The Royal Australasian College of Physicians (RACP) submission to the National Drug Strategy Consultation Paper

March 2010

Acknowledgements

1 Physicians from the Australasian Chapter of Addiction Medicine who have specialised knowledge of substance misuse disorders.

THE ROYAL AUSTRALASIAN COLLEGE OF PHYSICIANS The Royal Australasian College of Physicians (RACP) is a Fellowship of more than 10,500 specialist physicians and 4,600 trainees who practise in more than 25 medical specialties including paediatrics, cardiology, respiratory medicine, general medicine, neurology, oncology, public health medicine, occupational and environmental medicine, rehabilitation medicine, palliative medicine, sexual health medicine and addiction medicine. Beyond the drive for medical excellence, the RACP is committed to developing health and social policies which bring vital improvements to the well-being of patients. The College works to establish and achieve the highest standards of contemporary knowledge and skill in the practice of medicine and promote the health and well being of the community, and of its members. The College, in collaboration with affiliated Specialty Societies, is the provider of frameworks and standards of education for specialist physicians and Trainees.

2 The RACP welcomes the opportunity to present feedback from College members to the National Drug Strategy (NDS) Consultation paper. The College would like to congratulate the Ministerial Council on Drug Strategy (MCDS) for preparing the paper and for conducting the evaluation which will allow us to better develop our submission.

The College has worked in association with other medical colleges to develop a suite of policies on addiction medicine issues that incorporate the social determinants of health. These are the:  Prescription Opioid Policy  Alcohol Policy  Tobacco Policy  Illicit Drug Policy These are all available on the College web site at http://www.racp.edu.au/index.cfm? objectid=D7FAA378-C4E8-A262-8B50B9D74850037D

The issues in the NDS consultation paper affect many of the College members as most members would deal with the results of drug and alcohol morbidity and mortality at sometime in a consultation process. In relation to this submission these particularly involve the Division of Paediatrics & Childhealth as well as the Australasian Chapter of Addiction Medicine. The College trains physicians in Addiction Medicine, which was recently recognised by the Australian Medical Council and Minister for Health and Ageing as a medical specialty.

The College has developed several training modules for physicians and other medical practitioners to improve the treatment of drug and alcohol issues in the community, particularly when pharmacotherapy is involved.

The College presents these comments as a summary of its views relevant to the National Drug Strategy. The College would be interested to participate in draft plans that emerge as a result of this consultation.

The College’s recommendations in this area focus on the following areas: 1. Ensuring there are clear and transparent process to declare any conflicts of interest that may occur in the delivery of services, during presentations and in publications of any written work in relation to drugs and alcohol;[1]

3 2. Presenting a strong evidence base for policy which also includes: a. Social determinants of health[2] b. Research[3-4] c. Data collection[5-6] d. Harm minimisation/reduction approach.[7] 3. Including early intervention as it relates to children, young people and their parents or carers;[8-10] 4. Promoting community education and engagement[11] 5. Developing appropriate, relevant and evidence based resources for training [12] 6. Supporting legislative measures[13-14] a. Taxation b. Sentencing[15-17] 7. Enhancing prevention efforts[18] 8. Enhancing treatment services particularly for women with children and their rehabilitation options.[19-20]

Conflict of interest statement No conflicts declared.

In the process of submitting this paper the College has restricted responses to the questions asked by the National Drug Strategy Consultation group as well as including some issues not included by the NDS.

4 Issues not addressed by questions posed in the consultation paper

Evidence based approach to policy

1. The College would like to emphasise the importance for the National Drug Strategy to be based on evidence. The need for this has been clearly articulated by the Australian Prime Minister. There is now strong evidence that the effectiveness of supply control for illicit drugs is not good, that negative unintended consequences are very significant and that there is almost no data on cost effectiveness. In contrast, the effectiveness of demand and harm reduction for illicit drugs is generally much more impressive, that negative unintended consequences are minor and some of the data on cost effectiveness is very impressive.

Balance between supply, harm and demand reduction

2. The College would like to support the need for funding for harm reduction in particular funding for methadone and buprenorphine treatment and needle syringe programs. Most literature on cost effective measures on harm reduction focus only on supply and demand reduction and there is a lack of balance for harm reduction programs that have been shown to be cost effective.

Human rights and health

3. The College would like more emphasis on a human rights approach in the National Drug Strategy paper.[21] The UN system is based on a commitment to three aspirations: economic development, national security and human rights. The UN commitment to international action against illicit drugs while important is not as high a priority as the commitment to human rights. Australia would not have managed to control HIV among injecting drug users without recognising and respecting their human rights. Respect for human rights should also mean that Australia has no part in capital punishment including collaboration with drug law enforcement authorities from other countries where that could lead to capital punishment. This should also influence Australia's actions in international arenas.

