Peer-Reviewed Article Abstracts
Cannabis and psychosis
Current Psychiatry Reports 4, 191-196
Louisa Degenhardt and Wayne Hall
There has been considerable debate about the reasons for the association observed between cannabis use and psychosis in both clinical and general population samples. Among the hypotheses proposed to explain the association are the following:1) common factors explain the co-occurrence; 2) cannabis causes psychosis that would not have occurred in the absence of cannabis use, 3) cannabis precipitates psychosis among persons who were vulnerable to developing the disorders; 4) cannabis use worsens or prolongs psychosis among those who have already developed the disorder; and 5) that persons with psychosis are more likely to become regular or problematic cannabis users than persons without psychosis. This article evaluates the evidence on each of theses hypotheses, including recent research on the role of the cannabinoid receptor system in schizophrenia. The evidence suggests that common factors do not explain the comorbidity between cannabis use and psychosis, and it is unlikely that cannabis use causes psychosis among person who would otherwise not have developed the disorder. The evidence is more consistent with the hypotheses that cannabis use may precipitate psychosis among vulnerable individuals, increase the risk of relapse among those who have already developed the disorder, and may be more likely to lead to dependence in persons with schizophrenia.
Copyright © 2002 by Current Science Inc.
Heroin use in New South Wales, Australia, 1996-2000: 5 year monitoring of trends in price, purity, availability and use from the Illicit Drug Reporting System (IDRS)
Addiction 97, 179-186
Shane Darke, Libby Topp, Sharlene Kaye and Wayne Hall
Aims. To document trends in the price, purity, availability and use of heroin in New South Wales detected by the Illicit Drug Reporting System (IDRS) between 1996-2000, and to demonstrate the utility of the IDRS in identifying such trends.
Design. The IDRS compares information derived from interviews with injecting drug users, key informants who work in the illicit drugs field, and key indicator data on illicit drug trends.
Setting. New South Wales, Australia.
Findings. The price of heroin approximately halved over this period, from a median of A$400 per gram in 1996 to A$220 per gram in 2000. While the price of heroin fell dramatically over the study period, the purity of police seizures of the drug was high across all years, ranging between 62% and 71%. In all years heroin was considered easy to obtain by both heroin users who purchased the drug, and by key informants from the law enforcement and health fields. Concurrent with large fall in heroin prices, there appeared to have been an increase in the number of heroin users. Between 1997 and 1998 there was a sharp increase in the injecting use of cocaine by heroin users in NSW, a pattern that has persisted.
Conclusions. Regular and formal monitoring of illicit drug trends provides timely data in a systematic way to inform health and law enforcement policies towards current and emerging illicit drug problems.
www.blackwell-science.com/add
Cannabis dependence in young adults: an Australian population study
Addiction 97, 187-194
Carolyn Coffey, John B. Carlin, Louisa Degenhardt, Michael Lynskey, Lena Sanci and George C. Patton
Objectives. The symptomatology of cannabis dependence remains ill-defined and its importance controversial. Compared with alcohol dependence, the symptom profile of cannabis dependence has received little attention. We aimed to (a) report cannabis use in a representative population of young adults, (b) examine cannabis dependence symptoms according to frequency in the dependence syndrome, and (c) contrast the symptomatology of cannabis and alcohol syndromes.
Methods. 1601 young adults (mean age 20.7 years) from an Australian longitudinal cohort study (N=2032) were surveyed in 1998. Regular substance users were assessed for DSM-IV cannabis and alcohol dependence. Prevalence estimates allowed for sampling variation and attrition.
Results. Fifty-nine per cent reported life-time use of cannabis, 17% used at least weekly and 7% (11% males, 4% females) met criteria for cannabis dependence. Symptom prevalence in dependent cannabis users was: persistent desire 91%; unintentional use 84%; withdrawal 74%; excessive time obtaining/using 74%; continued use despite health problems 63%; tolerance 21%; and social consequences 18%. The combination of withdrawal, persistent desire and unintentional use was reported by 57%. Dependent cannabis users reported compulsive and out-of-control use more frequently than dependent alcohol users, withdrawal similarly and tolerance considerably less often.
