1

Submission

To: the Inquiry into the supply and use of methamphetamines, particularly ‘Ice’, in Victoria

From: the Victorian Aboriginal Community Controlled Health Organisation

Date: 18 October 2013 2

Contents 1.Introduction ...... 2 2.Recommendations ...... 3 3.Victorian Aboriginal people and methamphetamine a snapshot ...... 3 4.Data on Victorian Aboriginal people and methamphetamines ...... 4 5.Victorian Aboriginal people and methamphetamine treatment ...... 7 6.Evidence-based Drug and Alcohol Education Strategies ...... 11 7.Economic cost and the justice system ...... 12

1. Introduction

The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) was established in 1996 as the peak representative Aboriginal health body in Victoria. VACCHO’s work is driven by the priorities of our members, Victoria’s Aboriginal Community Controlled Health Organisations (ACCHOs) located across the state and just over the border into New South Wales. By joining together under VACCHO’s umbrella, ACCHOs gain strength, share knowledge and speak with a united voice.

VACCHO champions community control and health equality for Aboriginal communities. We are a centre of expertise, policy advice, training, innovation and leadership in Aboriginal health. VACCHO advocates for the health equality and optimum health of all Aboriginal people in Victoria.

Methamphetamine issues are frequently raised by the VACCHO membership as issues of urgent concern and VACCHO is involved in collating better evidence and supporting member organisations in this space. Below we outline evidence collated that focuses on Aboriginal Victorians and methamphetamines and provide associated recommendations. 3

2. Recommendations

A. Improve understanding of effectiveness of treatment processes and treatment outcomes for Aboriginal people with methamphetamine dependence B. Increase diversionary options from the Justice System to Drug Treatment and Mental Health support C. Strengthen Aboriginal Community Controlled Health Services to deliver evidenced based harm reduction approaches suited to local community needs D. Strengthen Aboriginal Community Controlled Health Services to provide evidenced based methamphetamine dependence treatment suited to local community needs E. Improve access to drug treatments, including timeliness to detoxification and rehabilitation that address specific needs of methamphetamine, for example, longer detoxification periods F. The enquiry assess sustainable and systematic service provision that meets client need

3. Victorian Aboriginal people and methamphetamine a snapshot

• 1 in 10 young Aboriginal people use methamphetamine compared to 1 in 20 young non-Aboriginal people • Of young Aboriginal people who use methamphetamine 1 in 2 use daily or weekly compared to 1 in 10 non Aboriginal people • Numbers of Aboriginal people in Victorian prisons have doubled in the last 10 years, almost all have drug dependence and this worsens after imprisonment • Health providers in Aboriginal Community Controlled health Organisations request in regard to methamphetamine treatment - professional development - improved partnerships and - more timely access to detox and rehabilitation • Aboriginal families with methamphetamine dependent members request improved support and skills in dealing with methamphetamine dependence • Little evidence of effectiveness of methamphetamine health education and prevention programs that work with Aboriginal people • Little evidence about effectiveness of methamphetamine treatment with Aboriginal people 4

• Concern that 'moral panic' about ICE, such as, ICE forums may further marginalise and deter methamphetamine users from help seeking behaviour. More targeted and solution focussed activities are required.

4. Data on Victorian Aboriginal people and methamphetamines

There is little information and data available about Victorian Aboriginal people and methamphetamine use. The Victorian Aboriginal Health Service has just begun to develop a research project planning to interview methamphetamine users. Below we have outlined available data on Aboriginal Australians and methamphetamines.

GOANNA Survey, 2013

The GOANNA surveyi was conducted by the Kirby Institute in partnership with VACCHO and others. The survey sample included Victorian Aboriginal young people. Nationally the survey found that compared to the Australia Household Drug Surveyii  Both cannabis (21.3% vs 32%) and methamphetamine (5% vs 10%) use was higher for Aboriginal young people  Higher everyday use of cannabis (11.2% vs 38%) and methamphetamine (11.3% vs 53%) among Aboriginal young people

Similar rates of drug use to the GOANNA survey were identified in the National Aboriginal and Torres Strait Islander Health Surveyiii (Figure 1).