4. Infants, children and young people

5 Early intervention involves providing advice or treatment before dependence has occurred and long before end stage and irreversible complications have become established. This involves pro-active identification, feedback regarding the nature and extent of risks, clarification of goals and targets, provision of strategies and follow-up. Different modes of brief alcohol interventions (BAI) have been found to be effective, ranging from a less-than five-minute structured consultation where advice is given about controlled drinking to a correspondence course by computer or mail.[22-23] [24] Early intervention, sometimes also called BAI, is now supported by compelling evidence of effectiveness in problem drinkers. A meta-analysis quotes brief interventions in non-treatment seeking populations as improving given outcomes by 55 per cent compared with 45 per cent in controls.[25]

Education of medical students regarding the health effects of alcohol is important to encourage their later adoption of screening, assessment and treatment of risky or high risk levels of alcohol consumption in their patients and the general public in the future.[26] It is also important to educate medical students about the need for their involvement in community mobilisation about alcohol when they become doctors. There are opportunities for early intervention in Australia as medical professionals detect 30 per cent of alcohol-related problems. However, barriers to early intervention include lack of time, perceived lack of training, uncertainty that BAI is part of the medical role, reluctance to cause conflict with the patient, lack of specific remuneration, and lack of feedback concerning outcomes which may not become evident for some time.

Fetal Alcohol Spectrum Disorder (FASD) FASD is not a diagnosis but comprises a number of diagnostic groups. Alcohol is known to have teratogenic effects.[27] Drinking alcohol while pregnant increases the risk of fetal problems developing, including all categories within Fetal Alcohol Spectrum Disorder (FASD). Fetal alcohol syndrome (FAS) is a chronic disorder with poor prognosis. There are no prevalence figures for FASD in Australia however the birth prevalence data for (FAS) is low. [28] The prevalence in some Aboriginal communities is estimated to be as high as 2.3 to 1.7 per 1000 live births, if cases identified as partial FAS or alcohol-related neurodevelopmental disorder (ARND) because of insufficient records, were assumed to have full FAS. In indigenous children, the corresponding prevalence was calculated to be between 1.87 and 4.7

6 per 1000 live births. The difference between indigenous and non-indigenous rates of FAS was significant (P < 0.0001).[29-31] All pregnant women should be given information on the risks associated with drinking alcohol during pregnancy and be advised that no level of alcohol consumption has been determined as completely low risk for the fetus. The Australian Alcohol Guidelines note that the first two to three weeks after conception, prior to the first missed period, are probably the most crucial in relation to alcohol. During this period it is unlikely the woman will know she is pregnant, particularly in the case of unplanned pregnancy. For this reason, there is a strong need for education about low risk drinking for all women of child-bearing age, including young women still at school.

No high level evidence is available regarding the effectiveness of prevention and early intervention programs for FASD. There is lower level evidence that professional education improves obstetricians’ knowledge about FASD.[32] There is also limited evidence that advocacy to enhance case management of at-risk mothers increases their engagement and decreases their alcohol consumption.[33]

A systematic review of the literature of interventions for FASD reported that there were some evidence to suggest that virtual reality training, cognitive control therapy, language and literacy therapy, mathematics intervention and rehearsal training for memory may be beneficial strategies. Three studies evaluating social communication and behavioural strategies (two RCT) suggested that social skills training may improve social skills and behaviour at home and Attention Process Training may improve attention. [34]

Australian data suggest although up to 79- 65 per cent of women consume alcohol at a high or risky level before or during early pregnancy, less than half of health professionals routinely ask about alcohol use during pregnancy. Furthermore, self- report of alcohol use may be unreliable and biochemical screening may be appropriate to confirm alcohol use in high risk groups.[35-36]

Mothers of children with FASD often use a range of potentially harmful agents in addition to alcohol, including nicotine, cocaine, heroin, solvents, methadone and marijuana.[37] Children reported to the Australian Paediatric Surveillance Unit (APSU) with FASD use multiple services. These include specialised paediatric, child development, community, remedial education, respite and psychological medicine.

7 Case management alone is not sufficient: a model of para-professional advocacy for at risk mothers has been developed which included the following interventions:[33]

 public and professional education;

 an alcohol and pregnancy information and crisis telephone line;

 screening for alcohol use in prenatal clinics; and,

 treatment programs for women who drink and children affected in utero. This program resulted in increased knowledge of risks and early diagnosis and referral for alcohol-related problems in pregnancy and infancy.[38] [39]

Children In 2002, five per cent of 12 – 14 year-old children were at risk because of their own alcohol consumption.[40] Most children are at risk because of risky or high risk levels of alcohol consumption by adults, usually their parents.