Conclusions. Cannabis use appears to be normative behaviour in young Australian. Progression beyond weekly use of cannabis carries a significant risk of dependence that should be considered in the public health response. The differing profiles of cannabis and alcohol dependence, particularly with regard to craving, draws attention to the need for further study of cannabis dependence as an important and distinct disorder in young adults.
www.blackwell-science.com/add
The injection of methadone and benzodiazepines among Sydney injecting drug users 1996-2000: 5-years monitoring of trends from the Illicit Drug Reporting System
Drug and Alcohol Review 21, 27-32
Shane Darke, Libby Topp and Joanne Ross
Trends in the injection of methadone and benzodiazepines by injecting drug users (IDU) recruited in Sydney for the Illicit Drug Reporting System over the period 1996-2000 were examined. A total of 788 IDU were interviewed over the 5-year period. The proportion of IDU reporting recent methadone injecting declined significantly over the study period, from a peak of 31% in 1997 to 13% in 2000. Unlike the injection of methadone, there was no significant difference between the proportions of IDU reporting recent benzodiazepine injecting over the study period, which ranged between 10% and 16%. A consistent minority (range 5-7%) of IDU reported having injected both methadone and benzodiazepine injecting in any individual year. Both methadone and benzodiazepine injecting were independently associated with higher levels of injection related health problems. Given the substantial harms associated with these practices, continued monitoring of their prevalence is warranted.
www.apsad.org.au/danda_fs.html
Public policy and the prevention of substance-use disorders
Current Opinion in Psychiatry 2002, 15:235-239
Catherine Spooner and Wayne Hall
Drug prevention has traditionally focused on influencing individual attitudes and behaviours. In particular, efforts have been directed towards adolescents in the school setting. However, evaluations of school-based drug education have identified limited success. There is increasing recognition that drug abuse is one of a number of risk behaviours, including truancy, delinquency and mental health problems, which share common antecedents that begin in the early years of childhood. Furthermore, these behaviours are shaped by macroenvironmental influences including the economic, social, cultural and physical environment. Drug prevention needs to adopt a broader perspective: with greater attention to the macroenvironmental influences on problem behaviours: and with greater attention to healthy development in the first years of childhood.
The relationship between suicide and heroin overdose among methadone maintenance patients in Sydney, Australia
Addiction 96, 1443-1453
Shane Darke and Joanne Ross
Aims. To examine the relationship between attempted suicide and non-fatal heroin overdose among methadone patients.
Design. Cross-sectional survey.
Setting. Sydney, Australia.
Participants. Two hundred and twenty-three methadone maintenance patients.
Findings. Forty per cent of participants reported a history of at least one suicide attempt. Females were significantly more likely than males to have attempted suicide (50% vs. 31%), and to have done so on more than one occasion (28% vs. 15%). There was a large difference between males ad females in the onset of attempted suicide. Females reported an initial attempt, on average, 6 years earlier than males (18.3 vs. 24.7 years), and were significantly more likely than males to have attempted suicide prior to the onset of heroin use (69% vs. 11%). While heroin overdose was common among the sample (66%), the most common methods employed for suicide attempts were overdose of a non-opioid drug (21%) and slitting of wrists (20%). A deliberate heroin overdose as a means of attempted suicide was reported by 10% of participants. Heroin overdoses appeared overwhelmingly to be accidental. Ninety-two per cent of those who had overdosed reported that their most recent overdose was accidental.
Conclusions. Attempted suicide presents a major clinical problem to staff at drug treatment programmes, but one distinct from heroin overdose. While both overdose and suicide present interesting clinical problems, they are separate problems, and require different responses.
www.blackwell-science.com/add
Ambulance calls to suspected overdoses: New South Wales patterns July 1997 to June 1999
Australian and New Zealand Journal of Public Health 25, 447-450
Louisa Degenhardt, Wayne Hall and Barbara-Ann Adelstein
Aim. Using data on New South Wales ambulance calls to suspected overdoses from July 1997 to June 1999 to: a) examine temporal and geographic trends in calls; and b) compare geographic patterns of fatal and non-fatal opioid overdose.
Method. The NSW Ambulance Service provided data on the occasions when an ambulance attended a person on whom the drug overdose/poisonings protocol was used, and to whom naloxone was administered. The geographic distribution of ambulance attendances was approximated to the Australian Bureau of Statistics Statistical Local Area (SLA) and Statistical Subdivision (SD). Estimates of social disadvantage were correlated with the rate of ambulance attendances for each region.
Results. 9,116 callouts were made. In cases with data on age and gender, 89% were aged between 15-44 years, and 31% were female. South Sydney (n=1,819) and Liverpool (n=1,602) SLAs accounted for 37% of calls; the higher rates outside Sydney were in Newcastle, Orange and Kiama. There was a strong correlation between rates of ambulance callouts and fatal heroin overdoses. The number of calls increased from an average of 361 calls per month in 1997-98 to 399 in 1998-99. The majority of calls (54%) were made between midday and 9pm.
