ACT ATOD Sector Research eBulletin - February 2017
The monthly ACT ATOD Research eBulletin is a concise summary of newly-published research findings and other research activities of particular relevance to ATOD and allied workers in the ACT.

Its contents covers research on demand reduction, harm reduction and supply reduction; prevention, treatment and law enforcement. ATODA's Research eBulletin is a resource for keeping up-to-date with the evidence base underpinning our ATOD policy and practice.



 

ACT Research Spotlight

An overview of smoking in pregnancy

The most recent issue of ACT Health’s quarterly Population Health Bulletin contains information about smoking in pregnancy in the ACT. The article asks the question ‘Why is it important?’, and answers it as follows:

  • Smoking in pregnancy is the most important preventable cause of a wide range of adverse pregnancy outcomes. Smoking causes poor outcomes for mother and baby and there is growing evidence of serious harm extending into childhood and even adulthood.
  • Unfortunately, most smokers who become pregnant continue to smoke and most of those who quit relapse after delivery. Smoking interventions in pregnancy can significantly reduce the relative risk of low birthweight and pre-term birth.
  • To maximise the benefits of smoking cessation in pregnancy, the mother should stop smoking in the first 20 weeks.
It goes on to explain that ‘Information about tobacco smoking in pregnancy is collected at antenatal visits at two points in time, once early in pregnancy (first 20 weeks) and again later in pregnancy (second 20 weeks). Women are asked whether they currently smoke tobacco and if they answer yes, they are asked how many cigarettes per day they smoke. Information on characteristics of women giving birth is also collected…’. 

The data presented show a 36% reduction in smoking prevalence in these women between 2009 and 2014: from 11% to 7%. On the other hand, it reports that over 30% of pregnant teenage women smoked in 2014, and that ‘Smoking in pregnancy is also higher for Aboriginal and Torres Strait Islander women who were four times more likely to smoke during pregnancy than non-Aboriginal and Torres Strait Islander women’.
 
ACT Data on the impacts of smoking in pregnancy are also provided.
 
ACT Health, Health Improvement Branch 2016, ‘An overview of smoking in pregnancy’, ACT Population Health Bulletin, vol. 5, no. 4, pp. 34-5, http://www.health.act.gov.au/healthy-living/population-health#Bulletin.

Comment: ATODA continues to advocate for approaches to reducing smoking during pregnancy that are women-centred (i.e. they consider the health of women, not only their unborn babies) and avoids stigma and blame. These approaches should also consider the interrelation of smoking with other family, social and wellbeing issues within a community context, and across the entirety of a woman’s life (not just when she’s pregnant).

The ACT Health’s quarterly Population Health Bulletin statement that “most smokers who become pregnant continue to smoke” requires unpacking. Research shows that women are more likely to give up smoking during pregnancy than at other times in their lives, and indeed most women want to give up smoking when they discover they are pregnant. A significant minority of pregnant women ‘spontaneously quit’ before their first antenatal visit (for example up to 49% (Chamberlain et al 2014)). These women are presumably not captured in the ACT Health data that asks about smoking status at an antenatal visit in the first 20 weeks. The ‘spontaneous quit’ rates noted above are, however, likely to be lower among women who face health and/or social disadvantage—for example, women who spontaneously quit are more likely to be older, have lower nicotine dependence, have a non-smoking partner, and have more support and encouragement at home for quitting.

The 36% reduction in the rates between 2009 and 2014 of ACT women who smoke during pregnancy is encouraging. However, the higher rates among young women under 20 years of age, and among Aboriginal and Torres Strait Islander pregnant women reflects the trend that still exists in the ACT community more generally. That is, while smoking rates in the ACT are the lowest in the country, there are still disadvantaged sub-populations of the ACT community that have disproportionately higher smoking rates and impacts from tobacco-related harms. This includes: people accessing specialist alcohol and drug services, who are economically disadvantaged; people living with mental illness; and people living with, or at risk of, homelessness. Women (including pregnant women), their partners, and their families in all of these disadvantaged groups are more likely to be dependent on tobacco, and face significant challenges to quitting or reducing smoking.

Evidence is clear that the majority of people who smoke (including those from disadvantaged groups) want to quit, and can do so with the right interventions. Expert consensus is that disadvantaged sub-populations are not responding equally to population level policy levers and mass media campaigns that have been successful at lowering the smoking rate in Australia generally. Rather than focusing on legislative measures, disadvantaged ‘hard-to-reach’ sub-populations with higher smoking rates require additional better targeted and more intensive strategies to access the treatment tools that are known to help people to quit. These include, for example, screening and brief interventions, access to effective treatments (such as nicotine replacement therapy), and the availability of on-going, repeated and tailored psychosocial support. This is consistent with findings of a Cochrane Review of smoking cessation interventions during pregnancy that found the provision of health education and risk advice is not effective, but that intensive and targeted psychosocial interventions were most effective at supporting women to stop smoking during pregnancy (Chamberlain et al 2014).

ATODA advocates for the provision of smoking cessation support that is tailored and intensive, and provides psychosocial supports to women, men and families in service settings where people are accessing treatment and/or support. Based on what is known about the pattern of smoking prevalence, these supports should be particularly targeted to service settings that are accessible to disadvantaged sub-populations. Addressing smoking cessation among sub-populations with high smoking rates will have an impact across the community, including among young (pregnant) women and their partners.

Reference: Chamberlain, C., O’Mara-Eves, A., Oliver, S., Caird, J.R., Perlen, S.M., Eades, S.J. and Thomas, J. (2014). ‘Psychosocial interventions for supporting women to stop smoking in pregnancy’. Cochrane Database of Systematic Reviews, 10:CD001055. Doi:10.1002/14651858.CD001055.pub4.