Young people Young people are particularly vulnerable to the harmful effects of alcohol because of their lack of experience of drinking, and their frequent combination of high-risk drinking with high-risk activity with a potential for accidental injury. Fortunately, most teenagers drinking at high risk levels manage to survive a usually brief period of adolescent turbulence without clinical interventions. Some, however, will continue to drink at high risk levels and some will suffer irreparable harm.

Protective factors linked to positive outcomes, even when children are growing up in adverse circumstances and are heavily exposed to risk, include:[41]

 strong bonds with family friends and teachers;

 healthy standards set by parents, teachers and community leaders;

 opportunities for involvement in families, schools and the community;

 social and learning skills to enable participation; and,

 recognition and praise for positive behaviour.

There has been a significant increase in regular binge drinking (drinking at least 5 drinks in one session) to the point of intoxication in young Australians in recent years. Drinking to the point of intoxication and therefore exposure to risk has become more common among young Australians in recent years. This rise has been especially

8 dramatic in young women. [42-43] In 2004, 87 per cent of Australian students aged 18-19 years reported drinking at least weekly.[44] In 2004, of all young people aged 14-19, 19 per cent of males and 15 per cent of females drank at least once a month at risky or high risk levels.[45]Comparisons between 1996 and 2003 surveys show that the proportion of female adolescent drinking in excess of levels associated with chronic harm increased from one per cent to 10 per cent.[46-47]

In Australia, 11.4 per cent of Aboriginal and Torres Strait Island youth aged 15 to 24- year-olds reported high-risk alcohol consumption in the previous month.[48] The weight of evidence in relation to the risk and protective factors being “predictors” of harmful alcohol consumption highlights the importance of focusing on women and children and future generations of Indigenous people.

Adolescents may be at risk because of parental domestic intoxication, and some already report problematic alcohol consumption. Adolescents growing up in households where one or both parents have a drinking problem are at greater risk of developing a drinking problem themselves or becoming abstinent from alcohol.[49]

A longitudinal study of the health of women in Australia reported that the majority of women did not change their level of alcohol consumption.[50] Most women who reported consuming alcohol at all were doing so at low levels of long-term risk.[43]

Manifestations of early problematic alcohol use Adolescence is a time of experimentation with many different types of risks, including the risks of drinking immoderate amounts of alcohol. Deciding when an adolescent has crossed the line and has developed a clinically pathological pattern of alcohol consumption is difficult. Consequently the issue of drinking by teenagers is a source of much anxiety for parents, medical profession and the community. Acute alcoholic poisoning and episodes of severe intoxication (e.g. blackouts) with or without physical and social harm are all early warning signs of serious problems emerging in a young person.

In young people with a strong family history of alcohol-related problems, clinicians should ask about alcohol use and advise parents to discuss the risks of heavy drinking and the options available, including clinical interventions.[51] Follow-up of

9 these young people and their families is important and helps the adolescent to manage their alcohol intake.[52]

There is growing evidence that family life during the critical developmental phases of early childhood is a significant factor in building resilience and reducing the risk of a range of subsequent social and behavioural problems, including problematic alcohol use.[53] Children and young people are particularly vulnerable during times of developmental change. Transition to high school can herald a period of high risk drinking.[54]

Risk factors in childhood and adolescence do not guarantee that young people will suffer from alcohol-related problems. The interaction between risk and protective factors initiated during childhood and adolescence continues into adulthood and reinforces the importance of prevention and early intervention. [55]

Identifying alcohol-related harm in young people Effective engagement of young people by health professionals is a crucial first step in identifying alcohol-related harm. It is important to ask ALL young people who present to health services about the use of alcohol and other risk behaviours as part of a general psychosocial screening interview. This needs to be performed in an open- minded, non-judgmental, developmentally appropriate way that takes into account the level of cognitive and psychosocial development of each individual adolescent. Research shows that assurance of confidentiality at the beginning of a consultation is important to encourage accurate disclosure of sensitive health information.

Interventions for adolescents The results from the School Health and Alcohol Harm Reduction Project (SHAHRP, Western Australia) support the use of harm reduction goals and classroom approaches in school alcohol education.[56] The table at the end of this chapter identifies interventions that have been shown to be effective in reducing alcohol and drug consumption by young people.