Conclusions. Rates of ambulance attendance at suspected overdoses is a promising indicator that allows monitoring of trends and identification of areas with high rates of opioid use.
The relationship between cannabis use and other substance use in the general population
Drug and Alcohol Dependence 64, 319-327
Louisa Degenhardt, Wayne Hall and Michael Lynskey
This study examined if (1) there is an association in the general population between cannabis use, DSM-IV abuse and dependence, and other substance use and DSM-IV substance abuse/dependence; (2) if so, is it explained by demographic characteristics or levels of neuroticism? It used data from the Australian National Survey of Mental Health and Well-Being (NSMHWB), a stratified, multistage probability sample of 10 641 adults, representative of the general population. DSM-IV diagnoses of substance abuse and dependence were derived using the Composite International Diagnostic Interview (CIDI). There was a strong bivariate association between involvement with cannabis use in the past 12 months and other substance use, abuse and dependence. In particular, cannabis abuse and dependence were highly associated with increased risks of other substance dependence. These associations remained after including other variables in multiple regression. Cannabis use without disorder was strongly related to other drug use, an association that was not explained by other variables considered here. The high likelihood of other substance use and substance use disorders needs to be considered among persons seeking treatment for cannabis use problems.
www.elsevier.com/locate/drugalcdep
Overdose among heroin users: evaluation of an intervention in South Australia
Addiction Research and Theory 9, 481-501
Catherine McGregor, Robert Ali, Paul Christie and Shane Darke
An evidence-based intervention addressing heroin overdose among heroin users was developed and evaluated in South Australia. The intervention comprised three strands: information materials, peer education training and achievement of structural change through the establishment of partnerships with user groups, police and ambulance services. Liaison with police and ambulance services resulted in new guidelines being developed for police attendance at overdoses. Pre- and six months post intervention surveys showed and increase in awareness of risk factors associated with overdose including the concomitant use of other central nervous system depressants with heroin and using heroin while alone. Amongst respondents exposed to the intervention, more rang an ambulance to the most recent witnessed overdose and indicated less fear of police involvement if an ambulance was called. It is concluded that heroin users will respond to appropriate, targeted health education messages developed in conjunction with the user community and implemented using an intersectoral approach.
Alcohol, cannabis and tobacco use among Australians: a comparison of their associations with other drug use and use disorders, affective and anxiety disorders, and psychosis
Addiction 96, 1603-1614
Louisa Degenhardt, Wayne Hall and Michael Lynskey
Aims. To compare relationships between alcohol, cannabis and tobacco indicators of mental health problems in the general population.
Method. A survey of a nationally representative sample of 10,641 Australian adults (the National Survey of Mental Health and Well-Being (NSMHWB)) provided data on alcohol, cannabis and tobacco use and mental health (DSM-IV anxiety disorders, affective disorders, other substance use disorders and screening positively for psychosis)..
Findings. Alcohol showed a ‘J-shaped’ relationship with DSM-IV affective and anxiety disorders: alcohol users had lower rates of these problems than non-users of alcohol, while those meeting criteria for alcohol dependence had the highest rates. Tobacco and cannabis use were both associated with increased rates of all mental health problems examined. However, after controlling for demographics, neuroticism and other drug use, cannabis was not associated with anxiety or affective disorders. Alcohol dependence and tobacco use remained associated with both of these indicators of mental health. All three types of drug use were associated with higher rates of other substance use problems, with cannabis having the strongest association.
Conclusions. The use of alcohol, tobacco and cannabis are associated with different patters of co-morbidity in the general population.