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Research Findings

What are the latest and most accurate findings about the extent to which alcohol and other drugs are risk factors for road traffic crashes?

What relationships have been observed between legalised medicinal cannabis programs and road traffic crash fatalities?

How effective are alcohol ignition interlock laws in reducing alcohol-involved fatal crashes?

Should cannabis be used to prevent nausea during pregnancy?

How effective are juvenile drug courts in reducing recidivism and drug use?

What can we learn from the Portuguese experience of decriminalisation of drugs?

What moral grounds are there for prohibiting the use of cannabis or heroin?

To what extent does parental supply of alcohol to adolescents lead to them consume more alcohol, and binge drink?

What are the effects of needle-sharing and OST on the incidence of hepatitis C virus infection and reinfection in people who inject drugs?

How cost-effective are supervised injecting facilities?

The rising price of naloxone — risks to efforts to stem overdose deaths

To what extent would the use of precise, agreed-upon, terms help reduce stigmatisation and discrimination in social and public health policies?

What can be done to address the human rights implications of smoking bans in prisons and mental health facilities?

What are the impacts of long-term, low-intensity cigarette smoking on mortality?

How significant is the use of anabolic steroid use among men for concerns about appearance?

Index

Note: Many of the items referenced below are available from the Library of the Australian Drug Foundation http://primoapac01.hosted.exlibrisgroup.com/primo_library/libweb/action/search.do?vid=ADF 

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What are the latest and most accurate findings about the extent to which alcohol and other drugs are risk factors for road traffic crashes?

Edited abstract:
This study used a case-control design to estimate the risk of crashes involving drivers using drugs, alcohol or both. Data was collected in Virginia Beach, Virginia, USA, for 20 months. The study obtained biological measures on more than 3,000 crash drivers at the scenes of the crashes, and 6,000 control (comparison) drivers. The crash risk associated with alcohol and other drugs was estimated using odds ratios that indicate the probability of a crash occurring over the probability that such an event does not occur. If a variable (alcohol and/or drugs) is not associated with a crash, the odds ratio for that variable will be 1.00. A higher or lower number indicates a stronger relationship between the probability of a crash occurring and the presence of that variable (alcohol and/or drugs in the driver). Confidence intervals (CIs) of an odds ratio indicate the range in which the true value lies—with 95 percent confidence.
 
Alcohol: Alcohol was the largest contributor to crash risk. When adjusted for age and gender, drivers with blood alcohol concentrations of .05g% are 2.07 times more likely to crash than drivers with no alcohol. The adjusted crash risk for drivers at .08 g% is 3.93 times that of drivers with no alcohol.
 
Drugs: Unadjusted drug odds ratio estimates indicated a significant increase in crash risk. However, after adjusting for gender, age, race/ethnicity, and alcohol, there was no indication that any drug significantly contributed to crash risk. The adjusted odds ratios for THC were 1.00, 95 percent CI [.83, 1.22], indicating no increased or decreased crash risk. Odds ratios for antidepressants were .86, 95 percent CI [.56, 1.33]; narcotic analgesics were 1.17, 95% percent drugs as an overall category were .99, 95 percent CI [.84, 1.18], and prescription and over-the-counter medications were 1.02, 95 percent CI [.83, 1.26].
 
Alcohol and Drugs: Analyses found no statistically significant interaction effects when drivers were positive for both alcohol and drugs. Although initial analyses suggested that the combination of alcohol and other drugs were contributors to increased crash risk, additional analyses adjusting for other risk factors indicated no significant effect. When both alcohol and other drugs were consumed, alcohol alone was associated with crash risk.
 
Lacey, JH, Kelley-Baker, T, Berning, A, Romano, E, Ramirez, A, Yao, J, Moore, C, Brainard, K, Carr, K, Pell, K & Compton, R 2016, Drug and alcohol crash risk: a case-control study, Report No. DOT HS 812 355, National Highway Traffic Safety Administration, Washington, DC, https://one.nhtsa.gov/staticfiles/nti/impaired_driving/pdf/812355_DrugAlcoholCrashRisk.pdf .
 
Comment: This is the report of what ATODA understands to be the highest quality, and most reliable, research conducted in real-world conditions into the extent to which alcohol and other drugs, separately and in combination, contribute to road traffic crashes. The low contribution of drugs (compared to other risk factors such as alcohol, speeding, fatigue and distraction) after controlling for age and sex, is notable. This has important implications for setting priorities for road safety initiatives in the ACT, highlighting ATODA’s calls in the past for road safety resources to be used where they will be most effective—and that is a higher focus on random breath testing for alcohol use.

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What relationships have been observed between legalised medicinal cannabis programs and road traffic crash fatalities?

Abstract:
Objectives. To determine the association of medical marijuana laws (MMLs) with traffic fatality rates.
Methods. Using data from the 1985-2014 [USA] Fatality Analysis Reporting System, we examined the association between MMLs and traffic fatalities in multilevel regression models while controlling for contemporaneous secular trends. We examined this association separately for each state enacting MMLs. We also evaluated the association between marijuana dispensaries and traffic fatalities.
Results. On average, MML states had lower traffic fatality rates than non-MML states. Medical marijuana laws were associated with immediate reductions in traffic fatalities in those aged 15 to 24 and 25 to 44 years, and with additional yearly gradual reductions in those aged 25 to 44 years. However, state-specific results showed that only 7 states experienced post-MML reductions. Dispensaries were also associated with traffic fatality reductions in those aged 25 to 44 years.
Conclusions. Both MMLs and dispensaries were associated with reductions in traffic fatalities, especially among those aged 25 to 44 years. State-specific analysis showed heterogeneity of the MML-traffic fatalities association, suggesting moderation by other local factors. These findings could influence policy decisions on the enactment or repealing of MMLs and how they are implemented.
 