Figure 1: Illicit substance use among Indigenous people aged 15 years and over 5

Notes: 1) Pain-killers/analgesics are for non-medicinal use. 2) Estimate for LSD or synthetic hallucinogens in last 12 months has a relative standard error of between 25 and 50% and should be used with caution.

Source: Australian Government. National Aboriginal and Torres Strait Islander Health Survey, 2008

Qualitative study

A qualitative study with Aboriginal methamphetamine users in Sydney found that most participants had reduced or were planning to reduce their drug use, or "at least have it under control". Motivators for seeking treatment were to "keep out of jail", "keep children", and because of a genuine desire to make positive changes in their life. Some did not want their children to know of their drug use, or to become involved with drugs themselves. Around half had tried residential rehabilitation in the past and found it beneficial, all had relapsed.

Barriers to accessing treatment services focused on the rules and lack of freedom that these services offer.

"I don't want to have to follow their rules."

"No freedom."

"I feel the program is judging me, as in preaching"iv.

VACCHO Ice forums

“Please don't produce any more resources it's a waste of money!!The mainstream and existing information is efficient”

In 2013 VACCHO ran three forums with Aboriginal Community Controlled Health Organisations. Participants were a mixture of service providers and Aboriginal community members and audience size varied from over 100 to 15. Participants were asked to fill in evaluations with one question asking ‘what would you like more information about’. Participants’ responses are grouped into themes in Table 1. In particular, health staff requested professional development in methamphetamine 6 treatment and families wanted support to deal with methamphetamine dependent family members and their behaviours. Rather than promoting ICE forums VACCHO now recommends more targeted solution based workshops. There are also concerns that 'ICE Forums' create moral panic and marginalise ICE users further potentially deterring them from help seeking behaviour.

Table 1: Ice forum participant responses to the question, ‘What would you like more information about?’ Participants thought early intervention for young at risk clients, Prevention providing self-care, and holistic programs for young people were important interventions. Participants wanted clarity on what harm reduction and treatment Treatment options should be implemented for clients. More places in detox and rehabilitation were needed. Family Participants asked for better support and advice about how they can support make a difference with supporting loved ones. Making sure mainstream services were culturally safe and running Service access support programs for drug users and their families. Participants wanted to know more about helpful strategies that work Sharing with Ice users and sharing of best practice models. Participants also information wanted more information about what Ice users need for their journey to improved health.

Workers’ perspectives on the Victorian alcohol and drug treatment system

In November 2012 VACCHO facilitated a discussion of the proposed Victorian government AOD treatment system reforms with a combined group of Aboriginal AOD, mental health and social and emotional wellbeing (SEWB) workersv. The focus of this discussion was barriers and enablers to effective treatment for Aboriginal clients. Key themes drawn from this discussion were:  Complexity and breadth of responsibilities – The complexity of the work required of AOD workers is not well understood or acknowledged  Staff turnover, lack of workforce stability – Participants perceived heavy workloads and inadequate support for workers dealing with complex issues as major causes of staff turnover 7

 Regional/rural inequity – Disparities in treatment experienced by clients in rural areas, compared to those living in metropolitan areas, including lack of treatment facilities and lack of choice in service providers (e.g. the only GP in town lacks knowledge of drug treatment). The requirement to move clients from their families, off country to access treatment services was also considered to be a consequence of the inequitable resourcing of rural/regional communities

The first two dot points are compounded by a lack of training and supervision. VACCHO’s most recent AOD and SEWB worker skills survey prepared for the government identifies an undertrained and unsupported workforce. Among workers surveyed, less than half (43%) had formal Diploma or Certificate IV level qualifications in AOD. While 25% were undertaking training (mostly at a Cert IV level), 32% did not have or were not completing AOD qualifications. In another VACCHO survey only 20 of 47 AOD workers had an AOD qualification at Certificate IV-level or higher. Workers also reported low levels of supervision with only 10 workers receiving regular supervision compared to 27 that did not receive supervision or received inadequate supervision (10 workers were not on site to answer).