www.blackwell-science.com/add
Heroin purity and composition in Sydney, Australia
Drug and Alcohol Review 20, 439-448
Lisa Maher, Wendy Swift and Michael Dawson
The aim of the study was to provide baseline data on the pharmacological properties of heroin available for retail sale in Cabramatta, Sydney. A retrospective sampling frame was constructed consisting of all suspected heroin seizures in Cabramatta between October 1996 and March 1997 (n = 487). A total of 33 street-level ‘exhibits’, comprising 88 samples, were selected. Ion chromatography was used to determine whether heroin was present as the free base or as the hydrochloride (or other salt). High performance liquid chromatography with diode array detection was used to assess the presence of diacetylmorphine hydrochloride (heroin hydrochloride), 0-6-monoacetylmorphine hydrochloride (degradation product) and acetylcodeine hydrochloride (synthesis byproduct). Gas chromatography/mass spectrometry and high performance liquid chromatography with refractive index detection were used to detect adulterants and diluents. All samples contained heroin as the hydrochloride salt. No heroin free base was encountered. The mean purity was 66% with 85% of samples having an average purity of at least 50%. The samples were free of harmful adulterants. Adulterants detected were pharmacologically inactive diluents largely used to add bulk (sugars) or pharmacologically active adulterants used to improve the bioavailability of heroin HCL when smoked (caffeine). Results have implications for attempts to reduce drug-related harms and, in particular, suggest that interventions designed to facilitate transitions from heroin injecting to smoking require careful consideration of the pharmacological factors associated with routes of administration.
www.apsad.org.au/danda_fs.html
The validity of an Australian modification of the AUDIT questionnaire
Drug and Alcohol Review 20, 143-154
Louisa Degenhardt, Katherine Conigrave, Sonia Wutzke and John Saunders
The Alcohol Use Disorders Identification Test (AUDIT) has been used widely and is reported to be superior to conventional questionnaires in detection of current hazardous and harmful alcohol use. We assessed the validity of an Australian modification of the AUDIT (the AusAUDIT), which has been employed widely in Australian and New Zealand early intervention programmes. We used a cross-sectional study of 370 subjects from the follow-up phase of a randomised controlled trial of early intervention to reduce hazardous alcohol consumption. Scores on the AusAUDIT were compared against 12-month ICD-10 diagnoses of harmful alcohol use and dependence, as determined by the Composite International Diagnostic Interview, and against self-report of alcohol consumption exceeding Australian National Health and Medical Research Council (NH&MRC) recommended limits. AusAUDIT had good internal consistency and discriminated significantly between persons meeting criteria for ICD-10 alcohol use disorders, and drinkers who did not. At currently recommended cut-off scores, AusAUDIT detected more than 85% of people meeting criteria for ICD-10 alcohol use disorders, or drinking over NH&MRC recommended limits, but its specificity was limited (29% in men, and 58% in women for drinking over NH&MRC limits). No subset of questions performed as well as the full AusAUDIT in detection of drinking problems, but the alcohol consumption items provided a reasonable screen for drinking over NH7MRC limits. We conclude that AusAUDIT is effective in detecting problematic drinking, but positive cases should be confirmed by clinical assessment. The findings illustrate the need for validation of questionnaire modifications, and the difficulty in increasing test sensitivity without reducing specificity.
www.apsad.org.au/danda_fs.html
Physical injecting sites among injecting drug users in Sydney, Australia
Drug and Alcohol Dependence 62, 77-82
Shane Darke, Joanne Ross and Sharlene Kaye
A sample of 200 injecting drug users were interviewed about their bodily injection sites. The mean number of injection sites ever used by subjects was 3.1, with a mean of 2.0 sites used in the previous 6 months. Sixteen percent of subjects had injected in five or more sites. Almost all (99%) had injected in the cubital fossa (crook of the arm). The next most popular site was the forearm (71%). Other sites included the hand (53%), foot (19%), leg (18%) and groin (6%). There was a clear progression in sites used, from the cubital fossa at initial injection to the use of such sites as the groin after 10 years of injecting. Females had used significantly more injection sites than males and reported more injection-related problems. The use of more injection sites was independently associated with a greater number of injection-related problems and a greater number of drug classes ever injected.
www.elsevier.com/locate/drugalcdep
A randomised controlled trial of brief interventions for cannabis problems among young offenders
Drug and Alcohol Dependence 63(s1), s32
Jan Copeland, Wendy Swift, John Howard, Roger Roffman, Robert Stephens and James Berghuis
There is a well-identified association between early age of initiation and heavy cannabis use and involvement in crime among adolescents. However, there is a serious gap in the development of effective service provision to this group of young people. This paper describes the methodology and latest progress of a randomised controlled trial of the Cannabis Check-up and the more intensive Cannabis Check-up Plus among 460 young offenders in Sydney, Australia. The Cannabis Check-up is a one session intervention that provides personalised feedback on aspects of cannabis use. The Check-up Plus includes the young person’s family and incorporates two additional sessions of skills based cognitive-behaviour therapy. Subject recruitment will be via a range of strategies such as Children’s Court magistrates, youth justice conferencing and formal police cautions. Participants are re-interviewed for six months following the check-up for cannabis-related and criminal re-offending outcomes. Recent cannabis consumption will be validated at Vaseline and follow-up by urinalysis.
