the other hand, has never frightened anyone.

"We've needed to develop de-escalation techniques. We talk to them in a way that shows we are not going to harm them. They're not bad people, but they think the paramedics are giant werewolves who are about to eat them. They're terrified, and if they're frightened enough they'll behave in exotic ways. You have to find a balance between calming them down and not hurting yourself."

A Victorian ambulance officer, Alan Eade, has helped to write a new procedural manual for ambulance paramedics to address the meth problem. "We're seeing more extreme psychotic behaviour," he says. "Acutely aggressive psychotic reactions to speed or crystal - they're the ones we find it hard to manage." The issue of meth psychosis, he says, is rare - about one out of every 8500 weekly ambulance calls in Melbourne - but powerful enough to demand its own responses.

"Last year I was assaulted by a guy who was punching the front of a bus … We were called in - a bald man with no shirt was spotted screaming at traffic. A passer-by yelled abuse at him and he turned on me, because I was the nearest person. It wasn't directed personally at me. It felt different from a drunk. Drunks can get very personal. This guy just lashed out. The look in their eye is quite empty. I ended up with bruises and scrapes and broke my glasses.

"It's the cases like these that require so many resources. Security staff and police are called in to sedate them [and] because they're so powerful there's always an element of risk. On the other hand, the majority are lovely people and end up in hospital without incident."

Beaver Hudson, a clinical nurse consultant, emergency and psychiatry, at St Vincent's Hospital in Darlinghurst, says that when he started at the hospital nine years ago "staff were desensitised to violence - the name-calling and the destruction were all part of being in emergency at StVincent's. I was absolutely appalled at what the staff had to put up with and what they accepted.

"We couldn't punch back, but we could reject them from admission or make them wait, or deny them pain relief … that turned out to be the way," Hudson says."We set up zero tolerance. Rather than medicalise that behaviour, we'd ask for the police to come. If people were being violent, that was a police problem. It got around in the community that if you went to St Vincent's and acted that way, you were handed to the police.

"The staff now have duress alarms which alert security staff. The security office is next door to PECCS [the special rooms in which violent patients are examined]. People want help, but don't want to be strong-armed out. But that's how we've dealt with them."

From the police angle, the focus has been on supply reduction. When the ice problem hit the headlines in 2005, the Federal Government rescheduled medicines containing pseudoephedrine to make them harder to get. The pharmacist had to be involved in the sale and large boxes became prescription only. But the harassment continued.

Pharmacists tended to react in two extreme ways, says Logan, now president of the Queensland branch of the Pharmacy Guild of Australia. "Some reacted by going overboard and not stocking it, while others said they were not policemen and would not make value judgments about people, so they just went ahead and sold it. Pseudoephedrine is a useful drug for treating an annoying and very common symptom, so we don't want to have to ban it.

"The expert pseud runners knew that a pharmacist might phone five local pharmacies to see if they'd turned up, so they moved over a much greater geographic area," says Shaun Singleton, the manager of innovation and development at the Queensland branch of the Pharmacy Guild.

"Now, Queensland pharmacists must ask for ID if someone buys pseudoephedrine. In other states it's a question of consent. If the person doesn't consent [to present ID], the pharmacist will say we can offer you alternative medication."

Pseud runners could notionally get around the obstacle by providing false identification, but then they would need many, many false identities to escape detection on the network.

Privacy concerns are well-managed under the program, says Leahy. "The information people give us has no other use and won't be given to anyone else."

The benefit for pharmacists is twofold - they can sell what Singleton calls "the ultimate weapon against common sinus pain" without having to guess whether the purchaser is going to misuse it, and they can avoid the kind of harassment Logan suffered a few years ago when a pseud runner chased him into his dispensary to try to find Sinutab.

"It's been tremendous in my pharmacy," Logan says. "Project STOP [has] made work much safer. In my experience, if pseud runners realise they can't buy it, they just give up."

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