Name Address Occupation Special Commission of Inquiry into the Drug 'Ice' STATEMENT OF DR SUJATHA VENKATESH 28 May 2019 Dr Sujatha Venkatesh 2 Edith Street, Waratah NSW 2298 Clinical Director for Psychiatric Emergency Service at Hunter New England Mater Mental Health On 28 May 2019, I, Dr Sujatha Venkatesh, state: 1. This statement made by me accurately sets out the evidence that I would be prepared, if necessary, to give in court as a witness. The statement is true to the best of my knowledge and belief and I make it knowing that, if it is tendered in evidence, I will be liable to prosecution if I have wilfully stated in it anything that I know to be false, or do not believe to be true. 2. I haye been provided with a copy of the Expert Witness Code of Conduct (Code) and have read the Code. I agree to be bound by the Code, insofar as it relates to the provision of this statement and in giving evidence at the hearing of the Special Commission in East Maitland. Background 3. Since 2018, I have been the Clinical Director of the Psychiatric Emergency Service (PES) at Hunter New England Mater Mental Health, which comprises the Psychiatric Emergency Care Centre (PECC) and the Psychiatric Intensive Care Unit (PICU). 4. I have worked within the Hunter New England Local Health District (HNELHD) for 12 years. 5. From 2009 to 2016, I worked as a psychiatric trainee in accordance with the Royal Australian and New Zealand College of Psychiatrists (RANZCP). I finished my Fellowship in 2016, and over the last two and a half years I have worked as a Psychiatric Consultant. 6. I understand Amphetamine-type stimulants (ATS) to refer to a group of drugs whose principal members include amphetamine and methamphetamine. However, a range of other substances also fall into this group, such as methcathinone, fenetylline, ephedrine, Page 1 of6 SCII.005.008.0044
Transcript
Name
Address
Occupation
Special Commission of Inquiry into the Drug 'Ice'
STATEMENT OF DR SUJATHA VENKATESH
28 May 2019
Dr Sujatha Venkatesh
2 Edith Street, Waratah NSW 2298
Clinical Director for Psychiatric Emergency Service at Hunter New England Mater Mental Health
On 28 May 2019, I, Dr Sujatha Venkatesh, state:
1. This statement made by me accurately sets out the evidence that I would be prepared, if
necessary, to give in court as a witness. The statement is true to the best of my knowledge
and belief and I make it knowing that, if it is tendered in evidence, I will be liable to
prosecution if I have wilfully stated in it anything that I know to be false, or do not believe
to be true.
2. I haye been provided with a copy of the Expert Witness Code of Conduct (Code) and have
read the Code. I agree to be bound by the Code, insofar as it relates to the provision of
this statement and in giving evidence at the hearing of the Special Commission in East
Maitland.
Background
3. Since 2018, I have been the Clinical Director of the Psychiatric Emergency Service (PES)
at Hunter New England Mater Mental Health, which comprises the Psychiatric Emergency
Care Centre (PECC) and the Psychiatric Intensive Care Unit (PICU).
4. I have worked within the Hunter New England Local Health District (HNELHD) for 12 years.
5. From 2009 to 2016, I worked as a psychiatric trainee in accordance with the Royal
Australian and New Zealand College of Psychiatrists (RANZCP). I finished my Fellowship
in 2016, and over the last two and a half years I have worked as a Psychiatric Consultant.
6. I understand Amphetamine-type stimulants (ATS) to refer to a group of drugs whose
principal members include amphetamine and methamphetamine. However, a range of
other substances also fall into this group, such as methcathinone, fenetylline, ephedrine,
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pseudoephedrine, methylphenidate and MDMA or 'Ecstasy' - an amphetamine-type
derivative with hallucinogenic properties.
7. The prescription medication for ADHD (dexamphetamine) is also a form of ATS. ATS is
available in different forms such as a crystallised form which is 'ice'. ATS also comes in
the form of powder, liquid, paste and pills.
8. In my experience, the use of ATS within my region has increased over the last two years.
We commonly see ATS affected patients present with acute intoxication, symptoms of
withdrawal and in psychotic states. Patients also present with chronic side effects of ice
use, which include depression, chronic psychosis or chronic amotivation. Furthermore, we
commonly see patients presenting in acute stages with acute behavioural issues which
can lead to significant harm to themselves or others.
9. Some common features that I have observed in ATS users who present within my region,
are:
• low socio-economic background;
• younger in age 18 to 25 years;
• co-morbidity of mental illness;
• lack of social and family support and often come from a dysfunctional family
situation; and
• high indigenous use.
10. In my experience, ATS users most commonly report using 'ice'. The most prevalent
methods of administering ATS, appear to me to be, smoking and injecting. Less common
methods include snorting, eating and drinking.
Harms/ process
11. In my experience, referrals to mental health are often related to psychiatric symptoms
that are known to be associated with methamphetamine usage such as paranoia, resulting
in acute behavioural disturbance posing significant harm to the patient and/or others.
Significant disinhibition is also a common presenting feature. Most referrals come through
the Emergency Department, or through police and ambulance.
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12. In my experience and from data collected by the PES, 95% of mental health presentations
to the PECC come via the Emergency Department. Around 17% of those presentations
are ATS related. This is because we are a co-located mental health assessment and
admission centre. Approximately 3 to 4% of mental health presentations to the PECC are
via the police, and around half of those presentations are ATS-related.
13. At HNE Mater Mental Health, patients are generally screened for ATS use via urine drug
screens. Whilst we try to screen patients for ATS use, this is not always easy to do because
of the behavioural issues of some patients which can place staff at risk. There are other
patients who may not cooperate to provide a urine sample. We also screen patients by
use of questionnaires.
