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 2015 issue


ACT Research Spotlight

Research Findings

New Reports
 

Publisher’s abstract: Traditional felony probation programs in the United States often suffer from poor probationer compliance. In spite of dedicated and skilled probation officers using Evidence Based Principles, many probationers fail to successfully complete probation nationwide. Part of this systemic problem is an inability of Probation Officers and the Court to impose immediate consequences for probation violations because the only sanctions available to the justice system are an ‘all-or-nothing’ revocation of probation. Determined to create a better system that would help high-risk probationers change their patterns of behavior and succeed in probation, Judge Steven S. Alm and probation supervisor Cheryl Inouye created the Hawaii’s Opportunity Probation with Enforcement (HOPE) strategy of probation supervision.

HOPE probation focuses on providing swift, certain, consistent, and proportionate jail sentences for probation violations. Compared to the delayed, inconsistent, and often unnecessarily harsh consequences in probation-as-usual, HOPE probation helps probation violators understand the direct consequences of their actions and change their own behavior. This article details the philosophy behind the HOPE program and how Hawaii was successful in reforming the probation system through HOPE to drastically reduce rates of drug use among probationers and the amount of time probationers spend in prison.

Judge Alm and Hawaii (Honolulu) Drug Court Administrator Janice Bennett worked together to redirect the focus of the Hawaii (Honolulu) Drug Court after Judge Alm also became the Drug Court judge in 2011. The Honolulu Drug Court now focuses on the higher-risk probationers (even those with violent histories) as the target population, rather than lower-risk pretrial offenders. The article describes how the two strategies, HOPE and the now-redirected Drug Court, are working together to more effectively supervise offenders in Honolulu.

Alm, SS 2015, ‘HOPE Probation and the new drug court: a powerful combination’, Minnesota Law Review, vol. 99, no. 5, pp. 1665-96, open access http://www.minnesotalawreview.org/articles/hope-probation-drug-court-powerful-combination/.

Comment: In August the ACT Government’s Justice & Community Safety Directorate facilitated a visit to Canberra by Judge Alm. This provided opportunities for him to explain, to justice, health and community sector decision-makers, how HOPE Probation and the innovative Hawaii (Honolulu) Drug Court were developed and how they operate now. This formed the basis of a discussion of the implications for the ACT of what has been learned about swift, sure and fair sanctions for AOD-involved offenders. ATODA is an active participant in these discussions and in encouraging follow-up action.

 back to top

To what extent are both alcohol and cannabis implicated in Australian road crashes?

Researchers from the Centre for Automotive Safety Research at the University of Adelaide have examined the role of cannabis in road crashes in South Australia with a particular focus on the extent to which crashes involving cannabis also involve alcohol. They reviewed hospital data, police-reported crash data and the results of forensic tests of blood samples for drugs and alcohol relating to 1,074 drivers or motorcyclists who were admitted to hospital as a result of a road crash. They also sampled 135 coroners' reports to determine the role of alcohol and cannabis in fatal crashes.

The researchers found that ‘The hospital admission cases revealed that alcohol played a greater role in road crashes than other drugs. Approximately 1 in 5 drivers or motorcyclists had a blood alcohol concentration (BAC) above the legal limit of 0.05. Routine testing for cannabis, methamphetamine, and MDMA revealed a drug-positive rate of approximately 1 in 10 of those tested, with over half of these positive to cannabis. More than a third of cannabis cases also involved alcohol. The majority of those who were positive for alcohol had a BAC above 0.15 g/100 mL. BACs were similarly high among drivers positive for both alcohol and cannabis.’

‘The findings of the hospital data and the coroners' reports were consistent with each other in terms of providing confirmation that alcohol is still the drug associated with the greatest level of road trauma on South Australian roads. Furthermore, alcohol was also present in around half of the cannabis cases and, when present, tended to be present at very high levels. The results of this study emphasize that, although drug driving is clearly a problem, the most important form of impaired driving that needs to be the target of enforcement is drink driving. Roadside drug testing is important but should not be conducted in such a way that reduces the deterrent value of random breath testing.’

Baldock, MRJ & Lindsay, VL 2014, ‘Examination of the role of the combination of alcohol and cannabis in South Australian road crashes’, Traffic Injury Prevention, vol. 16, no. 5, pp. 443-9.
 