Santaella-Tenorio, J, Mauro, CM, Wall, MM, Kim, JH, Cerdá, M, Keyes, KM, Hasin, DS, Galea, S & Martins, SS 2016, ‘US traffic fatalities, 1985–2014, and their relationship to medical marijuana laws’, American Journal of Public Health, online ahead of print.

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How effective are alcohol ignition interlock laws in reducing alcohol-involved fatal crashes?

Researchers in the United States assessed the effects of laws requiring ignition interlocks for some or all drink-driving offenders on alcohol-involved fatal crashes using data on alcohol-involved crashes in each of the 50 states in 2014 from the National Highway Traffic Safety Administration Fatality Analysis Reporting System. They found that ‘State laws requiring interlocks for all drunk driving offenders were associated with a 7% decrease in the rate of BAC [blood alcohol concentration] >0.08 fatal crashes and an 8% decrease in the rate of BAC >/=0.15 fatal crashes, translating into an estimated 1,250 prevented BAC >0.08 fatal crashes’. They concluded that ‘Ignition interlock laws reduce alcohol-involved fatal crashes. Increasing the spread of interlock laws that are mandatory for all offenders would have significant public health benefit’.
 
McGinty, EE, Tung, G, Shulman-Laniel, J, Hardy, R, Rutkow, L, Frattaroli, S & Vernick, JS 2016, ‘Ignition interlock laws: effects on fatal motor vehicle crashes, 1982-2013’, American Journal of Preventive Medicine, online ahead of print.
 
Comment: This large new study is consistent with other research suggesting that, if alcohol ignition interlocks become mandatory for all drink driving offenders brought before the courts, significant reductions in fatal crashes will follow.

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Should cannabis be used to prevent nausea during pregnancy?

This ‘Viewpoint’, authored by the Director of the US National Institute on Drug Abuse and her colleagues, responds to the continuing process in the USA of expanding lawful access to medicinal cannabis, and legalising recreational cannabis. The authors state that ‘Currently, 29 states and Washington, DC, have passed laws to legalize medical marijuana. Although evidence for the effectiveness of marijuana or its extracts for most medical indications is limited and in many cases completely lacking, there are a handful of exceptions…Nausea is a medically approved indication for marijuana in all states where medical use of this drug has been legalized. However, some sources on the internet are touting marijuana as a solution for the nausea that commonly accompanies pregnancy, including the severe condition hyperemesis gravidarum. Although research on the prevalence of marijuana use by pregnant women is limited, some data suggest that this population is turning to marijuana for its antiemetic properties, particularly during the first trimester of pregnancy, which is the period of greatest risk for the deleterious effects of drug exposure to the fetus. Marijuana is the most widely used illicit drug during pregnancy, and its use is increasing.’
 
They draw attention to the damage to the foetus that cannabis can cause, and advise ‘Even with the current level of uncertainty about the influence of marijuana on human neurodevelopment, physicians and other health care providers in a position to recommend medical marijuana must be mindful of the possible risks and err on the side of caution by not recommending this drug for patients who are pregnant. Although no states specifically list pregnancy-related conditions among the allowed recommendations for medical marijuana, neither do any states currently prohibit or include warnings about the possible harms of marijuana to the fetus when the drug is used during pregnancy.’
 
Volkow, ND, Compton, WM & Wargo, EM 2017, ‘Viewpoint: The risks of marijuana use during pregnancy’, JAMA, vol. 317, no. 2, pp. 129-30.

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How effective are juvenile drug courts in reducing recidivism and drug use?

A systematic review and meta-analysis of the effects of juvenile drug courts in the United States on general recidivism, drug recidivism, and drug use, explored variability in effects across characteristics of the drug courts and juvenile participants. The meta-analysis found that, ‘…overall, juvenile drug courts were no more or less effective than traditional court processing, with mean effects sizes that were not statistically significant for general recidivism, drug recidivism, or drug use….However, the juvenile drug court evaluations were generally of poor methodological quality, with very few studies employing random assignment and many instances of substantial baseline differences between drug court and comparison groups’. As a consequence, the researchers concluded that ‘Juvenile drug courts were not found to be categorically more or less effective than traditional court processing for reducing recidivism or drug use. The great variability in effects, nonetheless, suggests that there may be effective drug courts, but no distinctive characteristics of the more effective courts could be identified from the descriptive information provided in the generally low quality research studies currently available’.
 
Tanner-Smith, EE, Lipsey, MW & Wilson, DB 2016, ‘Juvenile drug court effects on recidivism and drug use: a systematic review and meta-analysis’, Journal of Experimental Criminology, vol. 12, no. 4, pp. 477-513.

Comment: The ACT Government has announced that it will establish a Drug and Alcohol Treatment Court, the nature of which has yet to be announced. ATODA urges the Government to take account of the findings of this and related studies so as to implement this initiative in an evidence-informed manner.
 

Further, a key factor of success of the Drug and Alcohol Treatment Court will be its ability to quickly and effectively engage participants in sufficient (e.g. duration and frequency) and appropriate (e.g. type) AOD treatment. This is not possible within the current resources of the specialist AOD service system in the ACT—ACT specialist AOD services are struggling to meet current increasing demand for AOD treatment and support. ATODA advocates for additional funding being made available to programs associated with the proposed Drug and Alcohol Treatment Court (such as AOD treatment services) in order to maximize the potential effectiveness of this Court.

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What can we learn from the Portuguese experience of decriminalisation of drugs?

