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.

 

In the September 2013 issue

Canberra Collaboration

ACT Research Spotlight

2013 APSAD Awards

Research Findings

New Reports
 

 

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How do overdose responders feel about filling that role?   

Abstract
 
Background: Overdose prevention programs (OPPs) train people who inject drugs and other community members to prevent, recognise and respond to opioid overdose. However, little is known about the experience of taking up the role of an “overdose responder” for the participants.
 
Methods: We present findings from qualitative interviews with 30 participants from two OPPs in Los Angeles, CA, USA from 2010 to 2011 who had responded to at least one overdose since being trained in overdose prevention and response.
 
Results: Being trained by an OPP and responding to overdoses had both positive and negative effects for trained “responders”. Positive effects include an increased sense of control and confidence, feelings of heroism and pride, and a recognition and appreciation of one’s expertise. Negative effects include a sense of burden, regret, fear, and anger, which sometimes led to cutting social ties, but might also be mitigated by the increased empowerment associated with the positive effects. [For example, one female responder said ‘Everybody comes to get me right away, because they know I’m not gonna walk away from it. And that’s not really a good thing, either. That puts a lot on me. ‘Cause I can’t just, I can’t handle it. It’s really draining. I just wish they’d leave me alone sometimes. But then again, I don’t wanna see nobody die either. So I always go.’]
 
Conclusion: Findings suggest that becoming an overdose responder can involve taking up a new social role that has positive effects, but also confers some stress that may require additional support. OPPs should provide flexible opportunities for social support to individuals making the transition to this new and critical social role. Equipping individuals with the skills, technology, and support they need to respond to drug overdose has the potential to confer both individual and community-wide benefits.
 
Wagner, KD, Davidson, PJ, Iverson, E, Washburn, R, Burke, E, Kral, AH, McNeeley, M, Bloom, JJ & Lankenau, SE 2013, ‘“I felt like a superhero”: the experience of responding to drug overdose among individuals trained in overdose prevention’, International Journal of Drug Policy, online ahead of print.
 
Comment: The participants received training at two community-based needle and syringe programs. The training included giving rescue breathing, calling for an ambulance and administering naloxone, as happens in the ACT naloxone program. The article gives a number of quotations showing how good most felt about saving their peers’ lives by administering naloxone and using other techniques, along with participants’ comments about the negative aspects as well. For ACT program details see: http://www.cahma.org.au/Naloxone.html and www.atoda.org.au/policy/naloxone.


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What are the main causes of death among people who have been on OST programs in NSW?
 
Abstract
 
Aims: Examine changes in causes of death in a cohort treated for opioid dependence, across time and age; quantify years of potential life lost (YPLL); and identify avoidable causes of death.
 
Design: People in New South Wales (NSW) who registered for opioid substitution therapy (OST), 1985-2005 were linked to a register of all deaths in Australia.
 
Measurements: Crude mortality rates (CMRs), age-sex-standardised mortality rates (ASSRs) and standardised mortality ratios (SMRs) across time, sex and age. Years of potential life lost (YPLL) were calculated with reference to Australian life tables and by calculating years lost before the age of 65.
 
Findings: There were 43,789 people in the cohort, with 412,216 person-years of follow-up. The proportion of the cohort aged 40+ years increased from 1% in 1985 to 39% in 2005. Accidental opioid overdoses, suicides, transport accidents and violent deaths declined with age; deaths from cardiovascular disease, liver disease and cancer increased. Among men, 89% of deaths were potentially avoidable; among women, 86% of deaths were avoidable. There were an estimated 160,847 YPLL in the cohort, an average of 44 YPLL per decedent, and an average of 29 YPLL before age 65.
 
Conclusion: Among a cohort of opioid dependent people in New South Wales, 1985-2005, almost 9 in 10 deaths in the cohort were avoidable. There is huge scope to improve mortality among opioid dependent people.
 
