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.
How widespread is peer distribution of sterile injecting equipment among people who inject drugs?
Interviews were conducted with 31 members of peer distribution networks of sterile injecting equipment in NSW. Of them, ‘…five reported large-scale formal distribution, with an estimated volume of 34,970 needles and syringes annually. Twenty-two participated in reciprocal exchange, where equipment was distributed and received on an informal basis that appeared dependent on context and circumstance and four participants reported recipient peer distribution as their only access to sterile injecting equipment. Most were unaware that it was illegal to distribute injecting equipment to their peers’. The researchers concluded that ‘Peer distribution was almost ubiquitous amongst the PWID [people who inject drugs] participating in the study, and although five participants reported taking part in the highly organised, large-scale distribution of injecting equipment for altruistic reasons, peer distribution was more commonly reported to take place in small networks of friends and/or partners for reasons of convenience. The law regarding the illegality of peer distribution needs to change so that NSPs [needle and syringe programs] can capitalise on peer distribution to increase the options available to PWID and to acknowledge PWID as essential harm reduction agents in the prevention of BBVs [blood borne viruses]’.
Newland, J, Newman, C & Treloar, C 2016, ‘“We get by with a little help from our friends”: small-scale informal and large-scale formal peer distribution networks of sterile injecting equipment in Australia
’, International Journal of Drug Policy
, online ahead of print.
Comment: Last month, the Legislative Assembly for the ACT amended a number of pieces of legislation to remove the offence of supplying sterile injecting equipment without a permit to do so. ATODA and others including CAHMA have been advocating for this change and have strongly commended the ACT Government and, indeed, all the ACT legislators, on this important public health intervention. This means that extended distribution of sterile injecting equipment is legalised in the ACT.
In July 2015, ATODA hosted a roundtable, Public health and legislative amendments focused on people who inject drugs and their families and friends, which supported changes to a) enable extended distribution of sterile injecting equipment in the ACT and b) enable Good Samaritan protections for lay people who administer naloxone. The contributions of researchers (Drug Policy Modelling Program, Social Research and Evaluation, ANU’s Research School of Population Health) at the roundtable and since that time have been key in supporting evidence based drug law reform in the ACT.
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What evidence is available on the effectiveness of Australian policing interventions to reduce alcohol-related violence?
A systematic review of the literature on Australian interventions to reduce alcohol-related violence from the perspective of oral and maxillofacial (relating to the face and jaw) surgeons, assessed the effectiveness of these interventions in Australia. The researchers found that ‘The overall evidence base to support Australian policing interventions was found to be poor and was limited by the low-quality study design observed in the majority of the included studies. However, there is some evidence to suggest interventions involving proactive policing to be more effective than traditional reactive policing. There was also an increased emphasis on developing policing interventions in collaborative partnerships, demonstrating the synergistic benefits in crime prevention through community partnerships, where communities were encouraged to take ownerships of their own problems and develop targeted responses to alcohol-related violence rather than a one-size-fits-all approach’. They concluded ‘Further research is required to define their effectiveness with the use of more appropriate and robust methodologies’.
Liu, T, Ferris, J, Higginson, A & Lynham, A 2016, ‘Systematic review of Australian policing interventions to reduce alcohol-related violence—a maxillofacial perspective’, Addictive Behaviors Reports
, vol. 4, pp. 1-12, open access http://www.sciencedirect.com/science/article/pii/S2352853216300128
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How effective would an extension of the operating hours of public transport be in reducing drinking-related harms?
Using an agent-based computer simulation model, SimDrink, Australian researchers tested the effects of improved public transport (PT) and venue lockouts on verbal aggression, consumption-related harms and transport-related harms among a population of young adults engaging in heavy drinking in Melbourne. They found that ‘All-night PT reduced verbal aggression in the model by 21% but displaced some incidents among OU [outer-urban] residents from private to public settings. Comparatively, 1 am lockouts reduced verbal aggression in the model by 19% but led to IC [inner-city] residents spending more time in private rather than public venues where their consumption-related harms increased. Extending PT by two hours had similar outcomes to 24-hour PT except with fewer incidents of verbal aggression displaced. Although 3 am lockouts were inferior to 1 am lockouts, when modelled in combination with any extension of PT both policies were similar’. They concluded that ‘A two-hour extension of PT is likely to be more effective in reducing verbal aggression and consumption-related harms than venue lockouts. Modelling a further extension of PT to 24 hours had minimal additional benefits but the potential to displace incidents of verbal aggression among OU residents from private to public venues’.