14. A recently developed process for recording ATS has now started. The process records if
the admission is for ATS use or mental health. The information is obtained from the
patient's history and presentation. More information is requested from the patient, and
recorded.
15. In my view, available data would generally provide an accurate picture of the contribution
of ATS use to presentations and admissions. However, there will inevitably be a proportion
of ATS-related patients whose usage is undetected because the method of collection is
optional and some patients don't provide urine samples.
Comorbidities
16. In my experience, the more common occurring comorbidities in people presenting with
ATS-related conditions, include psychiatric disorders such as psychosis, mood disorders,
anxiety disorders and PTSD. In my view, this is most commonly evident in indigenous
people with a pre-existing psychotic disorder, younger males between the ages of 18 to
25 years, and people with a background of significant trauma.
17. ATS use can sometimes lead to an increase in the level of non-compliance with medication
prescribed for treating those patients with mental illnesses.
18. It can be difficult treating patients for both mental illness and substance use issues. There
is often a longer treatment process for patients suffering a relapse of mental illness in
conjunction with illicit substance use. Many patients come from a traumatic background
and it is hard to know what comes first, the mental illness or the substance use.
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19. The presence of comorbidities has a major impact on the management of people
presenting with ATS related conditions. ATS use has a direct impact on their well-being
in the community. If the patients are contemplative (ie seeking to change their behaviour
with respect to drug use), then we offer support through inpatient/outpatient drug and
alcohol service. If patients are precontemplative, then we need to ensure their mental
illness treatment is optimised.
20. Most of the time the primary issue for a patient is only drug dependence and patients
want help at that time which is unavailable due to long waiting lists. No drug and alcohol
service (either detox or rehabilitation) takes acutely mentally ill patients. Mental health
can only offer help in the acute stage not in the subacute or chronic stage. I feel that we
could improve our care with more housing options, more rehabilitation programs and step
down residential programs post-discharge from acute care. Delay in access to the various
services contributes to poor outcomes.
Referrals and interventions
21. Referral to mental health generally depends on the type of presentation. For example,
most acute presentations would come to mental health due to the level of behavioural
disturbance. The nature of the behavioural disturbance will often mimic features of a
mental illness such as paranoia, delusions and mania and be associated with significant
risk to oneself and others.
22. In my region, a drug and alcohol service is available in the general hospital, Calvary Mater
Hospital. However, this service is limited to business hours, Monday to Friday. This service
generally performs outpatient assessments. Only the Addiction Consultant has privileges
to consult patients face-to-face on the mental health ward, and this can lead to a
significant delay in offering appropriate services.
23. In my view, a drug and alcohol nurse practitioner based in the Emergency Department
(and who would be available to offer drug and alcohol services to PECC and the PICU)
would be of great value in providing initial assessment and determining the appropriate
pathway for the patient.
24. From my experience, housing can be a significant problem for ATS users due to users
often burning bridges with accommodation options because of violent and/or paranoid
behaviours that are exhibited whilst they are substance affected. There are often legal
complexities and familial disharmony that also affect housing options, particularly when in
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crisis. Having to resort to sub-optimal levels of accommodation that are often temporary
and are within a drug culture environment does not support recovery.
25. In my experience, ATS use definitely changes the treatment trajectory for people with
underlying mental health disorders. The treatment trajectory is affected because the ATS
drugs contradict the drugs required to address their mental health issues. This affects the
cycle of change with respect to their approach to seeking management of their mental
health issues.
Families
26. From my experience, crystal methamphetamine, or other ATS use, does have an
enormous impact on children and families, as often families become used and abused
through-out the course of a persons' ATS usage. However, sometimes ATS users have
disengaged from family or vice versa, so it may be difficult to determine the impact on
family in a meaningful way.
27. We are able to make appropriate referrals for children and families who have been
identified as being affected by ATS use. Those referrals would be to Family and Community
Services (FACS) and other appropriate services. The arrangements for referral to FACS
and other services are often ad hoc.
Custodial
28. In my LHD there are a number of correctional centres, including Cessnock Correctional
Centre, Tamworth Correctional Centre and Glen Innes Correctional Centre.
29. I do not feel that I am best placed to comment on reintegration issues encounted by ATS
users leaving custody.
Workplace issues
30. In my current role, I am regularly exposed to ATS users who have been intoxicated. Acute
behavioural disturbance can pose as a significant risk of harm to both the patient and
others. When clinically indicated, restraint and sedation may be utilised. Security are often
part of our acute management team and police may be involved when dealing with
extremely difficult patients.
31. Since HNE Mater Mental Health is co-located with the general hospital, Calvary Mater
Hospital, acutely intoxicated persons do present to mental health when what they need is
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more monitoring and management by the ED physicians to get over their severely agitated
state. It would be ideal to have a common space where different specialities (including,
ED staff, drug and alcohol staff and mental health staff) could work and manage patients
together during a patient's acute intoxication phase.
32. In my previous and current roles, I have received education about ATS and I have received
training directed toward how best to manage people who use ATS. This training has
helped me in understanding ATS users and managing ATS at work. I would welcome more
training on any evidence-based recent changes which can help patients.
33. At the PES at HNE Mater Mental Health, we manage a large number of patients who are
acutely intoxicated who could be at risk of physical compromise. I feel patients intoxicated
by crystal methamphetamines or other ATS would be better managed and monitored in
the Emergency Department until a proper mental and drug and alcohol assessment can
be performed.
34. The number of ATS-related presentations have increased and my impression is that ATS
are stronger and more easily available resulting in increased intensity in presentation.
Further, I see increased impairment arising from polysubstance use and from impurities.