Degenhardt, L, Larney, S, Randall, D, Burns, L & Hall, W 2013, ‘Causes of death in a cohort treated for opioid dependence between 1985-2005’, Addiction, online ahead of print.


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Are young ex-prisoners more likely to die in the year following their release than older ex-prisoners?

The identities of all persons released from adult prisons in Queensland from 1994 to 2007 were linked with the Australian National Death Index – over 42,000 individuals. The researchers compared the death rates of ex-prisoners in the year following release. They found that ‘Being young was protective against death from all causes…however, the elevation in risk of all-cause death relative to the general population was greater for those aged less than 25 years…than for older ex-prisoners…Almost all deaths in young ex-prisoners and the majority of those in older ex-prisoners were caused by injury or poisoning’. Young women ex-prisoners ‘experienced 20 times greater risk of death compared with age- and sex-matched peers in the general population’. The researchers conclude that ‘Young people are at markedly increased risk of death after release from prison’ and ‘the majority of deaths are due to preventable causes, particularly injury and poisoning, and suicide’.
 
van Dooren, K, Kinner, SA & Forsyth, S 2013, ‘Risk of death for young ex-prisoners in the year following release from adult prison’, Australian and New Zealand Journal of Public Health, vol. 37, no. 4, pp. 377-82.
 
Comment: Research is demonstrating the severe adverse effects of juvenile detention on children and young people. The number of young people in detention continues to grow although there is some indication that this trend is reversing.  Additionally, the ACT’s youth Aboriginal and Torres Strait Islander incarceration rate is the third highest in Australia.  The ACT Legislative Assembly’s Standing Committee on Justice and Community Safety current inquiry into sentencing provides an opportunity to strengthen sentencing options for all detainees, including young people.


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What proportion of prescription opioids is consumed by people who inject drugs?

A team of Australian researchers examined population-level prescribing of morphine, oxycodone and methadone tablets in NSW, Victoria, Tasmania and Queensland from 2002 to 2010. They analysed the levels and patterns of use of these opioids reported among people who inject drugs [PWID] in each of these states from 2004 to 2010, and compared ‘the estimated defined daily doses (DDD) consumed per 1000 PWID and per 1000 general population 20–69 years per year’. They found that ‘There were major differences between the states in levels of morphine and oxycodone prescribing…Tasmania had the highest levels of prescribing of all three opioids. Overall, population-level prescribing of morphine declined, oxycodone prescriptions steadily increased and methadone tablet prescriptions were stable across the study period in all states’.
 
The authors state that ‘the use of pharmaceutical opioids by PWID was inversely related to self-reported heroin use. In states with the lowest rates of regular heroin use, PWID had the highest rates of pharmaceutical opioid use and accounted for the largest proportion of pharmaceutical opioid use in the general population. In the state with the lowest heroin availability (Tasmania), PWID might have consumed as much as 28% (range 22–37%) of all morphine prescribed in 2010. Across all states except Tasmania in 2010, PWID were estimated to consume less than 5% of prescribed oxycodone’. They went on to suggest that ‘most of the increase in Australian oxycodone prescribing has most probably been accounted for use by patients with chronic pain of nonmalignant origin’. They conclude that ‘Regular use of pharmaceutical opioids among PWID indicates an unmet need for treatment for opioid dependence’ and ‘Opioid substitution therapy and other effective treatments need to be more available and attractive to PWID’.
 
Degenhardt, L, Gilmour, S, Shand, F, Bruno, R, Campbell, G, Mattick, RP, Larance, B & Hall, W 2013, ‘Estimating the proportion of prescription opioids that is consumed by people who inject drugs in Australia’, Drug and Alcohol Review, online ahead of print.
 
Comment: ACT Health is currently conducting a Consultation Regarding Proposed Changes to Controlled Medicines Prescribing Options in the ACT. The closing date is 18 October 2013. ATODA will be making a submission, to provide input please contact Carrie Fowlie on carrie@atoda.org.au. For more information: See the consultation paper, visit the ACT Health website or email hps@act.gov.au


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What are the trends in showing alcohol and tobacco use in popular movies?
 
