Faced with the severe limitations in treatment for these forms of drug misuse that have high morbidity and mortality, drug services have had to consider how best to achieve some benefits in terms of practical management.'1..8) The factors that appear important in such provision are:

• specific outreach programmes

• harm-reduction approaches

• rapid response where necessary

• targeted use of pharmacological treatments

• admission in severe cases.

To engage stimulant users at all can require specific outreach aimed at the subcultural groups in whom usage is common. Basic harm-reduction measures must be offered, including drug information, education about health risks, advice to reduce damaging injecting practices, and the provision of clean injecting equipment. Counselling of a supportive or more behavioural kind may be provided by various types of agency.

The periodic nature of stimulant problems means that rapid response can be important, for instance in states of acute crack withdrawal or psychiatric disturbance. Use of tranquillizers and antipsychotic medications may be necessary for various presentations, while fluoxetine appears to be increasingly favoured over other antidepressants, due to a possible anticraving effect and good acceptability. Inpatient admission is required relatively frequently in cases where no long-term measure is able to make much impact between acute crises. The possibility of any substitute prescribing in stimulant misuse is highly controversial, with some services seeing a role for oral dexamphetamine in heavily dependent amphetamine users experiencing extreme problems from injecting.(!9)

Drug-induced psychosis

The two aspects of management of this complication are the treatment of psychotic symptoms and the withdrawal of the drug which is thought to be causative. The latter can be very problematic other than as an inpatient, and is not guaranteed even then. In practice, ongoing semi-psychotic states in individuals who have not completely stopped drug use are common, and treatment may have to be attempted in such circumstances. The use of antipsychotic medications does not differ significantly from that in psychoses not produced by drugs.

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