Comment: ATODA has expressed concern, over a number of years, about roadside drug testing as it is currently implemented in the ACT. This reflects the fact that, although this approach to law enforcement has been used for over a decade in Australia, there has been no evaluation of its impacts on road safety. This South Australian study provides further evidence in support of ATODA’s concern that roadside drug testing has a potential for diverting resources away from what is clearly a highly effective road safety intervention, roadside breath testing for driver impairment by alcohol, into the unproven roadside drug driving intervention.

 back to top

Do cannabis growers have smaller plots in places with harsh penalties for growing cannabis?

A study undertaken in the USA examined the impact of certainty and severity of punishment on two important decisions made by cannabis growers: the size of the cultivation site and the number of accomplices involved. The researchers aimed ‘to examine the role of sanctions on restrictive deterrence’. (‘Restrictive deterrence’ has been defined as ‘the process whereby offenders limit the frequency, magnitude, or seriousness of their offenses to avoid pain’*.) They found some evidence that ‘the severity of state sanctions reduces the size of cultivation sites among growers who reside in the state. However, the number of contacts with the police had the opposite effect. In addition, we did not find a restrictive deterrent effect for the number of co-offenders, suggesting that different factors affect different decision points. Interestingly, objective skill and subjective skill had positive and independent effects on size of site’. They concluded that ‘state-level sanctions have a structuring effect by restricting the size of cultivation sites but further increases in sanctions or enforcement are unlikely to deter more individuals from growing cannabis. In fact, there may be some potential dangers of increased enforcement on cannabis growers’.

Nguyen, H, Malm, A & Bouchard, M 2015, ‘Production, perceptions, and punishment: restrictive deterrence in the context of cannabis cultivation’, International Journal of Drug Policy, vol. 26, no. 3, pp. 267-76.

* Jacques, S & Allen, A 2014, 'Bentham’s sanction typology and restrictive deterrence: a study of young, suburban, middle-class drug dealers', Journal of Drug Issues, vol. 44, no. 2, pp. 212-30.
 
How effectively do voluntary warning labels on Australian alcohol products give health messages to the general public?

Abstract

Background: There is limited research on awareness of alcohol warning labels and their effects. The current study examined the awareness of the Australian voluntary warning labels, the ‘Get the facts’ logo (a component of current warning labels) that directs consumers to an industry-designed informational website, and whether alcohol consumers visited this website.

Methods: Participants aged 18–45 (unweighted n = 561; mean age = 33.6 years) completed an online survey assessing alcohol consumption patterns, awareness of the ‘Get the facts’ logo and warning labels, and use of the website.

Results: No participants recalled the ‘Get the facts’ logo, and the recall rate of warning labels was 16% at best. A quarter of participants recognised the ‘Get the facts’ logo, and awareness of the warning labels ranged from 13.1–37.9%. Overall, only 7.3% of respondents had visited the website. Multivariable logistic regression models indicated that younger drinkers, increased frequency of binge drinking, consuming alcohol directly from the bottle or can, and support for warning labels were significantly, positively associated with awareness of the logo and warning labels. While an increased frequency of binge drinking, consuming alcohol directly from the container, support for warning labels, and recognition of the ‘Get the facts’ logo increased the odds of visiting the website.

Conclusions: Within this sample, recall of the current, voluntary warning labels on Australian alcohol products was non-existent, overall awareness was low, and few people reported visiting the DrinkWise website. It appears that current warning labels fail to effectively transmit health messages to the general public.

Coomber, K, Martino, F, Barbour, IR et al. 2015, ‘Do consumers “Get the facts”? A survey of alcohol warning label recognition in Australia’, BMC Public Health, vol. 15, pp. 816, open access http://www.biomedcentral.com/1471-2458/15/816.
 
Comment: This study adds to the body of evidence demonstrating that the Australian alcoholic beverages industry cannot be trusted to engage in effective self-regulation. External regulation of the industry, by governments, needs to be strengthened.

 back to top

How effective are brief alcohol interventions in linking people to higher levels of treatment services for alcohol problems?