It is acknowledged that the nature and type of tobacco and alcohol use portrayed in movies could be influenced by agreements between the movie industry and tobacco and alcohol industries. Tobacco brand placements (tobacco manufacturers paying moviemakers to portray smoking and/or their particular brands) were limited by the Master Settlement Agreement between government and the tobacco industry after 1998, while the depiction of alcohol use is subject to industry self-regulation only. The study examined trends in tobacco and alcohol use as portrayed in the top 100 box-office movie hits released in the USA from 1996 to 2009, 1,400 movies in all.
 
The researchers found that, overall, the 1,400 movies contained 500 tobacco and 2,433 alcohol brand appearances. After implementation of the MSA in 1998, tobacco brand appearances dropped markedly (by 7.0% each year), then remained steady at a level of just 22 per year after 2006. The researchers pointed out that, ‘In contrast, there was little change in alcohol brand appearances or alcohol screen time overall. In addition, alcohol brand appearances in youth-rated movies trended upward during the period from 80 to 145 per year, an increase of 5.2 (95% CI, 2.4-7.9) appearances per year.’ This led the researchers to conclude that ‘Tobacco brands in movies declined after implementation of externally enforced constraints on the practice, coinciding also with a decline in tobacco screen time and suggesting that enforced limits on tobacco brand placement also limited onscreen depictions of smoking. Alcohol brand placement, subject only to industry self-regulation, was found increasingly in movies rated for youth as young as 13 years, despite the industry’s intent to avoid marketing to underage persons.’
 
Bergamini, E, Demidenko, E & Sargent, JD 2013, ‘Trends in tobacco and alcohol brand placements in popular US movies, 1996 through 2009’, JAMA Pediatr, vol. 167, no. 7, pp. 634-9.
 
Comment: This study will provide further evidence for alcohol control advocates calling for the drinks industry to be treated in much the same way that the alcohol industry is now, owing to the consistent failure of many self-regulatory industry practices.


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How likely is it that users of synthetic cannabinoids will seek emergency medical treatment?
 
In late 2011, an anonymous global online survey of drug and alcohol use http://globaldrugsurvey.com collected data on ‘Demographics and prevalence of lifetime (ever used) and recent use (last year and number of days in the last month) of a large number of substances including SCs [synthetic cannabinoids]…All last-year users were asked if they sought emergency medical treatment in the preceding 12 months in association with the use of SCs and if so by what route they had consumed the SC product’. Almost a thousand had used SCs in the previous year and more than 2% reported seeking emergency medical treatment following the use of the product. ‘The most common presentations were panic and anxiety, followed by paranoia and breathing difficulties.’ This represents ‘a far higher rate than might be expected from a similar cohort of cannabis users’. The researchers concluded ‘Synthetic cannabinoid use appears to be associated with a high prevalence of adverse experiences among users, especially younger users. Further research is required to determine whether particular compounds carry a higher risk of harm than others and to assess potential consequences of longer term use’.
 
Winstock, AR & Barratt, MJ 2013, ‘The 12-month prevalence and nature of adverse experiences resulting in emergency medical presentations associated with the use of synthetic cannabinoid products’, Human Psychopharmacology, vol. 28, no. 4, pp. 390-3.


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Is there a link between the use of psychedelics and mental illness? 
 
Psychedelic drugs produce hallucinations and apparent expansion of consciousness. Psychedelic plants have been used for celebratory, religious or healing purposes for thousands of years. Researchers investigated whether lifetime use of psychedelics has an effect on mental health, using data from the US National Survey on Drug Use and Health from 2001 to 2004. Participants were those who reported any lifetime use of the psychedelics LSD, psilocybin, mescaline or peyote. The researchers found that there was ‘no relation between lifetime use of psychedelics and any undesirable past year mental health outcomes, including serious psychological distress, mental health treatment (inpatient, outpatient, medication, felt a need but did not receive), or symptoms of panic disorder, major depressive episode, mania, social phobia, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, or non-affective psychosis’.
 