There is good evidence that brief motivational interventions help to reduce alcohol consumption among adolescent heavy or binge drinkers. Furthermore, there is evidence that crisis intervention, harm reduction, assertive outreach and the building of social support networks are associated with better outcomes.[45] A study of the

10 prevalence and quality of alcohol prevention services delivered to adolescents in the United States reported clinicians providing inconsistent alcohol prevention services, and a failure to incorporate the most effective educational methods. Reported rates of universal screening and counselling were low, and younger adolescents were less likely to receive services. The clinicians’ beliefs about their alcohol management skills and perceptions of resource availability were the most consistent correlates of higher quality service.[57]

5. Justice and health The College would like more emphasis on harm reduction for the population of prison inmates serving sentences for drug related offences by greater use of non-custodial sentences and other reforms.[58] Prisons should only be used as a last resort. Evidence that incarceration changes the behaviour of drug users is lacking. Only about one half of drug dependent heroin users in Australia who want to and should be in methadone[59] and buprenorphine[60] treatment are currently in treatment. [61] The 1961 and the 1971 international drug treaties both emphasised the need for 'parties' (i.e. countries) to strongly support treatment and rehabilitation. People on methadone and buprenorphine treatment pay 30% of their low income as co- payment - no other chronic condition pays as high a co payment. It costs about the same to have a person serve a 12 month prison sentence as to have 30 patients on methadone or buprenorphine treatment in the community.

A WHO document stated that prisoners should have access to prevention and treatment health services which are at least as good as in the community.[62-63] There is a high prevalence of prison inmates serving sentences for alcohol and drug related offences, and therefore the College would like to suggest improved access to treatment available in prisons than in the community. There is abundant evidence of HIV and HCV transmission in prisons (including Australian prisons) yet we do not have any needle syringe program in any prison in Australia. [64]

6. Improved treatment services The College suggests that people with an alcohol or drug dependence who want to undergo detoxification have improved access to detoxification treatment and management services. Many alcohol and drug dependent persons with social support can manage with ambulatory detoxification but those who are homeless or lack social support require residential care.

11 7. The College would like more emphasis on strengthening self help options for people with problems from alcohol, tobacco, prescription and illicit drugs.[65] Self help such as telephone help lines[66], and internet sites [67]would have substantial benefits for the community.

8. The College suggests abandoning criminal penalties for personal possession of cannabis and replaces these with administrative mechanisms or small civil penalties.

9. The College supports application of best evidence in the use of medicines. The College recognises that cannabis is used by some to treat symptoms such as chronic pain and nausea. The College supports research that may lead to effective medical treatments and notes that cannabis or its ingredients should be submitted to the same scrutiny as other medicines.

10. The College would like to see supervised disulfiram considered for the PBS. Australia should encourage much greater use of pharmacotherapies for alcohol dependence.

11. The College would like to suggest rehabilitation services becoming more “family friendly” with improved options for mothers and children.[68]

12. The College would like to see improved access to quality treatment services. The Non-Government Organisation Treatment Grants Program (NGOTGP), Illicit Drug Diversion Initiative (IDDI), Amphetamine-type Stimulants Grants Program (ATSGP), and National Comorbidity Initiative (NCI) has all been important in expanding access to quality treatment. The NGOTGP has been particularly instrumental in increasing treatment services across the country. Resources for illicit drug treatment services have been allocated on the basis of sound processes that rely on collaboration at the jurisdictional level to deliver reasonable information about local needs, gaps, and opportunities and constraints in the Alcohol and other drugs (AOD) system. There is a need to continue to increase capacity for collaborative needs-based planning, more integrated seamless service delivery, data collection, performance monitoring and review.[69]

12 1. Emerging issues and new developments identified in this paper and how they might impact on patterns of tobacco, alcohol, illicit drug use and the misuse of licit substances (e.g. pharmaceuticals, performance and image enhancing substances) in the next five years, and appropriate responses to these patterns;

 High risk and risky consumption of alcohol, illicit drugs and tobacco smoking

Alcohol and tobacco tax reform Alcohol and tobacco tax reform has proven to be cost effective and to have good outcomes when dealing with high risk and risky consumption of alcohol and daily cigarette tobacco smoking. [70] This strategy was mentioned in the 2006 the Royal Australasian College of Physicians (RACP) policy on alcohol and tobacco.[71-73] There is now a body of literature that demonstrates that young people are very sensitive to prices increases in alcohol and tobacco.[74] The majority of alcohol consumed in a community by young people is drunk at high levels of risk of short- term harms.[8] Even small increases in taxation would achieve a worthwhile benefit (and be easier to achieve and sustain). Large increases risk stimulating a black market. Finally the College would like to suggest volumetric taxation of alcohol to be extended to home brewing supplies

 Misuse of licit substances (e.g. pharmaceuticals, performance and image enhancing substances)

Consideration of definitions used in the National Drug Strategy paper Often these licit substances are inappropriately prescribed rather than misused. This and other terms adapt poorly to the situation where prescription drugs are misused. In April 2009 the Royal Australasian College of Physicians (RACP) released a policy report Prescription Opioid Policy: Improving management of chronic non-malignant pain and prevention of problems associated with prescription opioid use.[75] This document outlines a number of other definitions of terms that may be more appropriate in relation to prescription pharmaceuticals.

