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 paper, prepared by some of the key instigators and the evaluators of the ACT’s naloxone program, looks back on how the program was developed. It notes that ‘Since the mid 1990s there have been calls to make naloxone, a prescription–only medicine in many countries, available to heroin and other opioid users, their peers and family members to prevent overdose deaths’ but little progress was seen in this direction until the ACT program came to life as a collaborative activity between a number of different organisations, under the leadership of Canberra Alliance for Harm Minimisation and Advocacy (CAHMA), facilitated by ATODA.
The paper discusses the early implementation of the Canberra program and how, subsequently, prescription naloxone programs were commenced in four of Australia’s states. It concludes that ‘The development of Australia’s first take-home naloxone program in the ACT has been an “ice-breaker” for development of other Australian programs. Issues to be addressed to facilitate future scale-up of naloxone programs concern: scheduling and cost; legal protections for lay administration; prescribing as a barrier to scale-up; intranasal administration; worker administration; and collaboration between key stakeholders.
Although all drug policy researchers hope that the products of their endeavours will be used to create policy changes, it is not often that one sees this occurring directly, owing to the diversity of influences that come to bear in any policy domain. This study is an exception. Drug Policy Modelling Program researchers, supported by ATODA, undertook a study for the ACT Attorney-General’s portfolio to develop evidence-based advice on determining what should be the threshold amounts for trafficable, commercial and large commercial drug offences. This reflected a long-standing perception that the existing thresholds could well have the effect of treating some drug users as traffickers and, conversely, some traffickers as users. The researchers analysed diverse information sources, including the amounts and patterns of purchasing and possessing illicit drugs in the ACT, to produce well supported recommendations for consideration by the ACT Government. Subsequently, the government legislated to change the consumer/provider thresholds for most of the illegal drugs, largely in accordance with the researchers’ recommendations. (Although the report is dated 2011, that being when it was submitted, its publication was withheld until the government made its decisions on the recommendations contained therein, and legislated accordingly.)
In highlighting this report, ATODA commends its authors, the responsible ACT public servants and the ACT Attorney-General and his staff, for their work in this area of drug policy. It is an excellent example of using research to produce sound, evidence-based policy in a complex area domain. ATODA is confident that the legislative changes that have been introduced make ACT drugs legislation fairer, and more likely to attain its societal goals, than was a position in the past.
What have been the effects of introducing random breath testing in Australia after taking into account reductions in the minimum legal drinking age?
This study used time series analyses of traffic fatalities in four Australian states (NSW, Vic., Qld and WA) over the period 1951 to 2010 to answer three research questions:
- What were the long-term effects of the introduction of random breath testing (RBT) on trafﬁc fatalities in the four Australian states?
- How did the effects of RBT vary across three different age groups: 17-20 years, 21-30 years and 31- 39 years?
- How did the lowering of the minimum legal drinking age (MLDA) affect trafﬁc fatalities in Qld and WA?
The study revealed that ‘RBT has substantially reduced traffic fatalities in all four states since it was introduced, particularly among the 17-year-olds to 20-year-olds and 21-year-olds to 30-year-olds. New South Wales received the biggest total net effect from RBT implementation on traffic deaths. By contrast, RBT produced only a modest reduction in traffic fatalities among 30-year-olds to 39-year-olds. Lowering the MLDA was associated with significant increases in traffic fatalities among 17-year-olds to 39-year-olds in Queensland and Western Australia…Controlling for the declining trend in traffic fatalities, the effects of changes in the MLDA law, the implementation of RBT has generated a huge effect, preventing an estimated 5279 traffic crash deaths in four Australian states. This provides further evidence that the implementation of RBT and increases in the MLDA are effective policies for reducing traffic fatalities.’
Jiang, H, Livingston, M & Manton, E 2014, ‘The effects of random breath testing and lowering the minimum legal drinking age on traffic fatalities in Australian states’
, Injury Prevention
, online ahead of print.