This project is jointly funded through the Commonwealth and NSW State Attorney’s-General Departments.
www.elsevier.com/locate/drugalcdep
The association between psychosis and problematical drug use among Australian adults: findings from the National Survey of Mental Health and Well-Being
Psychological Medicine 31, 659-668
Louisa Degenhardt and Wayne Hall
Background. The present paper aimed to (a) provide Australian estimates of the population-level association between psychotic ‘caseness’ and substance use; (b) examine liability to problematical substance use according to ‘caseness’ via the conditional prevalence (prevalence among users); and (c) examine associations between problematical substance use and the number of psychotic symptoms using ordinal logistic regression.
Method. Data were from the National Survey of Mental Health and Well-Being (NSMHWB), a stratified multi-stage probability sample of Australian adults, using a subset of persons under the age of 50 years (n = 6722). A screener assessed the presence of characteristic psychotic symptoms. Associations between ‘case’ status and DSM-IV alcohol, cannabis and other drug use disorders were examined. Ordinal logistic regressions predicting psychosis scores were carried out, including demographic, mental health and drug use variables.
Results. Ninety-nine persons (1.2%) screened positively for psychosis. Regular tobacco, alcohol and cannabis use were much more common among persons screening positively, as were alcohol, cannabis and other drug disorders. Among alcohol and cannabis users, psychosis ‘cases’ were much more likely to be dependent. Ordinal logisitic regressions revealed that regular tobacco use, cannabis and alcohol dependence, and opiate abuse were predictors of psychosis scores.
Conclusions. The mental health risks of problematical substance use need to be disseminated to persons at risk of, or suffering from, psychotic illness, and to heavy substance users. Work is needed to develop effective treatment approaches for problematical substance use among persons with psychosis.
Outcomes of a comprehensive treatment program for adolescents with a substance-use disorder
Journal of Substance Abuse Treatment 20, 205-213
Catherine Spooner, Richard Mattick and Wesley Noffs
Outcomes of a multimodal residential treatment program for adolescents were compared with usual care. The quasiexperiemntal design included pretest, 3-month posttest, and 6-month follow-up of program referrals (mean age 16; 53% male). The intervention group (IG) comprised referrals who entered the program (n = 61) and the comparison group (CG) comprised referrals who did not enter the program (n = 60). The six outcomes (substance use, criminal behavior, social functioning, psychological distress, physical health, and HIV risk-taking behaviour) were assessed using the Opiate Treatment Index and the Symptom Checklist-90-Revisited. The study groups demonstrated equivalent improvement on all six outcomes. Multiple factors are likely to have influenced these results, including inadequate program implementation and differential drop-out. There was, however, a higher prevalence of multiple improvements among the IG than the CG. It is concluded that adolescents with a PSUD can improve, however, a superior means of achieving this improvement has yet to be demonstrated.
The relationship between cannabis use, depression and anxiety among Australian adults: findings from the National Survey of Mental Health and Well-Being
Social Psychiatry and Psychiatric Epidemiology 36, 219-227
Louisa Degenhardt, Wayne Hall and Michael Lynskey
Background. This study aimed to examine the patterns of association between cannabis use, and anxiety and affective disorders, in the general population.
Method. Data from the Australian National Survey of Mental Health and Well-Being, a representative survey of Australians aged 18 years and over, were analysed to address the following questions: (1) is there an association between cannabis use, DSM-IV abuse and dependence, and DSM-IV affective and anxiety disorders; (2) if so, is it explained by: demographic characteristics, levels of neuroticism, or other drug use; and (3) does the presence of a comorbid affective or anxiety disorder affect the likelihood of treatment seeking among cannabis users?
Results. There was a moderate univariate association between involvement with cannabis use in the past 12 months and the prevalence of affective and anxiety disorders. Among those with DSM-IV cannabis dependence, 14% met criteria for an affective disorder, compared to 6% of non-users; while 17% met criteria for an anxiety disorder, compared to 5% of non-users. These associations did not remain significant after including demographics, neuroticism and other drug use in multiple regressions.
Conclusions. Cannabis use did not appear to be directly related to depression or anxiety when account was taken of other drug use. However, the association between heavier involvement with cannabis use and affective and anxiety disorders has implications for the treatment of persons with problematic cannabis use.