A meta-analysis of randomised controlled trials in several countries aimed to estimate the efficacy of brief alcohol interventions in linking people to higher levels of alcohol-related care. The researchers reported that ‘we found no evidence that brief alcohol interventions were effective in increasing the utilization of alcohol-related care. This lack of evidence calls into question the assumption that referral to treatment as part of SBI [screening and brief intervention] or SBIRT [brief intervention and referral to treatment] effectively links patients to higher levels of care for their alcohol problems’.

Glass, JE, Hamilton, AM, Powell, BJ et al. 2015, ‘Specialty substance use disorder services following brief alcohol intervention: a meta-analysis of randomized controlled trials’, Addiction, vol. 110, no. 9, pp. 1404-15.

 back to top

What is the cost to Australian businesses of alcohol and other drug related absenteeism?

An analysis of data from the Australian 2013 National Drug Strategy Household Survey estimated the cost of alcohol and other drug (AOD) related absenteeism on businesses and society in Australia. ‘Two measures of AOD-related absenteeism were used: participants’ self-reported absence due to AOD use (M1); and the mean difference in absence due to any illness/injury for AOD users compared to abstainers (M2). Both figures were multiplied by $267.70 (average day’s wage in 2013 plus 20% on-costs) to estimate associated costs’. The researchers’ findings were that ‘M1 resulted in an estimation of 2.5 million days lost annually due to AOD use, at a cost of more than $680 million. M2 resulted in an estimation of almost 11.5 million days lost, at a cost of $3 billion’. They concluded that ‘AOD-related absenteeism represents a significant and preventable impost upon Australian businesses’, and drew attention to the implications of this conclusion: ‘Workplaces should implement evidence-based interventions to promote healthy employee behaviour and reduce AOD-related absenteeism’.

Roche, A, Pidd, K & Kostadinov, V 2015, ‘Alcohol- and drug-related absenteeism: a costly problem’, Australian and New Zealand Journal of Public Health, online ahead of print.

 back to top

How can health technologies increase the effectiveness of vehicle alcohol interlocks?

Abstract: Among the earliest applications of health technologies to a safety program was the development of blood alcohol content (BAC) tests for use in impaired-driving enforcement. This led to the development of miniature, highly accurate devices that officers could carry in their pockets. A natural extension of this technology was the vehicle alcohol interlock, which is used to reduce recidivism among drivers convicted of driving under the influence (DUI) by requiring them to install the devices (which will not allow someone with a positive BAC to drive) on their vehicles. While on the vehicle, interlocks have been shown to reduce recidivism by two-thirds. Use of these devices has been growing at the rate of 10 to 15 percent a year, and there currently are more than 300,000 units in use. This expansion in the application of interlocks has benefited from the integration of other emerging technologies into interlock systems. Such technologies include data systems that record both driver actions and vehicle responses, miniature cameras and face recognition to identify the user, Wi-Fi systems to provide rapid reporting on offender performance and any attempt to circumvent the device, GPS tracking of the vehicle, and more rapid means for monitoring the integrity of the interlock system. This article describes how these health technologies are being applied in interlock programs and the outlook for new technologies and new court sanctioning programs that may influence the growth in the use of interlocks in the future.’

Voas, RB 2014, ‘Enhancing the use of vehicle alcohol interlocks with emerging technology’, Alcohol Research, vol. 36, no. 1, pp. 81-9, open access http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4432860/.
 
Comment: In recent years the ACT has expanded its range of interventions addressing drink-driving, including introducing motor vehicle ignition interlocks. This article is useful in pointing to a full range of interventions that may be appropriate in the ACT context.

 back to top

How risky is it to consume caffeine?

A paper published in the latest issue of the Australian and New Zealand Journal of Public Health draws attention to the steady increase in sales of highly caffeinated energy drinks (ED) since their introduction to the Australian market in the early 2000s and the risks associated with their use, particularly when mixed with alcohol as alcoholic energy drinks (AED). Caffeine can cause tachycardia and agitation in caffeine sensitive people. ‘The threshold for caffeine toxicity is…just 2.5 mg per kg per day in healthy children under the age of 12 years. Pregnant and lactating women and their babies are particularly susceptible to the effects of caffeine.’