Comment: This is an important study differentiating, for the first time, between the effects on road crash mortality in young adults of introducing random breath testing and reducing the minimum legal drinking ages. Combined with evidence from abroad (particularly the USA) it is now absolutely clear that reducing the minimum legal drinking ages has been a public health disaster, particularly impacting on young people. Perhaps it is time for attention to be directed towards raising the minimum legal drinking ages in Australia to 21 years, as has occurred in some other jurisdictions?
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How effective is web-based multimedia training for primary care providers in screening, intervention and referral to treatment for alcohol, tobacco and other drugs?
Researchers based in Washington State, USA, evaluated web-based multimedia training for primary care providers in screening, brief intervention and referral to treatment (SBIRT) programs for unhealthy use of alcohol, tobacco, and other drugs. ‘Physicians (n=37), physician assistants (n=35), and nurse practitioners (n=20) were recruited nationally by email and randomly assigned to online access to either the multimedia training or comparable reading materials. At baseline, compared to non-physicians, physicians reported lower self-efficacy for counseling patients regarding substance use and doing so less frequently. All provider types in both conditions showed significant increases in SBIRT-related knowledge, self-efficacy, and clinical practices. Although the multimedia training was not superior to the reading materials with regard to these outcomes, the multimedia training was more likely to be completed and rated more favorably.’ Their findings ‘indicate that SBIRT training does not have to be elaborate to be effective. However, multimedia training may be more appealing to the target audiences’.
Stoner, SA, Mikko, AT & Carpenter, KM 2014, ‘Web-based training for primary care providers on screening, brief intervention, and referral to treatment (SBIRT) for alcohol, tobacco, and other drugs
’, Journal of Substance Abuse Treatment
, vol. 47, no. 5, pp. 362-70.
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How effective are web-based interventions for amphetamine-type stimulant problems?
A team of Australian researchers conducted a randomised controlled trial to evaluate the effectiveness of a web-based intervention for amphetamine-type stimulant (ATS) problems on a free-to-access site compared with a waitlist control group. ‘The primary outcome measure was self-reported ATS use in the past three months assessed using the Alcohol, Smoking, Substance Involvement Screening Test (ASSIST). Other measures included quality of life (EUROHIS score), psychological distress (K-10 score), days out of role, poly-drug use, general help-seeking intentions, actual help-seeking, and “readiness to change”. The intervention consisted of three fully automated, self-guided modules based on cognitive behavioral therapy and motivation enhancement’. The researchers found that ‘The pre/post change effect sizes showed small changes… favoring the intervention group for poly-drug use, distress, actual help-seeking, and days out of role. In contrast, the control group was favored by reductions in ATS use, improvements in quality of life, and increases in help-seeking intentions.’ They concluded that ‘This Web-based intervention for ATS use produced few significant changes in outcome measures. There were moderate, but nonsignificant reductions in poly-drug use, distress, days partially out of role, and increases in help-seeking. However, high levels of participant attrition, plus low levels of engagement with the modules, preclude firm conclusions being drawn on the efficacy of the intervention and emphasize the problems of engaging this group of clients in a fully automated program’.
Tait, RJ, McKetin, R, Kay-Lambkin, F, Carron-Arthur, B, Bennett, A, Bennett, K, Christensen, H & Griffiths, KM 2014, ‘A web-based intervention for users of amphetamine-type stimulants: 3-month outcomes of a randomized controlled trial
’, JMIR Mental Health
, vol. 1, no. 1, p. e1.
To what extent do drug-related internet discussion forums contribute to harm reduction?
