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 cover 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.
This report provides information on range of indicators on health status, determinants of health and health system performance relating to Aboriginal and Torres Strait Islander people in the Australian Capital Territory. The report is based on the
; the fourth in a series of reports against the Aboriginal and Torres Strait Islander Health Performance Framework (HPF). Analysis presented in the ACT report includes both jurisdiction-specific measures and their comparison with national measures.
, cat. no. IHW 96, Australian Institute of Health and Welfare, Canberra.
Stakeholders are progressing a proposal to expand and strengthen alcohol, tobacco and other drug (ATOD) research in the ACT and region, and enhance ATOD policy and its implementation, through establishing a structured collaboration, such as a Centre for ATOD Research, Policy and Practice in the ACT. For more information please see the
On 15 July 2013 a working group composed of drug researchers based at the National Centre for Epidemiology and Population Health, ANU and ATODA met to discuss a future half-day workshop to be held by the end of October or early November. An aim of the
is to gather ACT based researchers across institutions to encourage promote networking, exchange ideas and supporting future collaboration.
of alcohol, tobacco and other drug researchers in the ACT. We highly encourage people who would like to be involved to contact us.
If you are interested in being involved please email Carrie Fowlie, Executive Officer, ATODA on
Most of the reports and research items referenced below are available from the Alcohol and Other Drug Council of Australia’s
What have been the trends in the incidence of hepatitis C virus infection among participants of Australian needle and syringe programs?
Australian researchers examined trends in the incidence (the number of new cases in a specified time period) of hepatitis C virus (HCV) infections among people who inject drugs and who attended needle and syringe programs (NSPs) in Australia from 1995 to 2010. They identified 180 HCV seroconversions over the study period (i.e. people who changed from being HCV negative to positive), for a pooled incidence density of 17.0 per 100 person-years. Incidence density fell from a high of 30.8 per 100 person-years in 2003 to a low of 4.0 in 2009.
The authors concluded that the research demonstrates ‘A decline in HCV incidence among Australian IDUs attending NSPs coincided with considerable expansion of harm reduction programs and a likely reduction in the number of IDUs, associated with significant changes in drug markets. Our results demonstrate the capacity of repeat cross-sectional serosurveillance to monitor trends in HCV incidence and provide a platform from which to assess the impact of prevention and treatment interventions.’
Iversen, J, Wand, H, Topp, L, Kaldor, J & Maher, L 2013, ‘Reduction in HCV incidence among injection drug users attending needle and syringe programs in Australia: a linkage study’, American Journal of Public Health
, online ahead of print.
This paper does not assert that NSPs, alone, have caused the very pleasing reduction in HCV incidence over the time period studied. It suggests, however, that this intervention has been part of a package that has produced this outcome. It is widely accepted that the introduction and expansion of NSPs has been one of the most effective, and cost-effective, public health interventions ever implemented in this country.
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How effective is it to train bystanders to recognise opioid overdoses?
A study examined the effectiveness of brief training provided by the New York State Department of Health to assist bystanders to recognise the signs of opioid overdose and to provide interventions, including the use of naloxone. It found that ‘Overdose training significantly increased participants’ ability to accurately identify opioid overdose…and scenarios where naloxone administration was indicated…Training did not alter recognition of non-opioid overdose or non-overdose situations where naloxone should not be administered’. The researchers concluded that ‘The data indicate that overdose prevention training improves participants’ knowledge of opioid overdose and naloxone use, but naloxone may be administered in some situations where it is not warranted. Training curriculum could be improved by teaching individuals to recognize symptoms of non-opioid drug over-intoxication’.
Jones, JD, Roux, P, Stancliff, S, Matthews, W & Comer, SD 2013, ‘Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users
’, International Journal of Drug Policy
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How effective are public warnings of the availability and dangers of an increase in heroin potency?
In May 2011, health authorities in British Columbia, Canada issued a warning that there had been a recent increase in heroin-related overdoses in Vancouver associated with higher potency heroin circulating within the province. People who inject drugs were encouraged not to use drugs alone, to call 911 (the local equivalent of Australia’s 000) in the event of an overdose and to use local support services including the Vancouver supervised injection site. Subsequent interviews with 18 active heroin injectors found that ‘Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages’.
The researchers concluded that ‘Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk’.
Kerr, T, Small, W, Hyshka, E, Maher, L & Shannon, K 2013, ‘“It’s more about the heroin”: injection drug users’ response to an overdose warning campaign in a Canadian setting’, Addiction
, vol. 108, no. 7, pp. 1270-6.