Scott, N, Hart, A, Wilson, J, Livingston, M, Moore, D & Dietze, P 2016, ‘The effects of extended public transport operating hours and venue lockout policies on drinking-related harms in Melbourne, Australia: results from SimDrink, an agent-based simulation model
’, International Journal of Drug Policy
, vol. 32, pp. 44-9.
What effects have Washington State's legalisation of both medical and non-medical marijuana had on adolescents' drug use?
A study in Washington State, USA, examined the prevalence of marijuana and other substance use before and after the state’s change from legal medical marijuana to legal medical marijuana plus legal non-medical marijuana, by means of cohort comparisons in a sample of adolescents. Participants were eighth graders enrolled in targeted Tacoma, Washington public schools. They were recruited in two consecutive annual cohorts. The analysis sample was 238 students who completed a baseline survey in the eighth grade and a follow-up survey after the ninth grade. Between the two assessments, the second cohort experienced the Washington State non-medical marijuana law change, whereas the first cohort did not. Self-report survey data on lifetime and past-month marijuana, cigarette, and alcohol use were collected. The researchers found ‘that cohort differences in the likelihood of marijuana use were significantly different from those for cigarette and alcohol use at follow-up (adjusting for baseline substance initiation). Marijuana use was higher for the second cohort than the first cohort, but this difference was not statistically significant. Rates of cigarette and alcohol use were slightly lower in the second cohort than in the first cohort’. They concluded that ‘marijuana use was more prevalent among teens shortly after the transition from medical marijuana legalization only to medical and non-medical marijuana legalization, although the difference between cohorts was not statistically significant. The findings also provided some evidence of substitution effects’.
Mason, WA, Fleming, CB, Ringle, JL, Hanson, K, Gross, TJ & Haggerty, KP 2016, ‘Prevalence of marijuana and other substance use before and after Washington State’s change from legal medical marijuana to legal medical and nonmedical marijuana: cohort comparisons in a sample of adolescents
’, Substance Abuse
, vol. 37, no. 2, pp. 330-5.
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What are the links between income inequality, drug-related arrests, and the health of people who inject drugs?
This paper reviews and then discusses selected findings from a seventeen year study about the population prevalence of people who inject drugs (PWID) and of HIV prevalence and mortality among PWID in 96 large US metropolitan areas. Unlike most research, this study was conducted with the metropolitan area as the level of analysis. It found that metropolitan area measures of income inequality and of structural racism predicted all of these outcomes, and that rates of arrest for heroin and/or cocaine predicted HIV prevalence and mortality but did not predict changes in PWID population prevalence. Income inequality and measures of structural racism were associated with hard drug arrests or other properties of policing. These findings, whose limitations and implications for further research are discussed, suggest that efforts to respond to HIV and to drug injection should include supra-individual efforts to reduce both income inequality and racism. At a time when major social movements in many countries are trying to reduce inequality, racism and oppression (including reforming drug laws), these macro-social issues in public health should be both addressable and a priority in both research and action.
Friedman, SR, Tempalski, B, Brady, JE, West, BS, Pouget, ER, Williams, LD, Des Jarlais, DC & Cooper, HLF 2016, ‘Income inequality, drug-related arrests, and the health of people who inject drugs: reflections on seventeen years of research
’, International Journal of Drug Policy
, vol. 32, pp. 11-6.
Comment: ATODA is not aware of corresponding research using Australian data but assumes that the disturbing relationships documented here apply in Australia as they do in the USA. These findings remind us that effective prevention work takes place not only in the AOD sector but also in other sectors addressing the social determinants of health—including what has been called ‘primordial prevention’, i.e. interventions that aim to ‘establish and maintain conditions that minimise hazards to health’ (Bonita, R, Beaglehole, R & Kjellström, T 2006, Basic epidemiology, 2nd edn, WHO, Geneva, pp. 103-4).
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How effective is it to provide training to law enforcement officers to respond to opioid overdoses with naloxone?