Swedish researchers studied the discussions about novel psychoactive substances (NPS) on three international internet forums. ‘Four themes emerged during the analysis: (1) uncovering the substance facts, (2) dosage and administration, (3) subjectively experienced effects, and (4) support and safety. The first theme dealt primarily with substance identification, pharmacology, and assessed not only purity but also legal status and acquisition. The second theme focused on administration techniques, dose recommendations, technical talk about equipment, and preferred settings for drug use. The third theme involved a multitude of self-reported experiences, in which many different aspects of intoxication were depicted in great detail. The users emphasized both positive and negative experiences. The last theme incorporated the efforts of the communities to prevent and minimize harm by sharing information about potential risks of the harmful effects or contraindications of a substance. Also, online support and guidance were given to intoxicated persons who experienced bad or fearful reactions.’ They concluded that ‘The findings showed that the discussions were characterized by a social process in which users supported each other and exchanged an extensive and cumulative amount of knowledge about NPS and how to use them safely. Although this publicly available knowledge could entail an increase in drug use, the main characteristics of the discussions in general were a concern for safety and harm reduction, not for recruiting new users. Drug-related Internet forums could be used as a location for drug prevention, as well as a source of information for further research about NPS’.
Soussan, C & Kjellgren, A 2014, ‘Harm reduction and knowledge exchange-a qualitative analysis of drug-related Internet discussion forums
’, Harm Reduction Journal
, vol. 11, no. 25.
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How effective are internet-based interventions for smoking cessation for people of low socioeconomic status?
A randomised controlled trial in the United Kingdom assessed a new interactive internet-based intervention (StopAdvisor) for smoking cessation that was designed with particular attention directed to people with low socioeconomic status. ‘The primary outcome was 6 month sustained, biochemically verified abstinence. The main secondary outcome was 6 month, 7 day biochemically verified point prevalence.’ The findings were ‘StopAdvisor was more effective than an information-only website in smokers of low, but not high, socioeconomic status. StopAdvisor could be implemented easily and made freely available, which would probably improve the success rates of smokers with low socioeconomic status who are seeking online support’.
Brown, J, Michie, S, Geraghty, AWA, Yardley, L, Gardner, B, Shahab, L, Stapleton, JA & West, R 2014, ‘Internet-based intervention for smoking cessation (StopAdvisor) in people with low and high socioeconomic status: a randomised controlled trial’, The Lancet Respiratory Medicine
, online ahead of print, open access http://www.thelancet.com/journals/lanres/article/PIIS2213-2600%2814%2970195-X/fulltext
Are people who use e-cigarettes more or less likely to give up smoking tobacco cigarettes?
Research undertaken in Indiana and Texas, USA, investigated whether or not e-cigarette use increases smoking cessation. This was a longitudinal study, a relatively powerful research design for answering this type of question. ‘Representative samples of adults in two U.S. metropolitan areas were surveyed in 2011/2012 about their use of novel tobacco products. In 2014, follow-up interviews were conducted with 695 of the 1374 baseline cigarette smokers who had agreed to be re-contacted (retention rate: 51%). The follow-up interview assessed their smoking status and history of electronic cigarette usage…At follow-up, 23% were intensive users, 29% intermittent users, 18% had used once or twice, and 30% hadn’t tried e-cigarettes. Logistic regression controlling for demographics and tobacco dependence indicated that intensive users of e-cigarettes were 6 times as likely as non-users/triers to report that they quit smoking...No such relationship was seen for intermittent users. There was a negative association between intermittent e-cigarette use and one of two indicators of motivation to quit at follow-up.’ The researchers concluded that the ‘Results of this study demonstrate that intensive use of e-cigarettes is significantly associated with a higher rate of quitting smoking relative to smokers who never tried e-cigarettes or merely used them once or twice. To use e-cigarettes daily for a month or more suggests that the user has made a commitment to the new product, and it is among these users that we see a significantly increased rate of sustained abstinence. In contrast, intermittent use, which may reflect experimentation or temporary substitution of e-cigarettes for tobacco cigarettes in order to cope with periodic environmental demands, is not associated with cessation at a rate greater than non-use’.
Biener, L & Hargraves, JL 2014, ‘A longitudinal study of electronic cigarette use in a population-based sample of adult smokers: association with smoking cessation and motivation to quit
’, Nicotine & Tobacco Research
, online ahead of print.
Comment: The ACT Government is currently conducting a public consultation about policy on the e-cigarettes and related alternative nicotine delivery systems in the ACT: http://health.act.gov.au/consumers/community-consultation/personal-vaporisers-e-cigarettes . Although the research evidence remains inconclusive about the effectiveness of these products (when they contain nicotine) as smoking cessation devices, studies such as the one reported upon here are adding to the body of knowledge in this domain.