A randomised controlled trial of brief cognitive-behavioral interventions for cannabis use disorder
Journal of Substance Abuse Treatment 21, 55-64
Jan Copeland, Wendy Swift, Roger Roffman and Robert Stephens
The increasing demand for treatment for cannabis dependence in Australia and internationally has led to the identification of significant gaps in knowledge of effective interventions. A randomised controlled trial of brief cognitive-behavioral interventions(CBT) for cannabis dependence was undertaken to address this issue. A total of 229 participants were assessed and randomly assigned to either a six-session CBT program (6CBT), a single-session CBT intervention (1CBT), or a delayed-treatment control (DTC) group. Participants were assisted in acquiring skills to promote cannabis cessation and maintenance of abstinence. Participants were followed up a median of 237 days after last attendance. Participants in the treatment groups reported better treatment outcomes that the DTC group. They were more likely to report abstinence, were significantly less concerned about their control over cannabis use, and reported significantly fewer cannabis-related problems than those in the DTC group. Those in the 6CBT group also reported more significantly reduced levels of cannabis consumption than the DTC group. While the therapist variable had no effect on any outcome, a secondary analysis of the 6CBT and 1CBT groups showed that treatment compliance was significantly associated with decreased dependence and cannabis-related problems. This study supports the attractiveness and effectiveness of individual CBT interventions for cannabis use disorders and the need for multisite replication trials.
Cannabis use and dependence among Australian adults: results from the National Survey of Mental Health and Wellbeing
Addiction 96, 737-748
Wendy Swift, Wayne Hall and Maree Teesson
Aims. To examine: (i) the prevalence of cannabis use and DSM-IV cannabis dependence among Australian adults, and (ii) correlates of levels of cannabis involvement.
Design. Cross-sectional survey assessing substance use and DSM-IV substance use disorders (abuse and dependence).
Settings and participants. A household survey of a nationally representative sample of 10 641 Australians aged 18 years and older.
Measurements. Trained interviewers administered a structured, modified version of the Composite International Diagnostic Interview (CIDI).
Findings: In the past 12 months, 2.2% (95%CI:1.8, 2.6) of adults were diagnosed with DSM-IV cannabis use disorder, comprising cannabis dependence (1.5%;95%CI:1.2,1.8) and cannabis abuse (0.7%, 95%CI:0.6, 0.8). Almost one-third of cannabis users (31.7%; 95%CI:27.7, 35.7) met criteria for cannabis dependence (21%; 95%CI:16.7, 25.3) and abuse (10.7%; 95%CI: 8.0, 13.4). Multinominal logistic regression revealed that compared to non-dependent cannabis users, non-users were more likely to be female, aged 25+ years, out of the labour force and married/de fact, and displayed lower levels of co-morbidity. In contrast, dependent cannabis users were more likely to be 18-24 years old, unemployed, and displayed higher levels of co-morbidity than non-dependent users.
Conclusions: Cannabis use disorders affect approximately 300 000 Australian adults. A better understanding of the factors associated with cannabis dependence may help identify groups who have difficulties controlling use and aid the development of strategies for reducing cannabis-related harm.
www.blackwell-science.com/add
Ketamine and GHB: new trends in club drug use?
Journal of Substance Use 6, 11-15
Paul Dillon and Louisa Degenhardt
Around the world the use of ecstasy and other party drugs appears to be increasing. LSD, amphetamines and cocaine, together with ecstasy and its derivatives, have been a part of the Australian dance party/nightclub scene for some time. In recent years, drugs such as ketamine (‘Special K’) and gammahydroxybutyrate (GHB) have also begun to become popular with some sections of the dance community. Ketamine was developed as a short-acting general anaesthetic for human and veterinary use. Little is known about the illicit use of the drug but a study examining 100 illicit ketamine users found they may experience temporary paralysis, confusion and lack of awareness of time. GHB first appeared in Australian in 1996 when a number of patrons collapsed outside a nightclub after taking what was then called ‘fantasy’. The street name of the drug has changed many times since, to names such as ‘liquid ecstasy’ and ‘liquid E’. Over 200 people overdosed on GHB in a two-month period in 1997, and GHB has caused significant problems for venues and dance party promoters. This paper examines the history of these drugs and their effects. The authors also suggest some possible harm reduction messages for GHB and ketamine users.