5. Victorian Aboriginal people and methamphetamine treatment

Aboriginal-specific programs for healing, detoxification and rehabilitation have proven effective, with services including:  Wulgunggo Ngalu Learning Place, Gippsland – a 'learning place' for Indigenous men undertaking community-based orders. A live-in program, accommodates up to 20 men at one time  Bunjilwarra youth healing service, Hastings – currently closed  Baroona Healing Centre, Echuca – youth focused

Wulgunggo Ngalu Learning Place in Gippsland for Aboriginal men on community based orders has achieved excellent results that continue to improve. The centre has been open since 2008, however 66.7% of those referred in 2010/11 successfully 8 completed the program, a figure increasing to 76.6% in 2011/12 and 97.1% in the 11 months to May 2013vi.

The 2011 Bunjilwarra Healing Service evaluation found that young people required repeated attempts at rehabilitation. Case studies demonstrated the complexities of each young person’s background and a lack of structures and supports in their early years. Turning lives around cannot happen in the immediate term. Participating in a healing framework is only part of this process, but had the potential to be the important and significant first step. The average length of stay was 69 days, with some staying a few weeks and others longer. It was common for a young person to stay for a short period followed by a longer period when they re-entered. The young people were found to have complex issues and high levels of social disadvantage, meaning the Healing Service addressed more than just substance abuse by concurrently addressing broader health and wellbeing issues. The author found a strength of Bunjilwarra was fostering an environment holding Indigenous culture in high regard with young people frequently reporting that living in the house helped them to be proud of their cultural background. For some this was a new experience and others knew very little about their Indigenous background. The study author suggests services and programs providing youth residential treatment or youth detention are ineffective without appropriate aftercarevii.

A NSW study examining the outcomes of Aboriginal and non-Aboriginal people in an Aboriginal-specific residential substance abuse rehabilitation centre found significant improvements among participants completing treatment. Outcomes included reduced psychological distress and increased refusal self-efficacy and empowerment. Aboriginal people rated cultural components of treatment slightly more helpful than non-Aboriginal participantsviii.

There is little data on success rates and treatment length in mainstream services. Aboriginal people also use mainstream services, however their cultural safety has not been assessed. A study assessing the acceptability and accessibility of mainstream services for Aboriginal Australians with alcohol or drug use disorders found 9

Aboriginal people were well represented in an urban Area Health Service analysed by the authors. Representative attendance was attributed to relationships between the local hospital and the Aboriginal Medical Service (AMS), particularly in pharmacotherapy dosing and outreach by Aboriginal staff members with the hospital’s Drugs in Pregnancy Unit. An existing collaboration between the treatment service and the AMS, including priority appointments for new Aboriginal clients, was also identified as an influencing factor. Interviews identified increased flexibility of services, increased outreach services and holistic and human care as the areas needing improvement, and the importance of Aboriginal staffing was emphasised by clients and staff membersix.

Evidence from meta-reviews of methamphetamine treatment options show few proven treatments are availablex,xi,xii,xiii. Evidence from behavioural treatments have led to reduced methamphetamine dependence, while pharmacotherapy-based treatments are yet to demonstrate effectiveness in large randomised controlled trials. Behavioural interventions demonstrating effectiveness include cognitive behavioural therapy (CBT) and contingency management. Contingency management offers incentives during treatment such as prizes and money to encourage abstinence. CBT- Contingency management hybrids such as the Matrix Model have also demonstrated improved outcomes although it is unclear if improvements are sustained over a longer periodxiv,xv,xvi.