An evaluation of a pilot law enforcement officers (LEOs) naloxone program in the United States assessed opioid overdose knowledge and attitudes, before and after a 30-minute training session on overdose and naloxone administration, and included qualitative interviews with LEOs who used naloxone to respond to overdose emergencies after the training. ‘Eighty-one LEOs provided pre- and post-training data. Nearly all…had responded to an overdose while serving as an LEO. Statistically significant increases were observed in nearly all items measuring opioid overdose knowledge… Opioid overdose competencies…and concerns about naloxone administration…significantly improved after the training, while there was no change in attitudes towards overdose victims…LEOs administered naloxone 11 times; nine victims survived and three of the nine surviving victims made at least one visit to substance abuse treatment as a result of a LEO-provided referral. Qualitative data suggest that LEOs had generally positive experiences when they employed the skills from the training’. The researchers concluded that ‘Training LEOs in naloxone administration can increase knowledge and confidence in managing opioid overdose emergencies. Perhaps most importantly, training LEOs to respond to opioid overdose emergencies may have positive effects for LEOs and overdose victims’.
Wagner, KD, Bovet, LJ, Haynes, B, Joshua, A & Davidson, PJ 2016, ‘Training law enforcement to respond to opioid overdose with naloxone: impact on knowledge, attitudes, and interactions with community members
’, Drug and Alcohol Dependence
, vol. 165, pp. 22-8.
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What are the impacts of needle and syringe programs and methadone maintenance therapy on incidence rates of HIV in the general population and among people who inject drugs?
Although many studies have found an association between harm reduction interventions and reductions in incidence rates of Human Immunodeficiency Virus (HIV) infection, scant research explores the effects of harm reduction cross-nationally. This study used a year- and country-level fixed effects model to estimate the potential effects of needle-and-syringe programs (NSPs) and methadone maintenance therapy (MMT) on incidence rates of HIV in the general population and among people who inject drugs (PWID), in a sample of 28 European nations. After adjusting for Gross Domestic Product (GDP) and total expenditures on healthcare, we identified significant associations between years of MMT and NSP implementation and lower incidence rates of HIV among PWID and the general population. In addition to years of implementation of NSP and MMT, the greater proportion of GDP spent on healthcare was associated with a decrease in logged incidence rates of HIV. The findings of this study suggest that MMT and NSP may reduce incidence rates of HIV among PWID cross-nationally. The current study opens a new avenue of exploration, which allows for a focus on countrywide policies and economic drivers of the epidemic. Moreover, it highlights the immense importance of the adoption of harm reduction programs as empirically-based health policy as well as the direct benefits that are accrued from public spending on healthcare on incidence rates of HIV within the general population and among subpopulations of PWID.
Marotta, PL & McCullagh, CA 2016, ‘A cross-national analysis of the effects of methadone maintenance and needle and syringe program implementation on incidence rates of HIV in Europe from 1995 to 2011’, International Journal of Drug Policy
, vol. 32, pp. 3-10, open access http://www.ijdp.org/article/S0955-3959(16)30015-9/fulltext
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To what extent are lecture-based educational programs effective in reducing drink-driving recidivism?
A randomised controlled trial in Switzerland measured the effects of lecture-based educational programs in reducing drink-driving recidivism. ‘Of 1588 drivers in the Canton of Geneva convicted of a first-time offence with a blood alcohol concentration (BAC) of between 0.80 and 2.49 g/kg from May 2001 to February 2004, 727 agreed to participate and were randomly assigned to either a seven-hour series of lectures, a four-hour series with a friend or close relative, or a brief two-hour lecture. Time until recidivism was retrieved from a national registry that contains details of recidivism that took place up to ten years after the first offence’. The findings were ‘Significant effects of briefer lectures over the standard day-long series of lectures were observed only during the most influential time period with regards to recidivism levels—the two years following the intervention. Replacing the usual one-day series of lectures by briefer two-hour lectures would reduce, by 25%...the risk of recidivism’. The researchers concluded that ‘This study does not support policymakers’ decision to rely on a seven-hour series of lectures to decrease DUI [driving under the influence of alcohol] recidivism. The advantages of shorter lectures over no lecture still need to be evaluated’.