Substance dependence is a pattern of maladaptive behaviours, including loss of control over use, craving and preoccupation with non-therapeutic use, and continued use despite harm resulting from use (with or without physical dependence or

13 tolerance) [WHO, DSM]. The terminology used in this field is constantly under review and may change in the future. This document uses the following terms as indicated: (a) ‘Inappropriate prescriber behaviour’ which refers to physician behaviour; (b) ‘Problematic opioid use’ which refers to patient behaviour; and (c) ‘Illicit or illegal use of prescription drugs’ which refers to the possession or consumption by anyone other than the person to whom they were initially prescribed.

Appropriate prescriber behaviour refers to prescription decisions based on the best available current evidence at the time of assessment and taking into account the patient’s perspective. Inappropriate prescriber behaviour refers to persistent prescribing of opioids despite absence of sustained improvement in function, deterioration of function and/or the development of unacceptable side effects. Problematic opioid use refers to patient behaviour defined as ‘deviating from an appropriately prescribed program’ of opioid treatment for CNMP. It is usually unsanctioned, but may be associated with inappropriate prescriber behaviour. In general the term ‘problematic drug use’ may be clearer, more descriptive and less judgemental than terms such as ‘drug misuse’ or ‘abuse’. 1 The AAPM/APS/ASAM consensus[76] defines ‘problematic opioid use’ as a pattern of overwhelming focus on opioid issues arising in the therapeutic context of prescribed opioids and impeding progress with other issues, with:

 early refills or escalating drug use;

 frequent accounts of lost, spilt, stolen medications; and/or

 use of supplemental sources of opioids

This policy document uses a wider definition of ‘problematic opioid use’ to include the above and other behaviours such as:

 use of oral medication parenterally by injecting or snorting;

 use to excess and/or in combination with other psychoactive drugs or alcohol to produce intoxication; and/or,

 diversion to or from the black market.

1 The Pain Society, Recommendations for the appropriate use of opioids for persistent Non- cancer pain: A consensus statement prepared on behalf of the Pain Society, the Royal College of Anaesthetists, the Royal College of General Practitioners and the Royal College of Psychiatrists March 2004. London. Access on 21.04.2008) http://www.britishpainsociety.org/pdf/opioids_doc_2004.pdf

14 Notes to this definition: 1. Problematic use and dependence are distinct but overlapping concepts.

2. Problematic opioid use is usually unsanctioned. However, in circumstances where such behaviours are tolerated by the prescriber (i.e. sanctioned), the problem becomes one of inappropriate prescriber behaviour. (See conceptual table below.) 3. The term ‘iatrogenic opioid dependence’ is not used in this document except when quoting studies, as this may imply medical negligence.

Illicit or illegal use of prescription drugs refers to their possession or consumption by anyone other than the person to whom they were prescribed. Sanctioned use of opioids is use, according to instructions, by a person to whom they were prescribed. Unsanctioned use of opioids is use by the person to whom they were prescribed but not according to instructions (problematic use) or any use by someone other than the person to whom they were prescribed (illicit use).

1.2 Other emerging issues that you think are relevant to the next phase of the National Drug Strategy

Prescription opioid use The RACP policy on opioids was tabled at the Ministerial Council on Drug Strategy meeting in November 2009 and a communiqué from the meeting reported that Ministers agreed to develop a National Pharmaceutical Misuse Strategy, in close consultation with the Australian Health Ministers Conference (AHMC) and with expert groups such as the Medical Colleges. Furthermore it was recognised that the issue of prescription drug misuse had been identified by both law enforcement and health agencies across Australia as an emerging issue of significant concern. Ministers agreed there was a need for a consolidated national response and endorsed the development of a strategy that would address prevention, reduction of supply, reduction of drug use and related harms, improved access to quality treatment.

The College would like to see MBS item numbers &/or PIP payments promoting quality use of those pharmaceuticals of potential misuse. Also we would like systematic feedback/monitoring re those doctors with higher prescribing habits.

15 The College recommends improved post marketing surveillance of adverse events in relation to drug and alcohol in particular opioid prescribing.