Krebs, TS & Johansen, P-Ø 2013, ‘Psychedelics and mental health: a population study’, PLoS One, vol. 8, no. 8, p. e63972.


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Are offenders given community service orders less likely to reoffend than those given good behaviour bonds?

Instead of imposing a sentence of imprisonment, a court may impose a community service order (CSO) ordering an offender to perform community service work for a particular number of hours, or make an order directing the offender to enter into a good behaviour bond. A recent BOCSAR Crime and Justice Bulletin reports on a comparison of NSW reoffending rates between adults given a CSO and those given bonds or a suspended sentence. The key finding from this study was that ‘Adults given a CSO are less likely to reoffend than offenders given a bond, holding other relevant and available characteristics equal’.
 
Snowball, L & Bartels, L 2013, Community service orders and bonds: a comparison of reoffending, Crime and Justice Bulletin no. 171.
 
Comment: This is an important piece of evidence to support the deliberations through the ACT Legislative Assembly’s Standing Committee on Justice and Community Safety currently inquiry into sentencing.   


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Do we have available models of peer support for people with a history of injecting drug use who are undertaking assessment and treatment for hepatitis C?

Senior staff of the New South Wales Users and AIDS Association (NUAA) have investigated models for providing peer support to people with a history of injecting drug use who are undertaking assessment and treatment for hepatitis C virus (HCV) infection. As background, they point out that ‘People who inject drugs (PWID) are the group most affected by HCV; however, treatment uptake has been low. Engagement between PWID and healthcare workers has been characterized by mistrust and discrimination. Peer support for HCV is one way to overcome these barriers.’
 
The authors note that peer support has been successfully applied for managing a range of health conditions. They point out that ‘HCV peer support models have been implemented in various settings, but those that include opioid substitution treatment have been more common. Most models have been either service generated (provider led) or community controlled (peer led). Peer support models have been implemented successfully, with a range of outcomes including increased treatment knowledge and uptake and improved service provision. Genuine partnerships between peers and services were common across models and led to positive transformations for both clients and services. Further investigation of peer support for HCV treatment and its impact on both individuals and services is recommended.’
 
Crawford, S & Bath, N 2013, ‘Peer support models for people with a history of injecting drug use undertaking assessment and treatment for hepatitis C virus infection’, Clinical Infectious Diseases, vol. 57, no. suppl 2, pp. S75-S9.
 
Comment: Discussions are currently underway in the ACT about how peer support programs for people who inject drugs and hepatitis C can be strengthened.


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What regulatory frameworks are available for minimising the harm from nicotine use?

Abstract: The tobacco problem can be usefully conceptualised as two problems: eliminating the most harmful forms of nicotine use (certainly cigarettes, and probably all smoked tobacco), and minimising the use and/or harms from use of lower-harm, but addictive forms of nicotine. A possible target would be to effectively eliminate use of the most harmful forms of nicotine within the next decade and then turn our focus to a long-term strategy for the low-harm forms. This paper focuses on the administrative framework(s) needed to accomplish these twin tasks. For a phase-out taking a long time and/or for dealing with residually net harmful and addictive products, there are severe limitations to allowing for-profit marketing of tobacco because such an arrangement (the current one in most countries) can markedly slow down progress and because of the difficulty of constraining marketing in ways that minimise undesirable use. A harm reduction model where the marketing is under the control of a non-profit entity (a regulated market) is required to curtail the incredible power of for-profit marketing and to allow tobacco marketing to be done in ways that further the goal of minimising tobacco-related harm. Countries with a nationalised industry can move their industry onto a harm minimisation framework if they have the political will. Countries with a for-profit industry should consider whether the time and effort required to reconstruct the market may, in the longer term, facilitate achieving their policy goals.
 