Vaucher, P, Michiels, W, Joris Lambert, S, Favre, N, Perez, B, Baertschi, A, Favrat, B & Gache, P 2016, ‘Benefits of short educational programmes in preventing drink-driving recidivism: a ten-year follow-up randomised controlled trial
’, International Journal of Drug Policy
, vol. 32, pp. 70-6.
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What evidence is available on the use of harm minimisation drug treatment programs in criminal justice settings?
This scoping review sought to map the emerging evidence on use of harm minimization drug treatment programs in criminal justice settings. A search of various data bases including Cochrane Database of Systematic Reviews Medline, ProQuest, SAGE Premier, Scopus, Taylor & Francis Online, and Web of Science yielded eight studies that met inclusion criteria. The available evidence suggests increasing adoption of harm minimization policy oriented programs by countries around the world. Specific programs adopted include needle and syringe exchange, methadone maintenance, buprenorphine maintenance and treatment in lieu of incarceration. Each of these programs has evidence to support their effectiveness in relation to individual harm reduction, disease reduction, increase treatment retention and reduced criminality. This article considers implications of the adoption of harm minimization policies by criminal justice systems.
Resiak, D, Mpofu, E & Athanasou, J 2016, ‘Drug treatment policy in the criminal justice system: a scoping literature review
’, American Journal of Criminal Justice
, vol. 41, no. 1, pp. 3-13.
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To what extent is outpatient treatment engagement associated with a reduced likelihood of subsequent detoxification admission?
A study in Massachusetts, USA, used data on over 11,000 clients who commenced outpatient treatment for a substance use disorder in 2006. Treatment engagement was defined as receipt of at least one treatment service within 14 days of beginning a new outpatient treatment episode and receipt of at least two additional treatment services in the next 30 days. The outcome was a subsequent detoxification admission. The researchers found that ‘Only 35% of clients met the outpatient engagement criteria, and 15% of clients had a detoxification admission within a year after beginning their outpatient treatment episode. Controlling for client demographics, insurance type, and substance use severity, clients who met the engagement criteria had a lower hazard of having a detoxification admission during the year following the index outpatient visit than those who did not engage’. The researchers concluded that ‘Treatment engagement is a useful measure for monitoring quality of care’.
Acevedo, A, Garnick, D, Ritter, G, Lundgren, L & Horgan, C 2016, ‘Admissions to detoxification after treatment: does engagement make a difference?
’, Substance Abuse
, vol. 37, no. 2, pp. 364-71.
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How effective is the Australian Stepping Stones program in assisting family members to cope with problematic drug use in the family?
‘Stepping Stones is primarily designed for people who have been dealing with another’s chronic long-term addiction; around 90% of participants are parents of adult children, with an average age around 50, of which approximately two-thirds are mothers. Partners, siblings, adult children, grandparents and friends comprise the balance. Recently there has been an increase in participation by partners of newly retired men, where retirement is accompanied by substantially increased alcohol or marijuana use.
‘Stepping Stones combines information sessions, participant sharing, experiential learning and group work. It aims to support the development of effective coping, and a more hopeful and enjoyable life regardless of the substance user’s actions. Participants identify the stage they are at, and share their expertise, experiences and emotional responses. This process helps them to understand the typical stages families experience, and that their feelings are normal.’
‘Problematic substance use by an individual is often highly destructive to their family, creating emotional turmoil and destroying healthy family functioning. The aim of this study was to evaluate the impact of participation in the Stepping Stones family support program on the coping capacity of family members affected by another’s substance use…A pre and post study of the Stepping Stones intervention for families was conducted, involving 108 participants recruited from March 2013 to March 2014…Significant improvement in coping across all domains was observed post course and at follow up on both outcome measures (Coping Questionnaire and the Family Drug Support Questionnaire). Improvements for participants were either increased or sustained at 3 months follow up. Participants recorded high satisfaction ratings…The findings from this study demonstrate that participation in the Stepping Stones program assists family members to cope better with problematic substance use of a family member, as indicated by reductions in negative coping strategies, such as over-engagement, making excuses for the drug user or hopelessly tolerating the problem, and improvements in positive coping strategies such as self-care and engagement with their own activities and interests.’
Gethin, A, Trimingham, T, Chang, T, Farrell, M & Ross, J 2016, ‘Coping with problematic drug use in the family: an evaluation of the Stepping Stones program’
, Drug and Alcohol Review
, vol. 35, no. 4, pp. 470-6.