Outcomes from a Stimulant Treatment Program in NSW where participants received a stepped-care approach including a median six counselling sessions over a three month period achieved a reduction in methamphetamine use. While there was no change in other drug use, crime or HIV risk behaviour, methamphetamine use in the preceding month fell from 79% at entry to 53% and 55% at three month and six month follow up. Reduction in use was more common among younger participants, people with no history of drug treatment, and people without concurrent heroin use. Psychotic symptoms, hostility and disability associated with poor mental health also reduced xvii. 10

Another NSW study on amphetamine treatment across NSW found regional and rural areas are disproportionately affected and clients often presented with concurrent cannabis and/or alcohol problems. Clients were overwhelmingly injecting drug users with poor socio-demographic characteristics. Counselling was the most common treatment service provided, followed by detoxification and residential rehabilitation. Detoxification was usually provided in an in-patient setting, particularly within metropolitan NSW. Compliance with residential rehabilitation was notably poor. The authors concluded that interventions for amphetamine use need to consider the majority of treatment clients will be based in a regional or rural setting, and treatment for amphetamine users often involves concurrent cannabis and alcohol problemsxviii.

A study analysing barriers to methamphetamine withdrawal treatment in Australia found current treatment practices are diverse and uncertain and a broad spectrum of barriers identified. 24 AOD workers (managerial, clinical leadership, and practitioners) were interviewed across Australia. The authors suggest that AOD service providers are not clear about the best way to respond to clients seeking methamphetamine withdrawal treatment and identified general pessimism about withdrawal treatment for this group. The authors concluded that treatment services should consider improving withdrawal protocols, educating clinicians and reconsidering entry criteria to better respond to methamphetamine users who have made the important first step into withdrawal treatmentxix.

Based on systematic reviews of interventions, the World Health Organization (WHO) recommends the following related to methamphetamine use:  Dexamphetamine should not be offered for the treatment of stimulant use disorders in non-specialized settingsxx  Brief interventions, based on motivational principles, should be offered for the treatment of stimulant use disorders in non-specialist settingsxxi  Patients with stimulant use disorders who do not respond to short duration psychological treatment may be referred for treatment in a specialist setting, when availableibid 11

 Individuals using cannabis and psychostimulants should be offered brief intervention, when they are detected in non-specialized health care settings. Brief intervention should comprise a single session of 5-30 minutes duration, incorporating individualised feedback and advice on reducing or stopping cannabis / psychostimulant consumption, and the offer of follow-upxxii  People with ongoing problems related to their cannabis or psychostimulant drug use who does not respond to brief interventions should be considered for referral for specialist assessmentibid

An analysis of relapse factors after methamphetamine treatment among people in the United States found longer time in treatment resulted in improved outcomes. The analysis also found no difference in relapse between residential and outpatient treatment. People who had previously been enrolled in methamphetamine treatment programs were found to have poorer outcomesxxiii.

6. Evidence-based Drug and Alcohol Education Strategies

Knowledge and awareness are generally ineffective for prevention of use of illicit drugsxxiv. A Cochrane review of non-school based interventions including education and skills training interventions, family interventions, and multi-component community interventions found a lack of evidence proving their effectiveness in preventing or reducing drug use by young peoplexxv. While some studies suggest some interventions may be effective, small sample sizes, high loss to follow up and other factors meant the authors could not draw firm conclusions. Similar conclusions were drawn in a systematic review of primary prevention of cannabis usexxvi.

In a large, systematic review of tobacco and substance abuse prevention programs interactive programs were found to be more effective than non-interactive programs, with the latter described at best only marginally effective. Specifically, interactive programs more effectively reduced, prevented and delayed drug use among adolescents for tobacco, alcohol, and cannabis. Effectiveness was also linked to smaller numbers of participantsxxvii. 12

Family-based drug prevention programs have only proven effective when comprehensively implemented across life-spans and addressed multiple risk factors. The programs also require content based on proven prevention theory and research, material that is developmentally appropriate, sensitive to culture and community, of sufficient length and regularly followed up, interactively taught, includes training for prevention program providers, and evaluated to understand the effect on behaviourxxviii. Developing and coordinating such a program state-wide would require significant and sustained financial and human resources.

In a study of health behaviour modification, the most effective interventions across a range of health behaviours included physician advice or individual counselling, and workplace and school-based activitiesxxix. Other interventions to prevent drug use such as public service announcements on radio, television, print and the Internet have proven ineffectivexxx,xxxi.