Borland, R 2013, ‘Minimising the harm from nicotine use: finding the right regulatory framework’, Tobacco Control, vol. 22 Suppl 1, pp. i6-9.
 
Comment: In June 2013, Professor Ron Borland, Cancer Council Victoria, presented the 6^th Annual ACT ATOD Sector Conference on Regulatory Options for Moving to the Elimination of Smoking. To see the presentation, click here.


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How effective are electronic cigarettes, and how tolerable are they?

Italian researchers make the important point that ‘Electronic cigarettes (e-Cigarette) are battery-operated devices designed to vaporise nicotine that may aid smokers to quit or reduce their cigarette consumption. Research on e-Cigarettes is urgently needed to ensure that the decisions of regulators, healthcare providers and consumers are evidence based.’ They recruited from the local hospital staff in Catania, Italy, 40 adults who had been smokers for at least ten years and who were not keen to quit smoking.
 
They were issued with e-cigarettes were followed up for two years. Seventeen of the participants were lost to follow-up at two years, eleven had reduced their cigarette use by more than fifty per cent (from a median of 24 cigarettes per day to just four per day), and five gave up smoking altogether. ‘Five subjects stopped e-Cigarette use (and stayed quit), three relapsed back to tobacco smoking and four upgraded to more performing products by 24 months. Only some mouth irritation, throat irritation, and dry cough were reported. Withdrawal symptoms were uncommon.’ From this study the researchers concluded that long-term e-Cigarette use can substantially decrease cigarette consumption in smokers not willing to quit and is well tolerated’.
 
Polosa, R, Morjaria, JB, Caponnetto, P, Campagna, D, Russo, C, Alamo, A, Amaradio, M & Fisichella, A 2013, ‘Effectiveness and tolerability of electronic cigarette in real-life: a 24-month prospective observational study’, Internal and Emergency Medicine, online ahead of print.


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What are the findings of the first randomised controlled trial comparing e-cigarettes, nicotine patches and placebo e-cigarettes?

An important randomised trial was conducted in New Zealand to help develop the evidence base to inform regulators, health professionals and cigarette smokers about the effectiveness of the e-cigarettes as an aid to tobacco harm reduction and quitting. In the study, a total of 657 people were randomised to nicotine e-cigarettes, nicotine patches or to placebo e-cigarettes, i.e. those that did not contain any nicotine (the type that we have legally available in Australia). Six months later verified abstinence was 7·3% with nicotine e-cigarettes, 5·8% with patches and 4·1% with placebo e-cigarettes because the achievement of abstinence was substantially lower than anticipated when the study was designed, it had insufficient statistical power to conclude superiority of nicotine e-cigarettes to patches or to placebo e-cigarettes. No evidence was observed of an association between adverse events and the type of study products used.
 
Despite the low statistical power of the study, the researchers were able to conclude that ‘E-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches, and few adverse events. Uncertainty exists about the place of e-cigarettes in tobacco control, and more research is urgently needed to clearly establish their overall benefits and harms at both individual and population levels.’
 
Bullen, C, Howe, C, Laugesen, M, McRobbie, H, Williman, VPJ & Walker, N 2013, ‘Electronic cigarettes for smoking cessation: a randomised controlled trial’, The Lancet, online ahead of print.


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Are cigarettes cheaper and more readily available in low socioeconomic areas?  

A two-day survey in South East Queensland in 2010 compared the availability and price of cigarettes in low socioeconomic status suburbs (SES) and high-SES suburbs. It showed that ‘the most disadvantaged suburbs…[had] a greater number of tobacco retailers…[and] cigarettes were sold in a broader range of outlets in suburbs of low-SES. The average price of the packs studied was significantly lower in the most disadvantaged suburbs compared to the most advantaged.’ In high-SES suburbs ‘tobacco retail outlets were predominately newsagencies and petrol stations’ whereas in low-SES suburbs ‘tobacco outlets were mainly Asian grocery stores, followed collectively by supermarkets, newsagencies and specialist tobacconist stores’. The researchers suggest a number of tobacco control strategies including compulsory licensing for tobacco retailers, and decreasing price competition by removing cigarettes from supermarkets where prices are heavily discounted.
 