In 2001 Portugal decriminalised the consumption of all narcotic drugs and psychotropic substances. An analysis in 2016 found that ‘The Portuguese policy of decriminalization of the “consumption, acquisition, and the possession for personal use of narcotic drugs and psychotropic substances” is known in the entire world as one of the most successful policies of its kind. Since it was adopted the consumption of narcotic drugs and psychotropic substances actually decreased…Also the initial fear that Portugal might turn into a “drug-tourist” destination did not come to pass. The number of cases of HIV and AIDS in drug users also decreased (even if it still is slightly above the EU average), and the number of deaths by drug overdose stabilized. The number of deaths by drug overdose in Portugal is actually one of the lowest in all of the European Union, at just 4.5 per million of inhabitants against the average in the EU of 19.2’.
The author of the analysis states that ‘There could be some advantages in a full legalization scenario, but we would also face some new challenges. Regarding the advantages, certainly there would be a decrease in the illegal commerce (both traditional and digital) of these substances…The existence of a legal alternative would guarantee higher health and hygiene standards in the selling of these products, the country could also tax them, providing a new source of revenue, a new industry could also be born from the legalization of narcotic drugs and psychotropic substances. A full legalization would be a very challenging and unpredictable solution. The spirit of the law in a legalization scenario would have to be fundamentally different from the one of the current law. No longer would the user of narcotic drugs and psychotropic substances be considered an ill person who needed help. Using the legalized narcotic drugs and psychotropic substances would be, at least in theory, accepted by the society. We say in theory because it is not possible to force the society to change its opinion by changing the law if it does not reflect the volksgeist [spirit of the people], it may help but is usually not enough. In this case, we would argue that it would depend on which narcotic drugs and psychotropic substances were legalized, in fact some already are well accepted by most of the Portuguese society while others even if legalized would not probably be well accepted’.
 
Cabral, TS 2017, ‘The 15th anniversary of the Portuguese drug policy: its history, its success and its future’, Drug Science, Policy and Law, vol. 3, open access http://journals.sagepub.com/doi/full/10.1177/2050324516683640

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What moral grounds are there for prohibiting the use of cannabis or heroin?

‘So long as others are not harmed, there are no moral grounds for restricting use of cannabis or heroin any more than alcohol or caffeine’, argues the famous British philosopher A. C. Grayling in the December 2016 issue of the British Medical Journal. He explains: ‘There are yet other substances in what we eat and drink that have narcotic, stimulant, or hallucinogenic effects—sugar, for example, in the stimulant class...But these too we do not outlaw…The argument of harm to user does not survive scrutiny. Alcohol is as dangerous as cannabis, and perhaps more so, and whereas cannabis is recognised as having some medical value… Drugs came under legal control in Britain for the first time in 1868, not for reasons of moral distaste but to protect the business of pharmacists, who wanted the sole right to dispense them’. He states ‘prohibition is a creator of problems, not their solution… To lift prohibitions is not to deregulate entirely; any group of people discussing their common interests would conclude that some rules are needed. But on Mill’s grounds, the presumption has to be on the side of permission, not prohibition; every limitation needs a very good justification.’
Grayling maintains that ‘The good life for an individual must include self government to the maximum degree consistent with the community setting. A life of dependency on drugs—whether alcohol, heroin, or tobacco—is not such a life, and it seems a feeble and, in my view, disagreeable way to live. But, that one does not like drugs, or the thought of people living in dependence on them, is no ground for judging their use immoral, still less for criminalising them. It is only a ground for persuading, educating, and making your own different ethical choices.’
 
Grayling, AC 2016, ‘Morality and non-medical drug use’, BMJ: British Medical Journal, vol. 355, pp. i5850.

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To what extent does parental supply of alcohol to adolescents lead to them consume more alcohol, and binge drink?

An Australian study investigated associations between parental supply of alcohol, supply from other sources, and adolescent drinking, adjusting for child, parent, family and peer variables. In 2010–2011 a cohort of adolescents and parents was recruited from grade 7 classes in Sydney, Hobart and Perth and was surveyed annually from 2010 to 2014. Measures included: consumption of alcoholic beverages; binge drinking (>4 standard drinks on any occasion); parental supply of alcohol; supply from other sources; child, parent, family and peer covariates. The study found that ‘…adolescents supplied alcohol by parents had higher odds of drinking whole beverages…than those not supplied by parents. However, parental supply was not associated with bingeing, and those supplied alcohol by parents typically consumed fewer drinks per occasion…than adolescents supplied only from other sources. Adolescents obtaining alcohol from non-parental sources had increased odds of drinking whole beverages…and bingeing’. The researchers concluded that ‘Parental supply of alcohol to adolescents was associated with increased risk of drinking, but not bingeing. These parentally-supplied children also consumed fewer drinks on a typical drinking occasion. Adolescents supplied alcohol from non-parental sources had greater odds of drinking and bingeing’.
 
Mattick, RP, Wadolowski, M, Aiken, A, Clare, PJ, Hutchinson, D, Najman, J, Slade, T, Bruno, R, McBride, N, Degenhardt, L & Kypri, K 2017, ‘Parental supply of alcohol and alcohol consumption in adolescence: prospective cohort study’, Psychological Medicine, vol. 47, no. 2, pp. 267-78.

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What are the effects of needle-sharing and OST on the incidence of hepatitis C virus infection and reinfection in people who inject drugs?