How likely is it that pulmonary tuberculosis can be transmitted by the sharing of a marijuana water pipe?
: New cases of pulmonary tuberculosis (TB) were noted in a cluster of young Caucasian males, an unusual ethnic group for this disease in Queensland, Australia. It was noted that marijuana water pipe ('bong') smoking was common amongst cases and contacts.
: To report this cluster of TB and to investigate whether shared use of a marijuana water pipe was associated with transmission of TB.
: All contacts were identified and screened according to standard protocols. Cases were asked to list contacts with whom they had shared a marijuana water pipe.
: Five cases of open pulmonary TB were identified clinically and on sputum culture, and all isolates of Mycobacterium tuberculosis were identical on typing. Of 149 contacts identified, 114 (77%) completed screening, and 57 (50%) had significant tuberculin skin test (TST) reactions on follow-up. Of 45 contacts who had shared a marijuana water pipe with a case, 29 (64%) had a significant TST reaction.
: Sharing a marijuana water pipe with a case of pulmonary TB was associated with transmission of TB (OR 2.22, 95 % CI 0.96-5.17), although the most important risk factor for acquiring TB infection in this cluster was close household contact with a case.
Munckhof, WJ, Konstantinos, A, Wamsley, M, Mortlock, M & Gilpin, C 2003, ‘A cluster of tuberculosis associated with use of a marijuana water pipe
’, International Journal of Tuberculosis & Lung Disease
, vol. 7, no. 9, pp. 860-5.
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How effective is heroin-assisted treatment in improving the lives of people who inject drugs?
A qualitative study of randomised trials of heroin-assisted treatment (HAT) of opioid dependence examined the way that the trials affected the lives of people who inject drugs (IDUs) in Vancouver, Canada. The research entailed 16 in-depth interviews with trial participants. The researcher found that ‘the randomized trials reduce criminal activity, sex work, and illicit drug use. In addition, the trials improved the health and social functioning of its clients, with some participants acquiring work or volunteer positions. Many of the participants have been able to reconnect with their family members, which was not possible before the program. Furthermore, the relationship between the staff and patients at the project appears to have transformed the behavior of participants. Attending HAT in Vancouver has been particularly effective in creating a unique microenvironment where IDUs who have attended HAT have been able to form a collective identity advocating for their rights’.
Jozaghi, E 2014, ‘“SALOME gave my dignity back”: the role of randomized heroin trials in transforming lives in the Downtown Eastside of Vancouver, Canada
’, International Journal of Qualitative Studies on Health and Well-being
, vol. 9, p. 23698.
Comment: The evidence from numerous studies of heroin-assisted treatment, implemented in diverse settings, is strong enough that we can conclusively say that this should be available to all heroin-dependent people who are not able to benefit from standard therapies. This qualitative research confirms the findings of the many more quantitative studies on the topic. ‘SALOME’ is the name of one of the most prominent trials: Vancouver’s ‘Study to Assess Longer-term Opioid Medication Effectiveness’ http://www.providencehealthcare.org/salome/index.html.
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What is the impact on mortality of people treated with oral naltrexone in Australia?
Naltrexone is an opioid receptor antagonist used in the management of alcohol dependence. In Australia some doctors use it to treat opioid dependence, offered in the form of sustained-release implants, accessing the medication under the TGA’s Special Access Scheme (SAS) as it is not approved, in Australia, for this purpose. (Naltrexone should not be confused with naloxone; the latter is used to revive people who are experiencing an opioid-induced overdose.) Researchers estimated the number of deaths that would have occurred among patients receiving oral naltrexone for opioid use if those patients had received methadone instead of naltrexone. Data were analysed from 1,097 Western Australian patients who received oral naloxone during the period 1998 to 2000, and all participants in the WA (n = 2,520) and NSW (n = 11,174) methadone programs over the same period. They calculated mortality rates among patients receiving naltrexone and methadone, and excess mortality among patients receiving naltrexone.