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'After 30 years of dissemination, have we achieved sustained practice change in motivational interviewing'?
Melbourne-based scholars point out that, in their views, ‘Motivational interviewing (MI) is the most successfully disseminated evidence-based practice in the substance use disorder (SUD) treatment field’. This led them to undertake a systematic review of the literature, addressing two questions of importance to both policymakers and service providers: 1) does training in MI achieve sustained practice change in clinicians delivering SUD treatment; and 2) do clinicians achieve a level of competence after training in MI that impacts upon client outcomes? They defined sustained practice change as being when over 75% of people trained in MI met beginning proficiency in MI spirit at a follow-up time-point.’ They found that, ‘Of the 20 studies identified, 15 measured training at a follow-up time-point using standard fidelity measures. The proportion of clinicians who reached beginning proficiency was either reported or calculated for 11 of these studies. Only two studies met our criterion of 75% of clinicians achieving beginning proficiency in MI spirit after training. Of the 20 studies identified, two measured client substance use outcomes with mixed results.’ This led the authors to conclude that ‘A broad range of training studies failed to achieve sustained practice change in MI according to our criteria. It is unlikely that 75% of clinicians can achieve beginning proficiency in MI spirit after training unless competency is benchmarked and monitored and training is ongoing. The impact of training on client outcomes requires future examination.’
Hall, K, Staiger, PK, Simpson, A, Best, D & Lubman, DI 2016, ‘After 30 years of dissemination, have we achieved sustained practice change in motivational interviewing?
, vol. 111, no. 7, pp. 1144-50.
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What evidence is available on parental drinking and adverse outcomes for children?
A systematic review of the literature on the consequences for children of parental alcohol use, and the limitations and gaps in this literature, found that ‘Adolescent drinking behaviour was the most common outcome measure and outcomes other than substance use were rarely analysed. In almost two of every three published associations, parental drinking was found to be statistically significantly associated with a child harm outcome measure. Several limitations in the literature are noted regarding its potential to address a possible causal role of parental drinking in children’s adverse outcomes’.
Rossow, I, Felix, L, Keating, P & McCambridge, J 2016, ‘Parental drinking and adverse outcomes in children: a scoping review of cohort studies
’, Drug and Alcohol Review
, vol. 35, no. 4, pp. 397-405.
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What are the views of people who inject drugs on the use of pre-exposure prophylaxis for HIV by people who are HIV-negative to protect themselves against acquiring HIV?
Background and aims:
Pre-exposure prophylaxis for HIV, or ‘PrEP’, is the use of antiretroviral medicines by people who are HIV-negative to protect themselves against acquiring HIV. PrEP has shown efficacy for preventing HIV acquisition. Despite the potential, many concerns have been voiced by people who inject drugs (PWID) and their organizations. There is a need to engage with these views and ensure their integration in to policy and strategy. This paper presents PWID views on PrEP to foster the uptake of these opinions into scientific and policy debate around PrEP
: Critical analysis of a report of a community consultation led by the International Network of People who Use Drugs (INPUD).
: The INPUD report highlights enthusiasm from PWID for PrEP, but also three main concerns: the feasibility and ethics of PrEP, its potential use as a substitute for other harm reduction strategies and how a focus on PrEP heralds a re-medicalization of HIV. Each concern relates to evidenced gaps in essential services or opposition to harm reduction and PWID human rights.
: People who use drugs have fundamental concerns about the potential impacts of pre-exposure prophylaxis for HIV which reflect a ‘fault line’ in HIV prevention: a predominance of biomedical approaches over community perspectives. Greater community engagement in HIV prevention strategy is needed, or we risk continuing to ignore the need for action on the underlying structural drivers and social context of the HIV epidemic.
Guise, A, Albers, ER & Strathdee, SA 2016, ‘“PrEP is not ready for our community, and our community is not ready for PrEP”: pre-exposure prophylaxis for HIV for people who inject drugs and limits to the HIV prevention response’
, online ahead of print.
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To what extent is heavy cannabis use associated with elevated risk of stroke?