1.3 The College believes that the top priorities for action over the

next five years should be:  Increased use of prescribed opioids;[75]  Benzodiazepines are now widely used in Australia as prescribed drugs and for recreational purposes; however, they have the potential to lead to addiction in vulnerable individuals. [77] Benzodiazepine use is a considerable problem in Australia among the elderly, middle aged people with severe medical illnesses and young polydrug users. Many young polydrug users on methadone or buprenorphine treatment also consume considerable quantities of benzodiazepines and this group has poorer outcomes for all treatment objectives. This is a much neglected problem.  Alcohol and tobacco tax reform;[71]  Effective prevention and early intervention.[9] This area has not received the focus that it deserves during the current and earlier phases of the National Drug Strategy (NDS). Nevertheless, the NDS Campaigns, Community Partnerships Initiative (CPI), National Comorbidity Initiative (NCI), and National Cannabis Prevention and Information Centre (NCPIC) all provide resources to strengthen early intervention and prevention (in the absence of an explicit prevention agenda within the NDS);[69]  Research and best practice resource development. Important achievements in the sector have been made by applying research-based evidence to policy and practice, and Australian researchers have contributed significantly to the evidence base. The National Drug Research Centres have made major contributions, as have researchers from other institutions. While National Drug Law Enforcement Research Fund (NDLERF) provides funds for drug law enforcement research, insufficient work has been done in developing the evidence base in this area, partly because of the lack of NDS-supported drug law enforcement research infrastructure. Still more could be done to use research evidence to respond to drug trends. The NDS still has no integrated national drug research strategy;[69]

16  Research in pharmacotherapies such as amphetamine stimulant treatments for which good evidence of treatment is needed; and  Increased research action on nicotine and alcohol dependence a major health burden as a result of nicotine and alcohol related disease.

2. Improved definition for “Harm minimisation”

The polarisation that the language of harm minimisation has produced is a distraction. Its use in the National Drug Strategy does not imply a particular view of the merits or otherwise of prohibition, or when it is an appropriate strategy. It does imply, however, that the choice between strategies should simply be determined by their relative costs and benefits. Moreover, the harm that is eliminated by any strategy needs to be greater than the harm that it imposes.[78]

A preferred definition is the Internal Harm Reduction Association (IHRA) definition “What is Harm Reduction?” A position statement from the International Harm Reduction Association, International Harm Reduction Association, London, United Kingdom, September 2009. Available at www.ihra.net

2.1 Cross Sectoral Approaches. Structures and processes

that could assist the National Drug Strategy more

effectively engage with sectors outside health, law

enforcement and education are as follows:

Strengthened partnerships and collaborations between levels and sectors of government and the public, private and not-for-profit service delivery sectors. Examples include the State Reference Groups that that assess grant applications under the Non-Government Organisation Treatment Grants Program (NGOTGP), and the collaborations involved in implementing Project STOP.[69]

2.2 Sectors that are particularly important for the National

Drug Strategy to engage with are:

17 Aboriginal and Torres Strait Islander health and community

sectors  Indigenous Centre for Excellence in Tobacco Control  Inaugural National Coordinator for Tackling Indigenous Smoking, Mr Tom Calma  National Indigenous Drug & Alcohol Committee  Close the Gap Steering Committee  NACCHO

2.3 How the IGCD and MCDS could more effectively access

external expert advice

 Hold community meetings across Australia  Give people the opportunity to list to a live recording of the meetings

3. Indigenous Australians

Where efforts should be focused in reducing substance use and associated harms in Indigenous communities?

 Prevention of alcohol and drug problems remains a high priority, and this should include urban as well as regional and remote areas. Too often scarce funds have been poured into education alone, which typically has a limited impact. Approaches such as community empowerment, and enhancement of resilience need to be further supported. The Gatehouse Project enhanced the connection between school, teachers, communities and home and the sense of belonging of young people, to promote resilience and success in young people[79]. This was associated with reduced likelihood to engage in substance abuse.[80] The potential of this approach in Indigenous communities has not been adequately explored. Also, past successful initiatives such as the Living With Alcohol Program in the NT have been ceased because of lack of funding[81]

18  Increased effort in workforce development for the Aboriginal alcohol and other drug workforce, including support and incentives to attend accredited training, advanced work placements, and on the job mentoring by specialist staff.

3.1 To reduce harm from substance use in Indigenous

communities efforts should be placed in the following

areas:

 Support for ACCHSs to incorporate social and emotional wellbeing services into PHC: Substance misuse and mental illness are tightly intertwined, yet too often services are not available to deal with mental health and substance misuse comorbidity. Prevention and early intervention for mental illness is critical yet many ACCHSs do not have well resourced Social and Emotional Wellbeing services to provide prevention, early intervention and treatment integrated with primary health care. This is despite the fact that the majority of ACCHS s identify Social and Emotional Wellbeing as a priority and many past reviews recommend increasing Social and Emotional Wellbeing services in ACCHSs. ACCHSs have the appropriate expertise in providing culturally secure services in this complex and difficult areas. They can reach out to the most marginalized and provide holistic care addressing both mental and physical illness whilst addressing issues early in people at high risk of developing AOD problems through screening and early intervention, both opportunistically and incorporated into adult health checks if they are supported.  These services should include support for substance use and psychiatric comorbidity which is particularly common in Aboriginal populations. Both substance misuse and mental health problems have common determinants including the legacies of past policies such as forced child removal, low levels of education, poverty and unemployment etc. [82]  ACCHSs should be funded to employ psychologists and social workers as well as Aboriginal Mental Health workers and community workers who are well trained and supported. Visiting medical

19 specialists including addiction medicine specialists and psychiatrists could provide support for the most complex patients.  ACCHSs in remote areas should also be supported to provide these services through innovative models such as regional specialist staff shared by two or more ACCHSs working with local teams in communities.