The findings of this study are disappointing as authorities in Australia routinely provide warnings, to people who use drugs, when particularly harmful or high potency drugs appear on the market. It is quite likely, however, that contextual factors specific to British Columbia and, especially to Vancouver, are instrumental in producing the outcomes reported. It would be valuable to replicate the study in an Australian setting to explore the importance of context.
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Are smoke-free prisons feasible?
A letter in the June 2012 issue of The New Zealand Medical Journal
from a group of New Zealand researchers states that the comprehensive smoke free prisons policy which was introduced in New Zealand in July 2011 ‘…appears to have been very successful so far. Initial concerns about the feasibility of establishing smoke-free prisons seem to have been overridden by the reported smooth transition, from 67% of the prison population previously being smokers to a situation of a fully smoke-free environment...The policy was reported to have been met with cooperation and even enthusiasm from many prisoners across the country’.
The writers mention three factors that were likely to have contributed to the widespread acceptance of smoke-free prisons in New Zealand: ‘…the comprehensive preparation provided by both the Department of Corrections and individual correction facilities;…the availability, range and standard of smoking cessation support services; and…the opportunity to learn from overseas experience and enact a comprehensive policy (covering both indoors and outdoors) as opposed to a partial policy’.
They explain that ‘Preparation for the smoke-free policy consisted of a year-long lead-in period…During this time, prisoners were provided with educational materials which outlined the health risks of smoking along with advice on how best to quit. After the proposed smoke free policy was announced and prior to its implementation, 2000 prisoners started nicotine replacement therapy (NRT)…Six voluntary smoke-free units were established across the country up to 9 months before the policy was enforced, receiving unexpected support from inmates…Tobacco sales were outlawed in prisons a month before the full smoke-free prison policy came into effect’.
Smoking cessation services available to inmates have consisted of both pharmacological and behavioural support. These have included NRT, access to a national free-phone service (Quitline), access to cessation guidance books and assistance from health care staff trained in smoking cessation support. While there were initial concerns over the level of cessation support available for prisoners prior to the policy implementation,19 extra activities were provided as part of the smoking cessation programme including: sporting events, exercise initiatives, 20 cultural activities and art classes. In one correctional facility, prisoners were provided with healthy snacks (carrot sticks) to assist with withdrawal symptoms’.
Smoking is prohibited within the entire prison premises (both indoors and outside) which makes it easier to enforce. As a result of this policy, New Zealand prisons are healthier and safer with a reduction in exposure to second-hand smoke and the incidence of in-prison arson.
Collinson, L, Wilson, N, Edwards, R, Thomson, G & Thornley, S 2012, ‘New Zealand’s smokefree prison policy appears to be working well: one year on’, The New Zealand Medical Journal
, vol. 125, no. 1357, http://journal.nzma.org.nz/journal/125-1357/5247/
it is likely that most if not all Australian prisons will become smoke-free over the next few years as governments become increasingly aware of, and respond to, their duty of care towards the health of prisoners, prison staff and other members of the prison community. All prisons in the Northern Territory became smoke-free from 1 July this year. New Zealand has demonstrated how this can be done with little or no adverse consequences. It is important that the Australian states and the ACT learn from the New Zealand and NT experience, and move towards making all Australian prisons smoke-free.
ATODA has been advocating for the Alexander Maconochie Centre, the ACT’s adult prison, to implement a workplace tobacco management project.
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Does self-medication play a role in the development of heroin dependence?
A leading scholar from the National Drug and Alcohol Research Centre has examined the role of self-medication as a pathway to heroin dependence. He concludes ‘It appears that self-medication plays a prominent, and plausible, role in generating and maintaining heroin dependence. Moreover, the role of childhood abuse appears central. The clinical picture is clear: heroin use is associated with high levels of psychopathology, and the onset of traumatic events and/or symptoms typically occurs well before the use of heroin. Of course, such clinical evidence is consistent with the “self-medication hypothesis”, but certainly is not proof of it. It would be passing strange if these events were not related causally. Again, this does not mean that each and every use episode will be self-medication. What it does mean, however, is that this is a prominent, indeed dominant, pathway to heroin use. The observed patterns of polydrug use appear to render the drug speciﬁcity component tenuous. At the risk of over-statement, all dependent heroin users are polydrug users. Speciﬁcity is not essential in any way to the core concept, and a more fruitful avenue is to explore the role of polydrug use as self-medication. In my opinion, self-medication has a major clinical role in the development of heroin dependence, and may well play similar roles in other low-prevalence, high-risk drug use. The childhoods of heroin users are not incidental. They are core’.