The study found that ‘Oral naltrexone patients had higher mortality than those treated with methadone, even when favourable assumptions were made about the effects of naltrexone on mortality. Total oral naltrexone mortality was significantly greater than for methadone in WA…and NSW...Among 1097 oral naltrexone patients we estimate that there were 25–29 deaths over two years that would probably not have occurred if these patients had received methadone. The major reason was higher mortality rate post-treatment cessation…. Large-scale use of oral naltrexone to treat opioid users may not have, as intended, saved lives. Implant naltrexone continues to be prescribed under the SAS in the absence of reliable efficacy and safety data. There is a need to review widespread use of unregistered medications under the SAS, particularly with vulnerable patient groups.’
Degenhardt, L, Larney, S, Kimber, J, Farrell, M & Hall, W 2014, ‘Excess mortality among opioid-using patients treated with oral naltrexone in Australia
’, Drug and Alcohol Review
, online ahead of print.
Comment: ATODA’s policy on naltrexone treatment of opioid dependence is online at http://www.atoda.org.au/policy/naltrexone/ . In the absence of research evidence for its effectiveness, and in light of the type of evidence cited above regarding adverse consequences including elevated mortality, ATODA continues to oppose the provision of the drug under the Special Access Scheme.
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What types of interventions are effective in reducing non-attendance in substance abuse services?
A review in the United Kingdom of interventions targeting non-attendance in drug treatment services found that ‘Both fixed value and intermittent reinforcement contingency management demonstrate potential for improving attendance…CM is a behavioural intervention based on the principles of reinforcement to target abstinence, medication adherence, goal performance or treatment attendance’. The researchers reported that ‘Appointment reminders by letter or telephone have demonstrated moderate evidence for improving attendance in substance-abusing populations. Text message appointment reminders are extensively utilised in general health-care settings and consistently improve attendance; however, there is a paucity of research examining the feasibility and effectiveness of text message reminders in addiction services’. They concluded ‘Non-attendance remains a persistent issue for addiction services. While there is limited evidence that contingency management improves attendance, more rigorous research is needed to determine the optimal intervention components and effectiveness in different populations, particularly those receiving maintenance treatments. Multicomponent text message interventions incorporating different delivery and content strategies demonstrate a promise for improving non-attendance and poor engagement’.
Milward, J, Lynskey, M & Strang, J 2014, ‘Solving the problem of non-attendance in substance abuse services
’, Drug and Alcohol Review
, online ahead of print.
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What size is a glass of wine?
An Australian researcher investigated the average self-reported size of a self-poured glass of wine for Australians aged 16 and over. ‘Cross-sectional survey data were taken from the first wave of the Australian arm of the International Alcohol Control study administered to 2020 Australians aged 16 and over with an oversampling of heavy drinkers. Respondents were asked about their usual consumption in eight locations, with specific questions asked about drink type and how much they consumed. The 639 respondents who stated that they drank bottled wine purchased at off-licensed premises by the glass were asked “How many glasses do you get to a bottle?”’ The findings were ‘On average, small, generic-sized and large glasses were 144, 156 and 166 mL respectively, with an average glass size of 154 mL overall’. The researcher concluded ‘Wine drinkers may be underestimating their own consumption due to large glass sizes, and survey data estimates of wine consumption should also be adjusted to account for glass size. The way a standard drink of wine is presented in health promotion materials should also be considered in light of these findings’.
Callinan, S 2014, ‘How big is a self-poured glass of wine for Australian drinkers?
’, Drug and Alcohol Review
, online ahead of print.
Comment: Should we reconsider the concept of the standard drink? Perhaps, rather than it being the amount of an alcoholic beverage that contains 10 g of pure alcohol, it should be the average amount of the beverage that people standardly drink?
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Are socioeconomically-advantaged people more or less likely to engage in alcohol-related risk-taking behaviours than people in low socioeconomic positions?