Researchers based in Melbourne examined whether the use of opioid substitution therapy (OST) and needle-and-syringe sharing behaviour among people who inject drugs [PWID] explained hepatitis C virus [HCV] incidence. They assessed HCV incidence, and risk factors, in 235 PWID in Melbourne. Pleasingly, they found that ‘Our HCV-naive and reinfection incidence rates are much lower than those measured in our group’s study of HCV transmission in a similar cohort recruited from the same locations between 2005 and 2007. As such, this study strengthens the evidence that HCV incidence in Australian PWID has declined over the past decade or more. Our study also reaffirms our previous finding that, descriptively, HCV reinfection incidence is greater than the rate of naive infection, although this is not universally the case in longitudinal cohorts of PWID. However, these data suggest a substantially greater decline in HCV reinfection (compared to naive infection) in PWID in Melbourne.’ They concluded that ‘Our data confirm previous evidence of greatly reduced HCV incidence in PWID, but not the significant protective effect of OST on HCV incidence detected in recent studies. Our findings reinforce the need for greater access to HCV testing and prevention services to accelerate the decline in incidence, and HCV treatment, management and support to limit reinfection.’
 
Aitken, CK, Agius, PA, Higgs, PG, Stoové, MA, Bowden, DS & Dietze, PM 2016, ‘The effects of needle-sharing and opioid substitution therapy on incidence of hepatitis C virus infection and reinfection in people who inject drugs’, Epidemiology and Infection, online ahead of print.

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How cost-effective are supervised injecting facilities?

There are currently no legal supervised injection facilities (SIF) in the United States. An analysis of the potential cost-effectiveness of establishing a SIF in San Francisco estimated the economic costs and benefits using mathematical models that combined local public health data with previous research on the effects of existing SIFs. The researchers considered potential savings from five outcomes: averted HIV and hepatitis C virus (HCV) infections, reduced skin and soft tissue infection (SSTI), averted overdose deaths, and increased medication-assisted treatment (MAT, e.g. methadone and buprenorphine) uptake. They found that ‘…each dollar spent on a SIF would generate US$2.33 in savings, for total annual net savings of US$3.5 million for a single 13-booth SIF. Our analysis suggests that a SIF in San Francisco would not only be a cost-effective intervention but also a significant boost to the public health system’.
 
Irwin, A, Jozaghi, E, Bluthenthal, RN & Kral, AH 2016, ‘A cost-benefit analysis of a potential supervised injection facility in San Francisco, California, USA’, Journal of Drug Issues, online ahead of print, open access http://journals.sagepub.com/doi/full/10.1177/0022042616679829

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The rising price of naloxone — risks to efforts to stem overdose deaths

American clinicians, writing in the prestigious New England Journal of Medicine, have deplored the huge increases in the price of naloxone in the USA. They argue that federal and state governments ‘…should explicitly call on manufacturers to reduce the price of naloxone and increase transparency regarding their costs, particularly those related to the development of new formulations’ as has apparently occurred regarding epi-pens. They point to other actions that governments can take to manage the price of naloxone to consumers, including bulk purchases (as occurs with vaccines), contracting with a manufacturer to act on behalf of the government to produce less costly versions of the drug, and allowing importation of generics from international manufacturers that have received approval from regulators. They conclude that ‘Naloxone coprescribing [with opioid analgesics] and expanded availability represents only one of many potential strategies for reducing the number of prescription-opioid and heroin overdose deaths in the United States. But when governments promote naloxone use, they have a responsibility to ensure the drug’s affordability. Taking action now is essential to ensuring that this lifesaving drug is available to patients and communities.’ (Our emphasis)

Gupta, R, Shah, ND & Ross, JS 2016, ‘Perspective: The rising price of naloxone - risks to efforts to stem overdose deaths’, New England Journal of Medicine, vol. 375, no. 23, pp. 2213-5, open access http://www.nejm.org/doi/full/10.1056/NEJMp1609578#t=article.
 
Comment by ATODA and CAHMA: In Australia the pharmaceutical benefits scheme offers some protection to consumers against pharmaceutical companies dramatically increasing the price of naloxone as any price increase must be negotiated with government.  Perhaps this is one of the reasons that we have not seen dramatic price rises in naloxone preparations in Australia, as has been seen in the US.  For advocates of increasing naloxone availability in Australia, the current problem is around the need for a fit for purpose preparation of naloxone that can be used easily in a community setting.  Australia still lacks an approved intra-nasal formulation of naloxone.  An intra-nasal preparation may go some way to removing many of the barriers to availability caused by an intra-muscular preparation.  In the meantime Australia is struggling to provide an alternative.  In the middle of last year the popular naloxone mini-jets ceased to be available in Australia, leaving ampoules as the sole available preparation.  In January, after considerable advocacy from the National Naloxone Reference Group, 2000 units of Prenoxad (a single use pre-filled syringe containing 5 400 microgram doses of naloxone) were released onto the market, a hard-fought step in the right direction.
 


Strategies for increasing naloxone availability have been implemented in Australia both federally and on a jurisdictional level.  Federally, naloxone has been re-scheduled to be available both over the counter as an S3 and also on a doctor’s prescription as an S4.  Jurisdictionally efforts have also been made, such as the revision of the ACT Good Samaritan legislation to ensure that people who administer naloxone in a first aid capacity are protected from civil or criminal liability.  Unfortunately anecdotal evidence suggests the re-scheduling of naloxone has not led to a corresponding increase in naloxone availability.
 

Even with Australia’s comparatively reasonable naloxone prices, its dual scheduling and legislative changes increasing naloxone availability seems to be a slow process.  Perhaps this indicates an underlying need to have a structured, strategic and systematic approach to naloxone availability which utilises a collaborative approach between pharmaceutical companies, state and federal governments as well as the affected community.

 
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To what extent would the use of precise, agreed-upon, terms help reduce stigmatisation and discrimination in social and public health policies?