Dalglish, E, McLaughlin, D, Dobson, A & Gartner, C 2013, ‘Cigarette availability and price in low and high socioeconomic areas’, Australian and New Zealand Journal of Public Health, vol. 37, no. 4, pp. 371-6.


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Are children living in disadvantage households more likely yo be exposed to second-hand smoke?

Abstract
 
Objective: The social gradient in smoking contributes substantially to the health gap between the rich and poor. Passive smoking by children is associated with increased risk of more severe asthma, respiratory diseases and infections, middle ear disease and Sudden Infant Death Syndrome. This study examined trends in the social gradient of children’s exposure to secondhand smoke in Australian households between 2001 and 2010.
 
Design: Series of cross-sectional national household surveys.
 
Results: Between 2001 and 2010, the proportion of Australian households containing a child aged under 15 years and a smoker declined by 22%. However, there was no change in the most disadvantaged households, with half of these households still containing at least one smoker in 2010. There was a social gradient in outdoor smoking in all survey years but the prevalence of outdoor-only smoking increased in all socioeconomic groups by around 50% between 2001 and 2010. The presence of a child aged 5 years or younger in the household increased the chances that smokers only smoked outdoors.
 
Conclusion: Children’s exposure to indoor smoking in households that contain a smoker is declining in all socioeconomic groups but the social class differentials in such exposure remain. The proportion of children who live with a smoker declined in all social groups except the most disadvantaged households, with half of these households still containing a smoker in 2010. More needs to be done to reduce secondhand smoke exposure of children in socially disadvantaged households.’
 
Gartner, CE & Hall, WD 2013, ‘Is the socioeconomic gap in childhood exposure to secondhand smoke widening or narrowing?’, Tobacco Control, vol. 22, no. 5, pp. 344-8.


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New Reports

Auditor-General, NSW 2013, Cost of alcohol abuse to the NSW Government: NSW Treasury, NSW Police Force, NSW Ministry of Health, Department of Premier and Cabinet, Department of Attorney General and Justice, Audit Office of NSW, Sydney.
 
Australian Institute of Health & Welfare: Pointer, S 2013, Trends in hospitalised injury, Australia, 1999–00 to 2010–11, Injury research and statistics series no. 86, cat. no. INJCAT 162, AIHW, Canberra. (Large file warning: 4 MB)
 
Australian National Council on Drugs 2013, ANCD position paper: drug testing, August 2013, ANCD, Canberra.
 
Australian National Council on Drugs 2013, Complementary funding for non-government organisations: a brief for the AOD sector, Australian National Council on Drugs, Canberra.
 
Australian National Preventive Health Agency (ANPHA) 2013, State of preventive health 2013, report to the Australian Government Minister for Health, ANPHA, Canberra. (Large file warning: 5.3 MB)
 
Hefler, M & Thomas, D 2013, The use of incentives to stop smoking in pregnancy among Aboriginal and Torres Strait Islander women: discussion paper, The Lowitja Institute, Melbourne.
 
National Coronial Information System (Australia) 2013, Opioid deaths 2007-2009, NCIS Fact Sheet April 2013 [Southbank, Vic.].
 
United Kingdom, Home Office 2013, Alcohol and drug statistics, https://www.gov.uk/government/organisations/home-office/series/alcohol-and-drug-statistics.
 
Van Buskirk, J, Roxburgh, A, Bruno, R & Burns, L 2013, Drugs and the internet, issue 1, National Drug and Alcohol Research Centre.

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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