The authors state that ‘it seems there is insufficient public awareness of the risks of excessive and rapid consumption of caffeine, especially for those in sensitive groups...There are additional concerns about the combination of caffeine and alcohol in ready-mixed AEDs or as bar-mixed cocktails’. They point out inconsistencies in the regulation of caffeine added to ED, AED and other products, and state ‘We contend that a more comprehensive policy response to the addition of caffeine to foods, particularly ED and AED, is needed’. They recommend the adoption of a number of measures including reducing the maximum concentration of caffeine in foods, clear and comprehensive labelling of foods containing caffeine, education campaigns to raise community awareness, restricting or banning discounts and promotions that encourage excessive use of AED, and restricting sales of highly caffeinated products.

Cowie, GA & Bolam, B 2015, ‘Commentary: An epidemic of energy? The case for stronger action on “energy drinks"’, Australian and New Zealand Journal of Public Health, vol. 39, no. 3, pp. 205-7.

 back to top

What have been the impacts abroad of raising the minimum tobacco sales age to 21 years?

Abstract:

Objective: Raising the tobacco sales age to 21 has gained support as a promising strategy to reduce youth cigarette access, but there is little direct evidence of its impact on adolescent smoking. Using regional youth survey data, we compared youth smoking trends in Needham, Massachusetts—which raised the minimum purchase age in 2005—with those of 16 surrounding communities.

Methods: The MetroWest Adolescent Health Survey is a biennial census survey of high school youth in communities west of Boston; over 16 000 students participated at each of four time points from 2006 to 2012. Using these pooled cross-section data, we used generalised estimating equation models to compare trends in current cigarette smoking and cigarette purchases in Needham relative to 16 comparison communities without similar ordinances. To determine whether trends were specific to tobacco, we also examined trends in youth alcohol use over the same time period.

Results: From 2006 to 2010, the decrease in 30-day smoking in Needham (from 13% to 7%) was significantly greater than in the comparison communities (from 15% to 12%; p<.001). This larger decline was consistent for both genders, Caucasian and non-Caucasian youth, and grades 10, 11 and 12. Cigarette purchases among current smokers also declined significantly more in Needham than in the comparison communities during this time. In contrast, there were no comparable differences for current alcohol use.

Conclusions: Our results suggest that raising the minimum sales age to 21 for tobacco contributes to a greater decline in youth smoking relative to communities that did not pass this ordinance. These findings support local community-level action to raise the tobacco sales age to 21.
 
Kessel Schneider, S, Buka, SL, Dash, K et al. 2015, ‘Community reductions in youth smoking after raising the minimum tobacco sales age to 21’, Tobacco Control, online ahead of print.
 
Comment: Although it is likely that the findings of this study cannot be directly generalised to other jurisdictions, such as those in Australia, it is a useful reminder that governments have available to it further significant reductions on the availability of tobacco products, including raising the age at which they can be legally purchased. Such initiatives are almost certainly likely to be more cost-effective than community education campaigns.

 back to top

Is there any evidence that nicotine-containing electronic cigarettes is associated with progression to tobacco smoking among adolescents?

Abstract:

Importance: Electronic cigarettes (e-cigarettes) may help smokers reduce the use of traditional combustible cigarettes. However, adolescents and young adults who have never smoked traditional cigarettes are now using e-cigarettes, and these individuals may be at risk for subsequent progression to traditional cigarette smoking.

Objective: To determine whether baseline use of e-cigarettes among nonsmoking and nonsusceptible adolescents and young adults is associated with subsequent progression along an established trajectory to traditional cigarette smoking.

Design, Setting, and Participant: In this longitudinal cohort study, a national US sample of 694 participants aged 16 to 26 years who were never cigarette smokers and were attitudinally nonsusceptible to smoking cigarettes completed baseline surveys from October 1, 2012, to May 1, 2014, regarding smoking in 2012-2013. They were reassessed 1 year later. Analysis was conducted from July 1, 2014, to March 1, 2015. Multinomial logistic regression was used to assess the independent association between baseline e-cigarette use and cigarette smoking, controlling for sex, age, race/ethnicity, maternal educational level, sensation-seeking tendency, parental cigarette smoking, and cigarette smoking among friends…

Exposures: Use of e-cigarettes at baseline.

Main Outcomes and Measures: Progression to cigarette smoking, defined using 3 specific states along a trajectory: nonsusceptible nonsmokers, susceptible nonsmokers, and smokers. Individuals who could not rule out smoking in the future were defined as susceptible.