 The social and emotional well-being and substance use disorders of Aboriginal prisoners need to be addressed given the very high morbidity in this group. If feasible, ACCHSs should be supported to deliver this service but if this is not possible, prison health services should take advice from their local ACCHSs on how best to support Aboriginal prisoners. Relapse prevention services, including for alcohol dependence should be available to inmates during incarceration, delivered in culturally appropriate ways. Planning for release should include offer of relapse prevention medications where appropriate and arrangement of follow-up counselling to reduce risk of relapse.

3.2 Aboriginal and Torres Strait Islander peoples needs

could be better addressed through the main National Drug

Strategy Framework in the following way:

 Collaborating with “Close the Gap” steering committee and incorporating alcohol and drug goals and targets; [83]  Working closely with the Indigenous Centre for Excellence in Tobacco Control as well as the new inaugural National Coordinator for Tackling Indigenous Smoking, Mr Tom Calma;  Strengthen aboriginal workforce development programs at Universities of Sydney, Newcastle and Wollongong;  As Aboriginal and Torres Strait Islander peoples are often part of mainstream communities, and attend mainstream services, there is a need for the main National Drug Strategy Framework to address their needs. However as stated below, given their particular burden of disease in relation to substance misuse, a more detailed complementary plan would also be advisable;

20  Measures to reduce alcohol availability and increase cost will reduce alcohol related harm in all Australians including Indigenous Australians[71]. The College supports the recommendation of the Preventative Health Taskforce on Alcohol control. In remote areas, communities must be supported to develop and implement alcohol management plans that are acceptable to the community as well as being evidence based. More broadly, to improving social determinants of health including employment and housing are likely to reduce harmful AOD use in the long term;  Substantial investment has been made by the Australian government in tobacco control in Aboriginal communities through the Council of Australian Governments (COAG) package. This is a welcome investment. However the training and support of the 57 tobacco coordinators and 200 Tobacco action workers to be employed through this package is not clear. There must be investment in training and support of these workers otherwise this investment is unlikely to make an optimal contribution to reduction in Indigenous smoking rates. A high quality formative evaluation needs to be implemented so that the roll out of the package can be modified according to progress.

3.3 In that context, would a separate National Drug

Strategy Aboriginal and Torres Strait Islander

Complementary Action Plan continue to have value?

The inequalities between Indigenous and non-Indigenous Australian health status and outcomes are well documented, and this is also apparent within drug dependence, high risk and risky consumption of alcohol and tobacco smoking.

The College believes that the problems with drug use amongst Indigenous peoples are so significant, that a separate review and more detailed plan are useful. Oppression and dispossession of Indigenous peoples over time has resulted in severe traumatisation and vulnerability for Indigenous peoples.

However a compendium should not replace coverage of Indigenous health in the main plan: otherwise only those interested in Indigenous health read the

21 specialised plan. It is important that Indigenous health becomes more and more part of mainstream health consciousness. A more detailed supplement should be made available such as the National Drug Strategy Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003-2009. The Complementary plan was comprehensive and formed under appropriate consultation but not funded to achieve its aims. The College would support revision and extension of a similar plan to complement the National Drug Strategy and Preventative Health Agency’s work. Many Aboriginal people access health care and other services from mainstream services not primarily designed for that population so that it is important to include Aboriginal people in the development of such services, and in consequence, in the overall NDS.

4. Capacity building

4.1 The support and development of drug and alcohol

sector workforce should be focused over the coming five

years in the following ways:

 Recognising and taking appropriate action as early as possible for children and young people of substance-abusing parents, and to be able to assist these children and families in seeking treatment as early as possible. [84]  Provide resources to ensure that Medical schools to include pain management and addiction medicine into their curriculums.  Training for counselors, psychologists, nurses, working in drug and alcohol field should include a core curriculum, which should be evidence based.  Workforce development and structures. An appropriately sized, skilled and qualified workforce is critical in sustaining effective delivery of interventions. Capacity to implement programs has been limited by staff shortages and turnover, and skill gaps in the alcohol and other drug (AOD) sector specifically and in the Australian workforce generally. The NDS contribution to training programs and resources is highly valued, as is the work of NCETA in developing a concept of

22 workforce development far broader than education and training. More attention is needed to building the capacity and profile of professionally-trained, specialist AOD workers. [69]  Attention is needed to competitive pay and conditions, incentives and benefits. A new national AOD workforce development strategy, as proposed by NCETA and recently discussed by IGCD, will be an important initiative.  The generalist specialist for example, the Addiction Medicine specialists should be supported to work more closely with primary health care and other health professionals to improve the linkages between the AOD system and other health practitioners which have less well developed linkages between most other specialist areas and other health practitioners. Shared care schemes in alcohol dependence and opiate dependence should be supported and replicated throughout the system if evaluations are positive.