A substantial body of research exists demonstrating that low socioeconomic position is a predictor of negative outcomes from alcohol consumption, while alcohol consumption itself does not exhibit a strong social gradient. A Drug Policy Modelling Program study examined socioeconomic differences in self-reported alcohol-related risk-taking behaviour to explore whether differences in risk-taking while drinking may explain some of the socioeconomic disparities in alcohol-related harm, using data from the 2010 Australian National Drug Strategy Household Survey. The researcher found that ‘Socioeconomically advantaged respondents reported substantially higher rates of alcohol-related hazardous behaviour [for example, operating a boat or driving a motor vehicle] than socioeconomically disadvantaged respondents. Controlling for age, sex, volume of drinking and frequency of heavy drinking, respondents living in the most advantaged quintile [i.e. 20%] of neighbourhoods reported significantly higher rates of hazardous behaviour than those in the least advantaged quintile. A similar pattern was evident for household income’. The conclusion of the study was that ‘Socioeconomically advantaged Australians engage in alcohol-related risky behaviour at higher rates than more disadvantaged Australians even with alcohol consumption controlled. The significant socioeconomic disparities in negative consequences linked to alcohol consumption cannot in this instance be explained via differences in behaviour while drinking. Other factors not directly related to alcohol consumption may be responsible for health inequalities in outcomes with significant alcohol involvement’.
Livingston, M 2014, ‘Socioeconomic differences in alcohol-related risk-taking behaviours
’, Drug and Alcohol Review
, online ahead of print.
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How does wastewater testing compare to random urinalysis as a method of monitoring illicit drug use in prisons?
A study in Oregon, USA, compared wastewater testing with random urinalysis (RUA) as methods to monitor illicit drug use in prisons. The researchers ‘collected daily 24-h composite samples of wastewater by continuous sampling, computed daily loads for 1 month and compared the frequency of illicit drug detection to the number of positive RUAs. Diurnal data also were collected for 3 days to determine within-day patterns of illicit drugs excretion’. The results were ‘Methamphetamine was observed in each sample of prison wastewater with no significant difference in daily mass loads between RUA testing and non-testing days. Cocaine and its major metabolite, benzoylecgonine, were observed only at levels below quantification in prison wastewater. Six RUAs were positive for methamphetamine during the month while none were positive for cocaine out of the 243 RUAs conducted’. They concluded ‘Wastewater analyses offer data regarding the frequency of illicit drug excretion inside the prison that RUAs alone could not detect’.
Brewer, AJ, Banta-Green, CJ, Ort, C, Robel, AE & Field, J 2014, ‘Wastewater testing compared with random urinalyses for the surveillance of illicit drug use in prisons
’, online ahead of print, Drug and Alcohol Review
Comment: In both Australia and abroad we are seeing increasing interest in the use of wastewater analysis in both institutions and communities for monitoring patterns and levels of both therapeutic and illicit drug use. The technologies are now well developed and have the potential to contribute to monitoring and evaluating the impacts of interventions, and producing early warning information about changing patterns of drug use.
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What dangers are associated with consuming energy drinks and how can the risks be reduced?
A review of the risks and dangers of energy drink consumption in Europe found that ‘The health risks associated with energy drink consumption are primarily related to their caffeine content, but more research is needed that evaluates the long-term effects of consuming common energy drink ingredients. The evidence indicating adverse health effects due to the consumption of energy drinks with alcohol is growing. The risks of heavy consumption of energy drinks among young people have largely gone unaddressed and are poised to become a significant public health problem in the future’.
The policy recommendations of the review are that ‘There should be an evidence-based, upper limit for the amount of caffeine allowed in a single serving of any drink…The restriction of sales to children and adolescents should be considered due to the potentially harmful adverse and developmental effects of caffeine on children…[and] Regulatory agencies should enforce industry-wide standards for responsible marketing of energy drinks and ensure that the risks associated with energy drink consumption are well known.’
Breda, JJ, Whiting, SH, Encarnação, R, Norberg, S, Jones, R & Jewell, J 2014, ‘Energy drink consumption in Europe: a review of the risks, adverse health effects and policy options to respond’, Frontiers in Public Health
, vol. 2, no. 134, http://journal.frontiersin.org/Journal/10.3389/fpubh.2014.00134/full
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What are illicit drug laws really for?