Results: Among the 694 respondents, 374 (53.9%) were female and 531 (76.5%) were non-Hispanic white. At baseline, 16 participants (2.3%) used e-cigarettes. Over the 1-year follow-up, 11 of 16 e‑cigarette users and 128 of 678 of those who had not used e-cigarettes (18.9%) progressed toward cigarette smoking. In the primary fully adjusted models, baseline e-cigarette use was independently associated with progression to smoking…and to susceptibility among nonsmokers...

Conclusions and Relevance: In this national sample of US adolescents and young adults, use of e‑cigarettes at baseline was associated with progression to traditional cigarette smoking. These findings support regulations to limit sales and decrease the appeal of e-cigarettes to adolescents and young adults.

Primack, BA, Soneji, S, Stoolmiller, M et al. 2015, ‘Progression to traditional cigarette smoking after electronic cigarette use among us adolescents and young adults’, JAMA Pediatr, online ahead of print.
 
Comment: The study revealed that 11 of 16 young people (69%) who were e-cigarette users at the beginning of the study progressed to smoking tobacco cigarettes after one year. In contrast, just 19% of those who had not used e-cigarettes progress to smoking tobacco cigarettes. Although these differences are statistically significant, the fact that there were so few adolescents in the e‑cigarette using group at the commencement of the study suggests that its findings need to be used with caution. That said, ATODA’s position with regard to e-cigarettes accords with that of the authors with respect to the importance of restricting young people’s access to both tobacco products and e-cigarettes.


 back to top

How effective are community-based education interventions in reducing harms associated with drug injection?

An intervention study which took place in 17 cities in France was conducted in nine intervention groups (programs offering the intervention) and eight control groups (programs not offering the intervention). The intervention comprised ‘A series of participant-centred face-to-face educational sessions. Each session included direct observation by trained NGO staff or volunteers of participants’ self-injecting the psychoactive product they habitually used; analysis by the trained NGO staff or volunteers of the participant’s injecting practices, identification of injection-related risks and explanation of safer injecting practices; and an educational exchange on the individual participant’s injection practices and the questions he or she asked’. The study found that ‘The proportion of participants with at least one unsafe HIV-HCV practice in the intervention group decreased significantly, from 44% at M0 to 25% at M6, as well as complications at the injection site (from 66% to 39% at M12) while in the control group it remained mostly stable’. The researchers concluded that ‘An inexpensive and easily implemented educational intervention on risks associated with drug injection significantly reduces unsafe HIV-HCV transmission practices and injection-related complications’.

Roux, P, Le Gall, J-M, Debrus, M et al. 2015, ‘Innovative community-based educational face-to-face intervention to reduce HIV, HCV and other blood-borne infectious risks in difficult-to-reach people who inject drugs: results from the ANRS-AERLI intervention study’, Addiction, online ahead of print.

 back to top

How justifiable is it to exclude people who use alcohol or other drugs from access to new treatments for hepatitis C virus?
 
An editorial in a forthcoming issue of the Journal of Hepatology states ‘Revolutionary new drugs to cure hepatitis C virus (HCV) infection represent one of the most important breakthroughs in clinical medicine in recent decades. However, high pricing of these well-tolerated, highly efficacious all-oral regimens and high demand (actual or anticipated) has led many payers in the United States and other countries to exclude people who have recently used illicit drugs, injectable drugs or alcohol (with the definitions of “use” varying by jurisdiction) from access to these treatments’. The authors contend that it is unethical to exclude these people from access to these treatments, and conclude ‘We strongly recommend that all restrictions on access to new HCV treatments based on drug or alcohol use or opioid substitution treatment be removed. There is no good ethical or health based evidence for such discriminations. Nor do the restrictions make clinical, public health or health economic sense’.

Grebely, J, Haire, B, Taylor et al. 2015, ‘Editorial: Excluding people who use drugs or alcohol from access to hepatitis C treatments - is this fair, given the available data?’, Journal of Hepatology, online ahead of print, open access http://www.journal-of-hepatology.eu/article/S0168-8278%2815%2900406-7/fulltext.

 back to top

What information is available on pharmacy-based naloxone to reduce overdoses and improve opioid safety?