Abstract
The language used to describe health conditions reflects and influences our attitudes and approaches to addressing them, even to the extent of suggesting that a health condition is a moral, social, or criminal issue. The language and terminology we use is particularly important when it comes to highly stigmatized and life-threatening conditions, such as those relating to alcohol and other drugs. Scientific research has demonstrated that, whether we are aware of it, the use of certain terms implicitly generates biases that can influence the formation and effectiveness of our social and public health policies in addressing them. Such research has made it difficult to trivialize or dismiss the terminology debate as merely ‘semantics’ or a linguistic preference for ‘political correctness.’ Furthermore, given that alcohol and other drug-related conditions are among the top public health concerns in the United States and in most English speaking countries globally (e.g., United Kingdom, Australia, Ireland), this is no trivial matter. In this article, the authors detail the conceptual and empirical basis for the need to avoid using certain terms and to reach consensus on an ‘addiction-ary.’ The authors conclude that consistent use of agreed-upon terminology will aid precise and unambiguous clinical and scientific communication and help reduce stigmatizing and discriminatory public health and social policies.
 
Kelly, JF, Saitz, R & Wakeman, S 2016, ‘Language, substance use disorders, and policy: the need to reach consensus on an “Addiction-ary”‘, Alcoholism Treatment Quarterly, vol. 34, no. 1, pp. 116-23, open access http://www.tandfonline.com/doi/full/10.1080/07347324.2016.1113103?src=recsys .
 
Comment: This article can be read in conjunction with the report referenced in the November 2016 ATODA Research eBulletin: Office of National Drug Control Policy (USA) 2016, Draft: changing the language of addiction, Office of National Drug Control Policy, Washington, DC. Sadly, it has been removed from the USA Government’s website following the installation of the Trump administration, but is available through the Internet Wayback Machine Archive https://web-beta.archive.org/web/20161220103114/https://www.whitehouse.gov/ondcp/changing-the-language-draft

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What can be done to address the human rights implications of smoking bans in prisons and mental health facilities?

‘There is a high prevalence of tobacco smoking amongst the populations of closed environments; particularly prisons and psychiatric settings. There are increasing attempts to ban smoking in these environments, which has implications (positive and negative) for the protection of human rights of the people detained and staff. Aspects of the culture of such environments make it challenging to reduce smoking prevalence. The article focuses on what Australia may learn from the legal decisions from jurisdictions that have more experience with the regulation of smoking in closed environments (the UK, New Zealand, USA and Canada).’ It examines unintended consequences of banning smoking in prisons including: an increase in violence and intimidation; protests, riots, violence towards staff; the development of black markets in tobacco; and imprisoned people resorting to making their own cigarettes. It also examines the human rights implications of banning smoking: exposure of non-smokers to cigarette smoke; smokers challenging the imposture of smoking bans; the right to life, liberty and security; protection from interference with privacy; freedom from discrimination; the right not to be treated in a cruel, inhuman or degrading way; and the right to be treated with humanity and respect. The analysis of case law from the UK, New Zealand, USA and Canada reveals that ‘the courts are willing to protect non-smokers exposed to second-hand smoking in certain circumstances, but human rights claims brought by smokers denied the ability to smoke are less likely to succeed’. Recommendations are made to ensure that smoking bans are implemented in a rights-respecting manner: adequate preparation for an education campaign on the health benefits; free cessation support; alternative activities to relieve boredom; and staff training.
 
Mackay, A 2016, ‘The human rights implications of smoking bans in closed environments: what Australia may learn from the international experience’, International Journal of Law, Crime and Justice, vol. 46, pp. 13-30.

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What are the impacts of long-term, low-intensity cigarette smoking on mortality?

American researchers drew attention to the fact that ‘A growing proportion of US smokers now smoke fewer than 10 cigarettes per day (CPD), and that proportion will likely rise in the future. The health effects of smoking only a few CPD over one’s lifetime are less understood than are the effects of heavier smoking, although many smokers believe that their level is modest.’ Given this, they set out to answer the question ‘Do people who smoke at low-intensity (ie, <1 or 1-10 cigarettes per day) over their lifetime have increased risk of mortality relative to those who never smoke?’ They found that ‘Among 290,215 older adults of the National Institutes of Health–AARP Diet and Health Study cohort, low-intensity smoking over the lifetime was associated with a significantly higher risk of all-cause mortality, including deaths from lung cancer and cardiovascular disease. Former smokers who had consistently used fewer than 1 or 1 to 10 cigarettes per day but who had quit smoking had progressively lower risks with a younger age at cessation… These findings provide further evidence that there is no safe level of cigarette smoking. All smokers should be targeted for smoking cessation, regardless of how few cigarettes they smoke per day. Further studies are needed to examine the health risks of low-intensity cigarette smoking in combination with electronic nicotine delivery systems and other tobacco products.’
 
Inoue-Choi, M, Liao, LM, Reyes-Guzman, C, Hartge, P, Caporaso, N & Freedman, ND 2016, ‘Association of long-term, low-intensity smoking with all-cause and cause-specific mortality in the National Institutes of Health–AARP diet and health study’, JAMA Intern Med, vol. online ahead of print, open access http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2588812.

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How significant is the use of anabolic steroid use among men for concerns about appearance?

A group of international researchers investigated the association between anabolic androgenic steroid (AAS) use and body image psychopathology in men, that is, negative body image and eating- and muscularity-oriented psychopathology. (‘Androgenic’ refers to any of the male hormones, including testosterone and androsterone.) The researchers recorded self-reported motivation for current and initial AAS use amongst 122 AAS using males in the north of England, alongside measures of current disordered eating and muscle dysmorphia psychopathology. (Dysmorphia can be defined as deformity or abnormality in the shape or size of a specified part of the body.) They found ‘Those reporting AAS for appearance purposes reported greater overall eating disorder psychopathology…and muscle dysmorphia psychopathology…than those using AAS primarily for performance purposes. Additionally, greater dietary restraint…functional impairment…and drive for size…was demonstrated in those using ASS for appearance purposes’. They commented ‘Motivation for AAS use may be important in accounting for differential profiles of body image psychopathology amongst users. Men whose AAS use is driven primarily by appearance-related concerns may be a particularly dysfunctional subgroup’.
 