Professor Desmond Manderson, an ANU-based scholar, is an international leader in exploring the origins, meanings and impacts of our approaches to psychoactive substances in society. In this contribution published in The Conversation, Manderson asks ‘What are illicit drug laws really for?’. He explains that, ‘In the early years of the 20th century, what had previously been a question of habit, pleasure, or shame, became branded as criminal. The crime of possession came, in time, to define drugs: a “drug” was that which could not be legally possessed; if it could be, then it was not a drug at all, but a medicine, a drink, or a smoke. Initially, racial anxieties lay behind these new distinctions. The first laws against drug possession were enacted around 1900, in the United States and Australia, Canada and South Africa. These laws, which formed the template and precedent on which all later “narcotic drugs acts” were built, focused exclusively on one form of one drug: “opium suitable for smoking”.’
Manderson, D 2014, Like men possessed: what are illicit drug laws really for?, http://theconversation.com/like-men-possessed-what-are-illicit-drug-laws-really-for-31739.
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Australian Institute of Health and Welfare 2014, Alcohol and other drug treatment and diversion from the Australian criminal justice system: 2012-13, cat. no. AUS 186, AIHW, Canberra, http://www.aihw.gov.au/publication-detail/?id=60129548946.
Australian Medical Association 2014, Cannabis Use and Health – 2014, https://ama.com.au/node/2556.
Chow, S, Iversen, J & Maher, L 2014, Drug injection trends among participants in the Australian Needle and Syringe Program Survey, 2009-2013, IDRS Drug Trends Bulletin, Kirby Institute, UNSW, Sydney, http://ndarc.med.unsw.edu.au/resource/drug-injection-trends-among-participants-australian-needle-and-syringe-program-survey-2009.
Enggist, S, Møller, L, Galea, G & Udesen, C (eds) 2014, Prisons and health, World Health Organization Regional Office for Europe, Copenhagen, http://www.euro.who.int/en/health-topics/health-determinants/prisons-and-health/publications/2014/prisons-and-health , large file warning 5.6 MB.
NADA: Network of Alcohol and other Drug Agencies 2014, Working with diversity in alcohol & other drug settings, NADA, Strawberry Hills, NSW, http://www.nada.org.au/media/59688/nada_working_with_diversity_sept14.pdf.
National Drug and Alcohol Research Centre, 2014 National Drug Trends Conference papers, including the Drug Trends Conference Handout: https://ndarc.med.unsw.edu.au/event/2014-national-drug-trends-conference . Also An overview of the 2014 Ecstasy and Related Drugs Reporting System (EDRS) https://ndarc.med.unsw.edu.au/resource/overview-2014-ecstasy-and-related-drugs-reporting-system-edrs and Key findings from the 2014 IDRS: a survey of people who inject drugs https://ndarc.med.unsw.edu.au/resource/key-findings-2014-idrs-survey-people-who-inject-drugs.
Nutt, D 2013, Decision making about illegal drugs: time for science to take the lead (lecture), https://www.youtube.com/watch?feature=player_embedded&v=mDo09IBVHZw.
Substance Abuse and Mental Health Services Administration (USA) 2014, SAMHSA’s concept of trauma and guidance for a trauma-informed approach, Substance Abuse and Mental Health Services Administration, Rockville, MD, http://store.samhsa.gov/product/SMA14-4884?WT.mc_id=EB_20141008_SMA14-4884.
United Kingdom, Home Office and The Rt Hon Lynne Featherstone MP 2014, Drugs: international comparators, Home Office, London, https://www.gov.uk/government/publications/drugs-international-comparators.
United Nations Office on Drugs and Crime 2014, A handbook for starting and managing needle and syringe programmes in prisons and other closed settings, Advance Copy, United Nations Office on Drugs and Crime, Vienna, https://www.unodc.org/unodc/en/hiv-aids/new/publications_prisons.html.
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