Darke, S 2013, ‘Pathways to heroin dependence: time to re-appraise self-medication’, Addiction
, vol. 108, no. 4, pp. 659-67.
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How effective is primary prevention in reducing cannabis use among young people?
Researchers from the National Cannabis Prevention and Information Centre conducted a systematic review of the literature to evaluate the effectiveness of primary prevention programs in averting young people from using cannabis. Most of the evaluations reviewed (21 of the 25) reported some form of psycho-education, and some social skills training, risk resiliency/refusal skills training and/or decision making skills training. Six studies covered all four content areas, of which five reported statistically significant results. The researchers found that the programs reviewed had statistically significant effect sizes ranging from trivial (0.07) to extremely large (5.26). Furthermore, ‘Despite this potential, evidence was largely inconclusive regarding a distinctive pattern of program efficacy as the percentages of statistically significant and non-statistically significant findings were often equivalent across program type and individual components.’
They concluded that ‘Overall, the current study suggests primary prevention programming may avert cannabis use. Albeit reliable and discernible patterns for program efficacy remain largely inconclusive, results of the current study implicate the importance of assessing the relative efficacy of all program types and the inter-dependent relationship of program type and individual program components...Given the high prevalence of cannabis use in young people…and the extent of problems associated with early initiation…further developments in this area are pertinent’.
Norberg, MM, Kezelman, S & Lim-Howe, N 2013, ‘Primary prevention of cannabis use: a systematic review of randomized controlled trials
’, PLoS One
, vol. 8, no. 1, p. e53187.
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Are people who smoke both tobacco and cannabis likely to have more health problems than those who only smoke cannabis?
An Australian study examined the effects on health of long-term use of cannabis and tobacco individually, and in combination. It involved 350 adults aged 40 or over: 59 smoked cannabis but not tobacco; 88 smoked both cannabis and tobacco; 80 smoked tobacco but not cannabis: and 123 who used neither drug. Participants completed a survey covering their drug use, diagnosed medical conditions, health concerns relating to smoking cannabis/tobacco, and general health. Significant differences were found among the four groups: ‘With regard to diagnosed medical conditions, the…three smoking groups reported significantly higher rates of emphysema than did the control group. However, all members of the cannabis-only group diagnosed with emphysema were former regular tobacco smokers. Total general health scores, general health subscales, and items addressing smoking-related health concerns also revealed several significant group differences, and these tended to show worse outcomes for the two tobacco smoking groups. Findings suggest that using tobacco on its own and mixing it with cannabis may lead to worse physical health outcomes than using cannabis alone’.
Rooke, SE, Norberg, MM, Copeland, J & Swift, W 2013, ‘Health outcomes associated with long-term regular cannabis and tobacco smoking
’, Addictive Behaviors
, vol. 38, no. 6, pp. 2207-13.
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Does using cannabis affect young people’s mental health?
A related Australian study examined current trends in cannabis use and cannabis use disorder among youth, and to investigate recent findings concerning the relationship between cannabis use and mental health concerns, with a focus on how use during adolescence may interact with related mental health disorders. The researchers’ main findings were that ‘Current data indicate that cannabis use disorder is most prevalent among youth. Regular cannabis use during adolescence doubles the risk of adulthood anxiety disorders. The relationship between cannabis use and depression is strongest during adolescence. Adolescent cannabis use is linked with suicidal ideation and personality disorders. Mental health services for adolescents will benefit from increasing their focus on cannabis.’
Copeland, J, Rooke, S & Swift, W 2013, ‘Changes in cannabis use among young people: impact on mental health’, Current Opinion in Psychiatry
, vol. 26, no. 4, pp. 325-9.
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How much money do Australian governments spend on illicit drug policy?
Number 24 of the Drug Policy Modelling Program Monograph Series estimates Australian governments’ direct or proactive spending on illicit drug policy for 2009-10. ‘Four drug policy domains were examined: prevention, treatment, harm reduction and law enforcement. Federal and state/territory expenditure estimates were derived for each of the four domains. A top-down approach was adopted wherever possible and consistency in method across the four domains was of central concern.