Researchers based at the Australian Capital Territory Centre for Research on Ageing, Health and Wellbeing, Australian National University, used data from a general population survey of Australians aged 20-24 years, 40-44 years and 60-64 years to determine the odds of lifetime stroke or transient ischemic attack (TIA) among participants who had smoked cannabis in the past year, while adjusting for other stroke risk factors. They found that ‘There were 153 stroke/TIA cases…After adjusting for age cohort, past year cannabis users…had 3.3 times the rate of stroke/TIA…The incidence rate ratio reduced to 2.3 after adjustment for covariates related to stroke, including tobacco smoking… Elevated stroke/TIA was specific to participants who used cannabis weekly or more often…with no elevation among participants who used cannabis less often. They concluded that ‘Heavy cannabis users in the general community have a higher rate of non-fatal stroke or transient ischemic attack than non-cannabis users’.
Hemachandra, D, McKetin, R, Cherbuin, N & Anstey, KJ 2016, ‘Heavy cannabis users at elevated risk of stroke: evidence from a general population survey
’, Australian and New Zealand Journal of Public Health
, vol. 40, no. 3, pp. 226-30.
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Is the 'brain disease' model of addiction helpful or harmful?
‘The world, led by the United States, is hell bent on establishing the absence of choice in addiction, as expressed by the defining statement that addiction is a “chronic relapsing brain disease” (my emphasis). The figure most associated with this model, the director of the American National Institute on Drug Abuse, Nora Volkow, claims that addiction vitiates free will through its effects on the brain. In reality, while by no means a simple task, people regularly quit their substance addictions, often by moderating their consumption, usually through mindfulness-mediated processes... Ironically, the brain disease model’s ascendance in the U.S. corresponds with epidemic rises in opiate addiction, both painkillers…and heroin…, as well as heroin, painkiller, and tranquilizer poisoning deaths... More to the point, the conceptual and treatment goal of eliminating choice in addiction and recovery is not only futile, but iatrogenic. Indeed, the National Institute on Alcohol Abuse and Alcoholism’s epidemiological surveys, while finding natural recovery for both drug and alcohol disorders to be typical, has found a decline in natural recovery rates…and a sharp increase in [alcohol use disorders]...’
‘People regularly quit addictions, including often by cutting down their consumption in the case of alcohol. Yet these phenomena—self-cure and moderation—are little noted in the dominant neuroscientific paradigm of addiction. Indeed, it may be impossible for this paradigm to accommodate these phenomena, which dominate both our lived experience and epidemiological data...
‘To form a realistic, useful scientific and policy approach to addiction we must instead recognize:
- Change in addictive behavior is usually self-initiated and self-propelled—i.e., mindful.
- Convincing people that they are not able to control their behavior is counterproductive.
- The dominant model of addiction, viewing people as passive victims, fuels addiction.’
Peele, S 2016, ‘People control their addictions no matter how much the “chronic” brain disease model of addiction indicates otherwise; we know that people can quit addictions—with special reference to harm reduction and mindfulness’, Addictive Behaviors Reports
, online ahead of print, open access http://www.sciencedirect.com/science/article/pii/S235285321630013X
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ACT Health 2016, Australian Capital Territory Chief Health Officer’s Report 2016, ACT Government, Canberra, http://www.health.act.gov.au/datapublications/reports/chief-health-officers-report-2016 large file warning: 5.6 MB
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---- 2016, Alcohol and other drug treatment services in Australia 2014–15: state and territory summaries, AIHW, Canberra, http://aihw.gov.au/publication-detail/?id=60129554768.
---- 2016, Medication use by Australia’s prisoners 2015: how is it different from the general community?, Bulletin no. 135, Cat. no. AUS 202, AIHW, Canberra, http://www.aihw.gov.au/publication-detail/?id=60129555362.
Bewley-Taylor, D, Jelsma, M, Rolles, S & Walsh, J 2016, Cannabis regulation & the UN drug treaties: strategies for reform, Global Drug Policy Observatory (GDPO), Swansea University, Swansea, Wales, http://www.swansea.ac.uk/gdpo/projectpages/cannabispolicyintheusimplicationsandpossibilities/.
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---- 2016, ACT trends in ecstasy and related drug markets 2015. Findings from the Ecstasy and Related Drugs Reporting System, Australian Drug Trend Series no. 156, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, http://www.drugtrends.org.au/reports/report-act-drug-trends-2015-findings-from-the-ecstasy-and-related-drugs-reporting-system-edrs/.
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