 More broadly, training and support to workers within community health care and welfare should be supported to enable workers to screen, identify and refer people with significant problems as well as delivering appropriate brief interventions to those who either refuse more formal help or who do not require formal help at this stage. Brief intervention training in tobacco cessation should be delivered to a broad range of professionals including welfare and youth workers and in a variety of settings.

4.2 Efforts should be focussed over the coming five years

to increase the capacity of the generalist health workforce

to identify and respond to substance use problems in the

following way:

 The Training of doctors, nurses, psychologists and counesllors should include a core curriculum on alcohol and other drugs, which should be evidence based. Currently it is of concern that different branches of the health care system periodically offer conflicting advice on management of alcohol and drug problems (e.g. a doctor will advise a client to enter a methadone maintenance program, a counselor may

23 advise them to enter a rehabilitation unit which requires them to be methadone free, and a private detoxification service may market rapid opioid detoxication. This creates considerable stress and confusion for members of the public.

5. New Technologies and On-Line Services

5.1 The particular opportunities and challenges that technology

development is likely to pose for the community and the

alcohol and drug sector over the next five years are as

follows:

 Electronic prescribing and the potential this may have to prevent diversion through the use of electronic prescriptions as opposed to paper based prescriptions;

 Develop a best practice system for monitoring the prescription of drugs of dependence. This system should be web based, confidential and real time. This will enable prescribing doctors and dispensing pharmacists to monitor prescriptions, to provide more effective, safer and cost-effective health care, and for government to monitor the overall use of these medications and evaluate the effectiveness of policy and other interventions.

The Colleges recommend improved systems for collection of data regarding the prescription and use of opioid analgesics and other prescription drugs of dependence. Such systems could have the following features:

24 i) Robust identification of the patient, similar to evidence needed to establish, for instance, a bank account, with photo ID or biometric ID; ii) Online, real time medication history available to potential prescribers at the time of prescribing, and to pharmacists at the time of dispensing; iii) Protected PIN held by the patient or accessible via a secure mechanism; iv) 24 hours per day, 7 days per week access by prescribers and pharmacists to prescription shopping information systems to identify unsanctioned use; v) Privacy safeguards; and vi) An audit trail to identify when patient’s record are accessed.

 Use modern IT solutions to provide widespread access to credible information and internet based intervention tools for D&A problems.  Timely periodic reports on alcohol and tobacco use should be nationally available, along with detailed reports addressing demographic patterns of substance use. Likewise periodic reports on treatment services and places should be made available, in relation to measures of need and unmet need.

6. Increased vulnerability

6.1 The National Drug Strategy could better complement

the social inclusion agenda such as addressing

unemployment, homelessness, mental illness and social

disadvantage in the following way:

The College supports the principles outlined in the social inclusion document[85] and would like to particularly note the following areas as being important:  Targeting jobless families with children to increase work opportunities, improve parenting and build capacity;  Improving the life chances of children at greatest risk of long term disadvantage;

25  Reducing the incidence of homelessness;  improving outcomes for people living with disability or mental illness and their carers;  Closing the gap for Indigenous Australians; and  Breaking the cycle of entrenched and multiple disadvantage in particular neighbourhoods and communities.

6.2 Effort be focused in reducing substance use and associated

harms among vulnerable populations in the following way:

 Ensuring the recommendations from the Government’s social inclusion paper “A Stronger, Fairer Australia” are implemented;  Supporting existing policy recommendations such as “Close the Gap;”  Implementing the findings from the Productivity Commission Inquiry announced in November 2009 into ways of improving long-term care and support for people with disability – including the feasibility of a no- fault social insurance scheme for people with profound disability;  In the broadest sense that is with consideration of the social determinants of health.

7. Performance Measures

7.1 Publicly available performance measures against the National

Drug Strategy that are desirable should include:

 The number of times an organisation, person and/or publication have included a declaration statement on any potential or actual conflicts of interest;  The number of recommendations from key policy documents previously mentioned implemented and evaluated;

7.2 Measures that would give a high level indication of progress

under the National Drug Strategy include:

26  Program performance monitoring and evaluation. Increase the capacity to engage in performance monitoring, review and evaluation. These include programs that have been implemented without documented or funded monitoring and evaluation components built in from the outset. Although a commitment to monitoring and evaluation is part of every phase of the NDS, more action is needed to make it a reality. References

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