‘The results reveal that Australian governments spent approximately $1.7 billion in 2009/10 on illicit drugs. This included programs to prevent or delay the commencement of drug use in young people, drug treatment services including counselling and pharmacotherapy maintenance, harm reduction programs such as the needle syringe program, police detection and arrest in relation to drug crimes and policing the borders of Australia for illegal importation of drugs and their precursors.
The $1.7 billion amount equates to 0.13% of GDP, and 0.8% of all government spending. In 2009/10 it represented per person spending of $76.28.’
Of this $1.7 billion, 66% was expended on drug law enforcement, 21% on treatment, 9% on prevention, 2% on harm reduction, and 1.4% on other areas.
Ritter, A, McLeod, R & Shanahan, M 2013, Government drug policy expenditure in Australia - 2009/10
, DPMP Monograph Series no. 24, National Drug and Alcohol Research Centre, Sydney.
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How effective is buprenorphine as a treatment for pregnant opioid users?
Abstract: ‘Pregnancy in opioid users poses a number of problems to treating physicians. Most guidelines recommend maintenance treatment to manage opioid addiction in pregnancy, with methadone being the gold standard. More recently, buprenorphine has been discussed as an alternate medication. The use and efficacy of buprenorphine in pregnancy is still controversial. This article reviews the current database on the basis of a detailed and critical literature search performed in MEDLINE (206 counts). Most of the relevant studies (randomised clinical trials and one national cohort sample) were published in the last 2 years and mainly compared buprenorphine with methadone. Some studies are related to maternal outcomes, others to foetal, neonatal or older child outcomes. With respect to maternal outcomes, most studies suggest that buprenorphine has similar effects to methadone. Very few data from small studies discuss an effect of buprenorphine on neurodevelopment of the foetus. Neonatal abstinence syndrome is common in infants of both buprenorphine- and methadone-maintained mothers. As regards neonatal outcomes, buprenorphine has the same clinical outcome as methadone, although some newer studies suggest that it causes fewer withdrawal symptoms. Since hardly any studies have investigated the combination of buprenorphine with naloxone (which has been suggested to possibly have teratogenic effects) in pregnant women, a switch to buprenorphine monotherapy is recommended in women who become pregnant while receiving the combination product. These novel findings indicate that buprenorphine is emerging as a first-line treatment for pregnant opioid users.’
Soyka, M 2013, ‘Buprenorphine use in pregnant opioid users: a critical review’, CNS Drugs
, online ahead of print.
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What do Australians think about drug policy?
A Drug Policy Modelling Program study used data from the 2010 National Drug Strategy Household Survey to analyse Australians’ attitudes to aspects of drug policy. It identified six classes of individuals which the researchers labelled ‘uninformed, ambivalent, detached prohibitionists, committed prohibitionists, harm reductionists and legalizers’.
The researchers state that ‘This analysis has demonstrated that whilst there are members of the public who could be described as holding strong ideological positions towards drug policy, in terms of a zero tolerance/legalization dichotomy, more than half of the Australian population do not hold such strong views; rather, they hold views somewhere “in between” these two polarized positions. The analysis has also demonstrated that support for harm reduction interventions such as NSPs does not necessarily equally support for drug legalization. Therefore, rather than thinking of a harm reduction/zero tolerance dichotomy when considering people’s attitudes to drug policy (where support for harm reduction and legalization are largely synonymous), it is perhaps more accurate to think of three separate strong ideological positions: zero tolerance, harm reduction and legalization…Whilst there was a large proportion of this sample (the legalizer, committed prohibitionist and harm reductionist classes made up almost two-thirds of the sample combined) who were likely to be firmly set in their opinions and who would be unlikely to change their mind in the near future, the remainder of the population appear to have less strongly held ideological views. With around one-third of the population holding relatively weak opinions towards drug policy, education and advocacy may be worthwhile if interest groups wished to influence public opinion’.
Matthew-Simmons, F, Sunderland, M & Ritter, A 2013, ‘Exploring the existence of drug policy “ideologies” in Australia’, Drugs: Education, Prevention, and Policy
, vol. 20, no. 3, pp. 258-67.
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How effective are mass media campaigns as a means of reducing smoking?