7. Economic cost and the justice system

There has been considerable debate about the cost effectiveness of policies that target activities to reduce drug supply. A recent review of policies aiming to reduce drug supply, including those in Australia, found that over the time these policies had been implemented drugs had become cheaper and of higher quality. The study concluded that the policies had been ineffective in reducing drug supplyxxxii. 13

The number of Aboriginal prisoners in Victoria has increased 82% since 2006, almost double the rate of non-Aboriginal prisoners. Aboriginal prisoners account for 7.4% of Victoria’s prison populationxxxiii,xxxiv. The Koori Prisoner Mental Health and Cognitive Functioning Study – conducted in a partnership between the Department of Justice, VACCHO and Monash University – found very high levels of substance abuse disorders (inclusive of methamphetamines) and mental illness among Victorian Aboriginal and Torres Strait Islander prisoners. These rates were considerably higher than for non-Aboriginal prisoners, contributing to increased contact with the justice systemxxxv. 14

Figure 2: Lifetime prevalence of mental illness among Koori prisoners by gender

Notes: White bars indicate levels found among non-Aboriginal prison population

Source: Ogloff et al. Koori Prisoner Mental Health and Cognitive Function Study. Victorian Department of Justice. 2013

In the five years to September 2012 the number of Aboriginal people in Victorian prisons rose by 144 peoplexxxvi. This represents an increase in prison expenditure of $45,360 per day in just five years, or $16.6 million per annum. These figures do not price the consequent economic costs of imprisonment (e.g. increased health and mental health services as well as losses in productivity through inability to work) nor the social costs. Using recidivism rates among Aboriginal prisoners as a yardstick for the effectiveness of imprisonment and prisoner rehabilitation, the significant increase in prison expenditure has failed: more than half return to prison within two years, rates are consistently 15 – 20 per cent higher among Aboriginal prisoners, and despite some variability rates have actually worsened xxxvii.

Drug use is known to become more regular and more dependent once a person has entered into the justice system.

“…in general, the lifetime drug using and offending career began with the onset of offending, followed by the onset of illegal drug use, persisting into regular offending, and finally regular illegal drug use. The first offence was 15

most likely to be minor property offending such as stealing without break-in or vandalism, and the drug first used was most likely to be cannabis.”

Drugs and crime: a study of incarcerated male offenders, Australian Institute of Criminology, 2003

The impact of imprisonment extends beyond prison expenditure. Prisoners are more likely to die or be hospitalised, especially Aboriginal prisoners xxxviii xxxix. Hospitalisation costs (based on bed days) of Aboriginal prisoners in the first year of release has been costed at $5.4 million in Western Australia alone, driven predominantly by mental and behavioural disorders and injuries xl. More than a third of Aboriginal women released from prison were hospitalised xli. This is just one area of the health system, in one jurisdiction, over a relatively short period. Aboriginal people are also much more likely to die after they are released from prison, most commonly through suicide, motor vehicle accidents, circulatory system diseases and drug- related deaths xlii xliii . These outcomes remain elevated throughout the first year of releasexliv xlv. Aboriginal prisoners also experience poorer health, with much higher rates of sexually transmitted infections, blood borne viruses, high blood sugar and diabetes, liver-disease markers, asthma and more xlvi. These afflictions lead to poor quality of life and premature death, and engender grief, loss, and trauma among family, friends, and communities.

These imprisonment costs bear a significant economic burden and an unquantifiable social cost. The period following release from prison represents a significant opportunity to reduce very high rates of morbidity and mortality and work alongside people to reduce rates of recidivism. Significant investment at the transition period between prison and the community could substantially reduce economic and social costs associated with health, mental health, and re-imprisonment, and has proven effective at significantly improving health service utilisation in Australia and overseasxlvii,xlviii,xlix,l.. i Ward et al. Sexual health and relationships in young Aboriginal and Torres Strait Islander people. Kirby Institute. 2013 ii Australian Government. Australian Household Drug Survey. 2010 iii Australian Government. National Aboriginal and Torres Strait Islander Health Survey, 2008 iv Australian Government. 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