Murray, SB, Griffiths, S, Mond, JM, Kean, J & Blashill, AJ 2016, ‘Anabolic steroid use and body image psychopathology in men: delineating between appearance- versus performance-driven motivations’, Drug and Alcohol Dependence, vol. 165, pp. 198-202.

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New Reports

ACT Health, Health Improvement Branch 2016, ‘An overview of smoking in pregnancy’, ACT Population Health Bulletin, vol. 5, no. 4, pp. 34-5, http://www.health.act.gov.au/healthy-living/population-health#Bulletin.
 
ACT data on smoking in pregnancy. ‘Smoking in pregnancy is the most important preventable cause of a wide range of adverse pregnancy outcomes. Smoking causes poor outcomes for mother and baby and there is growing evidence of serious harm extending into childhood and even adulthood. Unfortunately, most smokers who become pregnant continue to smoke and most of those who quit relapse after delivery. Smoking interventions in pregnancy can significantly reduce the relative risk of low birthweight and pre-term birth.’



Advisory Council on the Misuse of Drugs (ACMD) 2016, Reducing opioid-related deaths in the UK, Government of the United Kingdom, London, https://www.gov.uk/government/publications/reducing-opioid-related-deaths-in-the-uk. This independent report by the Advisory Council on the Misuse of Drugs investigates the increase of drug-related deaths in the UK.

It looks at:
  •     patterns and trends in opioid-related deaths
  •     causes and drivers of trends in opioid-related deaths
  •     policy and treatment responses to prevent opioid-related deaths.


Australian Medical Association (AMA) 2017, Blood Borne Viruses (BBVs) - 2017, Position Statement, AMA, Sydney, https://ama.com.au/position-statement/blood-borne-viruses-bbvs-2017.

The AMA supports:
  • …9. Evidence-based prevention strategies that reduce the risk of transmission of BBVs in custodial facilities, and establish a safer custodial environment for detainees and corrections staff, including regulated access to sterile injecting equipment (i.e. prison-based needle and syringe programs (NSPs)), to complement other harm minimisation measures.
  • 10. Strategies that ensure detainees and people who are in custodial facilities do not return to the community with undiagnosed and untreated BBVs.


Cameron, SM & McAllister, I 2016, Trends in Australian political opinion. Results from the Australian Election Study 1987–2016, School of Politics & International Relations, ANU College of Arts & Social Sciences, Canberra, http://www.australianelectionstudy.org/.

Includes trend data on attitudes towards the legal status of marijuana in Australia showing a marked shift in attitude in the last three years towards the view that ‘Marijuana should not be a criminal offence’.
 

Gannoni, A & Goldsmid, S 2017, Readiness to change drug use and help-seeking intentions of police detainees: findings from the DUMA program, Trends & Issues in Crime and Criminal Justice, no. 520, Australian Institute of Criminology, Canberra, http://www.aic.gov.au/publications/current%20series/tandi/501-520/tandi520.html.

‘The analysis revealed those detainees most in need of drug treatment were also those most ready to change their drug use. The findings serve as a reminder of the need and desire for interventions for drug abuse among the police detainee population, and have implications for the development of intervention strategies aimed at reducing drug use among offender populations.’
 

Hellard, M 2017, People who inject drugs can be successfully treated for hepatitis C (HCV), and treatment has the potential to reduce the community prevalence of HCV, Updated Policy Brief 3, Centre for Research Excellence into Injecting Drug Use (CREIDU), Melbourne, http://creidu.edu.au/policy_briefs_and_submissions/6-updated-policy-brief-people-who-inject-drugs-can-be-successfully-treated-for-hepatitis-c-hcv-and-treatment-has-the-potential-to-reduce-the-community-prevalence-of-hcv.

‘Professor Hellard describes the individual and community benefits of treatment of hepatitis C in people who inject drugs, and calls upon policy makers to ensure that health services are located and structured so that people who inject drugs can access hepatitis C treatment and can be appropriately supported whilst on therapy.’
 

Lee, N 2016, Health Check: what makes it so hard to quit drugs?, The Conversation, 12 Dec. 2016, https://theconversation.com/health-check-what-makes-it-so-hard-to-quit-drugs-69896.

Begins:

‘Most people who use alcohol and other drugs do so infrequently and never become dependent (or “addicted” as it’s sometimes called). On average about 10% of people who use alcohol or other drugs are dependent. The rate is around 6% for alcohol, around 10% for cannabis and around 15% for methamphetamine. But for those who do become dependent, reducing their use, getting off or staying off can be difficult.’
 

Lifeline Project 2016, Image and performance enhancing drugs (IPEDs): literature review, Lifeline Project, Manchester, UK, http://www.lifeline.org.uk/articles/ipeds/.

‘This report aims to summarise the currently available evidence and knowledge around IPED use, examine the challenges faced by drug service providers working with IPEDusers, and look at how we can better work with this group.’
 

Miller, P, Cox, E, Costa, B, Mayshak, R, Walker, A, Hyder, S, Tonner, L & Day, A 2016, Alcohol/drug-involved family violence in Australia (ADIVA), Monograph Series no. 68, National Drug Law Enforcement Research Fund, Canberra, http://www.ndlerf.gov.au/publications/monographs/monograph-68.