Abstract
The leading cause of adult injury death in the USA is drug overdose, the majority of which involves prescription opioid medications. Outside of the USA, deaths by drug overdose are also on the rise, and overdose is a leading cause of death for drug users. Reducing overdose risk while maintaining access to prescription opioids when medically indicated requires careful consideration of how opioids are prescribed and dispensed, how patients use them, how they interact with other medications, and how they are safely stored. Pharmacists, highly trained professionals expert at detecting and managing medication errors and drug-drug interactions, safe dispensing, and patient counseling, are an under-utilized asset in addressing overdose in the US and globally. Pharmacies provide a high-yield setting where patient and caregiver customers can access naloxone—an opioid antagonist that reverses opioid overdose—and overdose prevention counseling. This case study briefly describes and provides two US state-specific examples of innovative policy models of pharmacy-based naloxone, implemented to reduce overdose events and improve opioid safety: Collaborative Pharmacy Practice Agreements and Pharmacy Standing Orders.

Green, TC, Dauria, EF, Bratberg, J et al. 2015, ‘Orienting patients to greater opioid safety: models of community pharmacy-based naloxone’, Harm Reduction Journal, vol. 12, no. 1, open access http://www.harmreductionjournal.com/content/12/1/25 .

 back to top

How important is it for AOD services to provide clients with trauma-focused treatment?

The May 2015 issue of Drug and Alcohol Review includes a special section on the importance of providing trauma-informed care in alcohol and other drug services. The editorial points out that this approach has not been adopted in most AOD services, in part because service providers are concerned about their capacity to respond, because there has been little evidence to guide services in providing this type of care, and because there have been concerns about the well-being of the AOD workers themselves. The editor confirms that ‘research in this area has grown substantially in recent years, highlighting the importance of addressing trauma among AOD clients and demonstrating the efficacy of trauma-focused treatments’.

Mills, KL 2015, ‘Editorial: the importance of providing trauma-informed care in alcohol and other drug services’, Drug and Alcohol Review, vol. 34, no. 3, pp. 231-3.
 

 back to top

New Reports

Coghlan, S, Gannoni, A, Goldsmid, S et al. 2015, Drug Use Monitoring in Australia: 2013-14 report on drug use among police detainees, Monitoring Report no. 27, Australian Institute of Criminology, Canberra, http://aic.gov.au/publications/current%20series/mr/21-40/mr27.html.
 
Hancock-Allen, JB, Barker, L, VanDyke, M et al. 2015, ‘Notes from the Field: death following ingestion of an edible marijuana product - Colorado, March 2014’, MMWR; Morbidity and Mortality Weekly Report, vol. 64, no. 28, pp. 771-2, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6428a6.htm.
 
Intergovernmental Committee on Drugs 2015, National Aboriginal Torres Strait Islander Peoples Drug Strategy 2014-2019, IGCD, Canberra, http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/content/natsipds2014-19.
 
Intergovernmental Committee on Drugs 2015, National Alcohol and other Drug Workforce Development Strategy 2015-2018, IGCD, Canberra, http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/content/naodwds2015-18.
 
McNeill, A, Brose, L, Calder, R et al. 2015, E-cigarettes: an evidence update. A report commissioned by Public Health England, Public Health England, London, https://www.gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review.
 
NADK 2015, ‘New Cannabis section in National Alcohol & Drug Knowledgebase’ http://nadk.flinders.edu.au/kb/cannabis/.
 
New Zealand, Inter-Agency Committee on Drugs 2015, National Drug Policy 2015 to 2020, NZ Ministry of Health, Wellington, http://www.health.govt.nz/publication/national-drug-policy-2015-2020.
 
Roxburgh, A & Burns, L 2015, Drug-related hospital stays in Australia 1993–2013, National Drug and Alcohol Research Centre, Sydney, https://ndarc.med.unsw.edu.au/resource/drug-related-hospital-stays-australia-1993-2013.
 
United Kingdom, National Audit Office 2015, Outcome-based payment schemes: government’s use of payment by results, UK National Audit Office, London, http://www.nao.org.uk/report/outcome-based-payment-schemes-governments-use-of-payment-by-results/.
 
Wise, J 2015, ‘Heroin deaths increase by two thirds in two years, UK figures show’, BMJ (British Medical Journal), vol. 351, h4754, http://www.bmj.com/content/351/bmj.h4754.

 
 back to top