The Australian National Preventive Health Agency’s ‘Evidence Briefs’ series aims to disseminate information and inform dialogue relating to high priority preventive health concerns. A recent issue on tobacco control and mass media campaigns reviews evidence which indicates that ‘…tobacco control mass media campaigns reduce youth and adult smoking. Mass media campaigns have direct effects on smokers and youth by exposing them to messages that prompt quit attempts and avoidance of smoking. Campaigns also have indirect effects that support not smoking by more generally de-normalising smoking in society. Mass media campaigns require frequent population exposure…to achieve optimal effects on smoking behaviour…Achievement of adequate campaign intensity is especially important for vulnerable population subgroups, among whom pro-smoking influences are greater…Because they have high reach into populations, mass media campaigns are highly cost-effective with savings from averted health care costs exceeding campaign investment. Emotionally intense messages emphasising the negative health effects of smoking using graphic images or testimonials consistently perform better (lead to higher ratings, more Quitline calls, higher quit rates) than advertisements generating lower levels of negative emotion…Frequent broadcast of negative health effects messages using testimonials or graphic depictions may work well across population groups of adults and youth, and may contribute to reductions in disparities between high SES smokers and smokers with some degree of disadvantage.’
Australian National Preventive Health Agency 2013, Tobacco control and mass media campaigns evidence brief
, Australian National Preventive Health Agency, Canberra.
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Should electronic cigarettes be as freely available as tobacco cigarettes?
In its occasional series ‘Head-to-head’, the prominent medical journal BMJ
last month juxtaposed two brief opinion pieces on the topic of electronic cigarettes (e-cigarettes). The editors introduced the debate as follows: ‘The [UK] Medicines and Healthcare Products Regulatory Agency has decided to license electronic cigarettes as medicines from 2016. Simon Chapman agrees with regulation, seeing e-cigarettes as another way for big tobacco to try to make nicotine addiction socially acceptable again, but Jean-François Etter…says restrictions will result in more harm to smokers’.
Both writers are respected leaders in their fields. They present cogent arguments to support their positions. This debate highlights the need for policy-makers to engage with the research community to ascertain the optimal regulatory framework for e-cigarettes, one that will reduce the burden of death and disease that tobacco smoking currently creates.
Chapman, S 2013, ‘Should electronic cigarettes be as freely available as tobacco cigarettes? No
’, BMJ: British Medical Journal
, vol. 346:f3840.
Etter, J-F 2013, ‘Should electronic cigarettes be as freely available as tobacco? Yes
’, BMJ: British Medical Journal
, vol. 346:f3845.
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Australian Institute of Health and Welfare 2013, Aboriginal and Torres Strait Islander Health Performance Framework 2012 report: Australian Capital Territory, cat. no. IHW 96, Australian Institute of Health and Welfare, Canberra.
Australian Institute of Health and Welfare 2013, National Opioid Pharmacotherapy Statistics Annual Data collection: 2012 report, Drug Treatment series no. 20, cat. no. HSE 136, Australian Institute of Health and Welfare, Canberra.
Butler, K & Burns, L 2013, ACT drug trends 2012: findings from the Illicit Drug Reporting System (IDRS), National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW.
Butler, K & Burns, L 2013, ACT trends in ecstasy and related drug markets 2012: findings from the ecstasy and related drugs reporting system (EDRS), National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW.
Grace, J, Krom, I, Maling, C, Butler, T, Midford, R & Simpson, P 2013, Review of Indigenous offender health (updated).
Nicholas, R, White, M, Roche, A, Gruenert, S & Lee, N 2012, Breaking the silence: addressing family and domestic violence problems in alcohol and other drug treatment practice in Australia, National Centre for Education and Training on Addiction (NCETA), Flinders University, Adelaide.
Sindicich, N & Burns, L 2013, Australian trends in ecstasy and related drug markets 2012: findings from the Ecstasy and Related Drugs Reporting System (EDRS), National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW.
Stafford, J & Burns, L 2013, Australian drug trends 2012: findings from the Illicit Drugs Reporting System (IDRS), National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW.
Stöver, H 2013, ‘Drug use, mental health and drugs in prisons’, in Mental health and addiction in prisons, The Drugs in Prisons Programme of the Pompidou Group of the Council of Europe [Brussels], pp. 8-27.
United Nations Office on Drugs and Crime 2013, World Drug Report 2013, United Nations Office on Drugs and Crime, New York.
White, M, Roche, A, Nicholas, R, Long, C, Gruenert, S & Battams, S 2012, Can I ask? An alcohol and drug clinician’s guide to addressing family and domestic violence, National Centre for Education and Training on Addiction (NCETA), Flinders University, Adelaide.
For information on other reports, please visit the ‘Did you see that report?’ page at the website of the National Drugs Sector Information Service.
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