Clinical profile of participants in a brief intervention program for cannabis use disorder
Journal of Substance Abuse Treatment 20, 45-52
Jan Copeland, Wendy Swift and Vaughan Rees
The increasing demand for cannabis dependence treatment has led to the identification of significant gaps in the knowledge of effective interventions. A randomized controlled trial of brief cognitive-behavioural interventions (CBT) for cannabis dependence was undertaken to address this issue. A total of 229 participants were assessed and allocated to either a 6-session CBT program, a single-session brief intervention, a or a delayed-treatment control group. This paper demonstrates that individuals with cannabis use disorder will present for a brief intervention program. While they report similar patterns of cannabis use to nontreatment samples, they report a range of serious health and psychological consequences. While they appear relatively socially stable, they typically demonstrated severe cannabis dependence and significantly elevated levels of psychological distress, with the most commonly cited reason for cannabis use being stress relief. There were clinically relevant gender differences among the sample. This study provides more evidence of the demand for, and nature of issues relevant to, interventions for cannabis use disorders, and supports the need for further research into how best to assist individuals with these disorders.
Differential uptake of a smoking cessation programme disseminated to doctors and midwives in antenatal clinics
Addiction 96, 495-506
Margaret Cooke, Richard Mattick, and Raoul Walsh
Aims. Two methods of dissemination (simple and intensive) were used to disseminate a smoking cessation programme to doctors and midwives working in antenatal clinics. This paper describes the differential uptake of the smoking cessation programme by doctors and midwives. It investigates whether the number of smoking cessation interventions used differ due to the type of dissemination. It also examines the frequency with which doctors and midwives provide smoking cessation interventions after dissemination.
Design. Clinics were randomised to the method of dissemination (simple or intensive). Pre-post test design was used to examine the relationship between dissemination method and professional status at baseline and follow-up. A baseline survey collected data on the use of smoking cessation intervention in the clinics prior to dissemination. A follow-up survey was conducted 18 months after the dissemination.
Settings. Twenty-three public hospital antenatal clinics in NSW.
Participants. All clinical staff (midwives and doctors) working in the clinic during the 1-2 week survey period prior to dissemination and 18 months after the dissemination were asked to participate. The response rate was 63% (223) at baseline and 64% (182) at follow-up. Only 48% of midwives and doctors at follow-up were working in the original clinic.
Measures. The proportion of clinicians who initially adopted the programme; the proportion of clinicians who had one or more programme components in the last week; the number of types of smoking cessation intervention provided (maximum=13), and the estimated proportion of clients offered smoking cessation intervention.
Findings: More midwives than doctors ‘ever used’ the programme (76% vs. 25%) and continued to implement (58% vs. 22%) the programme 18 months after dissemination. Both midwives and doctors increased the number of types of smoking cessation intervention offered at follow-up compared to baseline (mean difference 2.8). Midwives provided more smoking cessation interventions than doctors at baseline (mean difference 0.9) and at follow-up (1.6), regardless of method used to disseminate the programme. Midwives’ mean estimates of the proportion of clients offered interventions were greater than doctors’ (midwives’ 59% vs. doctors” 35%) at follow-up.
Conclusions: The dissemination of a smoking cessation programme increased the level of smoking cessation interventions used by doctors and midwives. Doctors and midwives differ in their uptake of smoking cessation programmes. This information can be used to plan programme dissemination strategies in the future.
www.blackwell-science.com/add
Back-projection estimates of the number of dependent heroin users in Australia
Addiction 96, 433-443
Matthew Law, Michael Lynskey, Joanne Ross and Wayne Hall
Aims. To plan an appropriate response to heroin use in Australia, good estimates are needed of the numbers of dependent heroin users, the group who are most in need of treatment, most at risk of fatal opioid overdose and most at risk of contracting and transmitting blood-borne viruses.
Methods. Back-projection methods were used to estimate the numbers of people starting dependent heroin injecting in Australia between 1960 and 1997. Separate analyses were based on national opioid overdose deaths and numbers of new entrants to methadone treatment in New South Wales (NSW). Estimates of the rates at which dependent heroin users cease heroin use, commence methadone treatment or die from opioid overdoses were estimated from external data sources.
Results. Back-projection estimates derived from opioid overdose deaths indicated that there were 104 000 (lower limit of 72 000 and upper limit of 157 000) people who were heroin dependent in Australian between 1960 and 1997. Of these it was estimated that 67 000 (39 000 - 120 000) were still heroin dependent at the end of 1997. Back-projection estimates based on numbers of new entrants to methadone treatment in NSW indicated that there were 108 000 (82 000 - 141 000) heroin-dependent people in Australia between 1960 and 1997, of whom 71 000 (47 000 – 109 000) were estimated to be heroin dependent at the end of 1997. Both analyses indicated that the number of heroin-dependent people in Australia has increased substantially from the early 1970s onwards.