‘Family and domestic violence (FDV) are significant public health and social issues. According to the 2012 Personal Safety Survey (Australian Bureau of Statistics 2013), approximately 11.2 percent of the Australian population aged over 15 years (1.93 million people) have experienced physical or sexual violence perpetrated by a current or former partner. The negative consequences of FDV, which include physical injury, depression, suicide and post-traumatic stress disorder, have been well-documented (Stuart et al. 2013). A range of risk factors have been identified to contribute to FDV, including Alcohol and Other Drug (AOD) use. Of significance, AOD use represents risk factors that can be modified at individual and environmental levels.’
And see Miller, P & Mayshak, R 2016, Alcohol and drug use exacerbate family violence and can be dealt with, The Conversation, 15 December 2016, https://theconversation.com/alcohol-and-drug-use-exacerbate-family-violence-and-can-be-dealt-with-69986 .
 

National Academies of Sciences, Engineering, and Medicine (USA) 2017, The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research (2017), The National Academies Press, Washington, DC , https://www.nap.edu/catalog/24625/the-health-effects-of-cannabis-and-cannabinoids-the-current-state.

‘The Health Effects of Cannabis and Cannabinoids provides a comprehensive review of scientific evidence related to the health effects and potential therapeutic benefits of cannabis. This report provides a research agenda—outlining gaps in current knowledge and opportunities for providing additional insight into these issues—that summarizes and prioritizes pressing research needs.’
 

Public Health England 2016, The public health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies: an evidence review, PHE publications gateway number: 2016490, Public Health England, London, https://www.gov.uk/government/publications/the-public-health-
burden-of-alcohol-evidence-review
.

‘This review looks at the impact of alcohol on the public health and the effectiveness of alcohol control policies.’
 

Sander, G 2016, HIV, HCV, TB and harm reduction in prisons: human rights, minimum standards and monitoring at the European and international levels, Harm Reduction International, London, http://cilvektiesibas.org.lv/en/publications/monitoring-hiv-hcv-tb-and-harm-reduction-in-prison-400/.

‘This tool has been developed by Harm Reduction International, in consultation with an Expert Committee, to assist human rights-based monitoring bodies in fulfilling their preventive mandate in the context of HIV, HCV, TB and harm reduction in prisons.’
 

Task Force on Cannabis Legalization and Regulation 2016, A Framework for the legalization and regulation of cannabis in Canada. The Final Report of the Task Force on Cannabis Legalization and Regulation, November 30, 2016, Health Canada, Ottawa, http://www.healthycanadians.gc.ca/task-force-marijuana-groupe-etude/framework-cadre/index-eng.php.

‘On June 30, 2016, the Minister of Justice and Attorney General of Canada, the Minister of Public Safety and Emergency Preparedness, and the Minister of Health announced the creation of a nine-member Task Force on Cannabis Legalization and Regulation (“the Task Force”). Our mandate was to consult and provide advice on the design of a new legislative and regulatory framework for legal access to cannabis, consistent with the Government’s commitment to “legalize, regulate, and restrict access.”...In taking a public health approach to the regulation of cannabis, the Task Force proposes measures that will maintain and improve the health of Canadians by minimizing the harms associated with cannabis use’ (p.2).
 

U.S. Department of Health and Human Services 2016, E-cigarette use among youth and young adults. A report of the Surgeon General, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA, https://e-cigarettes.surgeongeneral.gov/resources.html.

‘The findings from this report reinforce the need to support evidence-based programs to prevent youth and young adults from using tobacco in any form, including e-cigarettes. The health and well-being of our nation’s young people depend on it.’

Comment: This report incorrectly refers to e-cigarettes and other personal vaporisers as ‘tobacco products’. They are nicotine delivery devices but do not contain, nor deliver, tobacco. ATODA is surprised that the Surgeon General’s office, an organisation with a fine reputation for scientific accuracy, would make this fundamental error. ATODA has recently developed a series of information sheets on electronic cigarettes that are available on its website at: http://www.atoda.org.au/projects/e-cigarette-information-series/
 

U.S. National Cancer Institute & World Health Organization 2016, The economics of tobacco and tobacco control, National Cancer Institute Tobacco Control Monograph 21, NIH Publication No. 16-CA-8029A, NCI & WHO, Bethesda, MD & Geneva, CH, http://www.who.int/tobacco/publications/economics/nci-monograph-series-21/en/.

From web:

‘This monograph, a collaboration between the National Cancer Institute and WHO, examines the current research and evidence base surrounding the economics of tobacco control—including tobacco use, tobacco growing, manufacturing and trade, tobacco product taxes and prices, and tobacco control policies and other interventions to reduce tobacco use and its consequences. This information can help direct future research and inform tobacco prevention and control programs and policies in countries around the world.’

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Contact ATODA:

Phone: (02) 6249 6358
Fax: (02) 6230 0919
Email: info@atoda.org.au
Mail: PO Box 7187,
Watson ACT 2602
Visit: 11 Rutherford Crescent, Ainslie

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The Alcohol Tobacco and Other Drug Association ACT (ATODA) is the peak body representing the non-government and government alcohol, tobacco and other drug (ATOD) sector in the Australian Capital Territory (ACT). ATODA seeks to promote health through the prevention and reduction of the harms associated with ATOD. 

Views expressed in the ACT ATOD Sector eBulletin do not necessarily reflect the opinion of the Alcohol Tobacco and Other Drug Association ACT. Not all third-party events or information included in the eBulletin are endorsed by the ACT ATOD Sector or the Alcohol Tobacco and Other Drug Association ACT. No responsibility is accepted by the Alcohol Tobacco and Other Drug Association ACT or the editor for the accuracy of information contained in the eBulletin or the consequences of any person relying upon such information. To contact us please email ebulletin@atoda.org.au or call (02) 6249 6358.








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Alcohol Tobacco and Other Drug Association ACT · 11 Rutherford Crescent Ainslie · Canberra, ACT 2602 · Australia

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