Conclusions: Back-projection estimates based on analyses of treatment entries and opioid overdose deaths provide an additional method for estimating the numbers of heroin-dependent people in the population. The addition of these methods to existing methods, using different data sources and statistical methods, should improve consensus estimates of the numbers of heroin dependent people.
www.blackwell-science.com/add
Is ultra-rapid opioid detoxification a viable option in the treatment of opioid dependence?
CNS Drugs 14, 251-255
Wayne Hall and Richard Mattick
Ultra-rapid opioid detoxification (UROD) involves the acceleration of opioid withdrawal by administering the opioid receptor antagonist naltrexone under general anaesthesia. There is evidence from uncontrolled and a few controlled studies that UROD accelerates opioid withdrawal and that it achieves high rates of completion of acute opioid withdrawal.
However, there is clear evidence that the use of a general anaesthetic is not required to accelerate withdrawal or to achieve high rates of completion of acute opioid withdrawal. These goals can be achieved by using naltrexone or naloxone to accelerate withdrawal under light sedation, a procedure known as rapid opioid detoxification under sedation (ROD). There is also evidence that use of an opioid antagonist is not required to achieve a high rate of completion of acute opioid withdrawal. The mixed agonist-antagonist buprenorphine has achieved comparable rates of completion in similarly selected patients with fewer withdrawal symptoms. There is no evidence from controlled trials that either UROD or ROD increases the rate of abstinence from opioids 6 or 12 months after withdrawal. UROD and ROD may increase the number of patients who are inducted onto naltrexone maintenance (NM) therapy but extensive experience with NM therapy suggests that it only has a limited role in selected patients. Given the lack of evidence of substantially increased rates of abstinence, and the need for anaesthetists and high dependency beds, UROD has at best a very minor role in the treatment of a handful of opioid dependent patients who are unable to complete withdrawal in any other way. ROD may have more of a role as one option for opioid withdrawal in well motivated patients who want to be rapidly inducted onto NM therapy or who want to enter other types of abstinence-oriented treatment.
The THC content of cannabis in Australia: evidence and implications
Australian and New Zealand Journal of Public Health 24, 503-508
Wayne Hall and Wendy Swift
Objective: To examine evidence on three claims that: 1) the THC content of Australian cannabis plants has increased up to 30 times; 2) problems experienced by cannabis users have increased in Australia in recent years; and 3) an increase in THC content is the most likely explanation of any increase in cannabis-related problems.
Methods: These claims were assessed by examining data: 1) on THC potency in Australia, the United States and New Zealand; 2) on cannabis-related problems; and 3) from the 1998 National Drug Strategy Household survey on patterns of cannabis use.
Results: 1) Published data do not show a 30-fold increase in THC potency of cannabis but show a more modest increase in the US. 2) There is suggestive evidence of an increase in cannabis-related problems among people seeking treatment for alcohol and drug problems, juvenile offenders and young adults with psychosis. 3) There are two other more plausible explanations for these reportedly higher rates of cannabis-related problems among adolescents and young adults: (i) more potent forms of cannabis (‘heads’) are more widely used; and (ii) cannabis users are initiating cannabis at an earlier age, thereby increasing the prevalence of harmful patterns of use.
Conclusions: There has probably been a modest increase in the THC content of cannabis, but changing patterns of cannabis use have probably made a larger contribution to any increase in rates of cannabis-related problems among young Australian adults.
Implications: Better data on the THC content of cannabis, the extent of cannabis-related problems and the ability of users to titrate the dose of cannabis would contribute to more informed debate.
The effects of adolescent cannabis use on educational attainment: a review
Addiction 95, 1621-1630
Michael Lynskey and Wayne Hall
This paper reviews research examining the link between cannabis use and educational attainment among youth. Cross-sectional studies have revealed significant associations between cannabis use and a range of measures of educational performance including lower grade point average, less satisfaction with school, negative attitudes to school, increased rates of absenteeism and poor school performance. However, results of cross-sectional studies cannot be used to determine whether cannabis use causes poor educational performance, poor educational performance is a cause of cannabis use or whether outcomes are a reflection of common risk factors. Nonetheless, a number of prospective longitudinal studies have indicated that early cannabis use may significantly increase risks of subsequent poor school performance and, in particular, early school leaving. This association has remained after control for a wide range of prospectively assessed covariates. Possible mechanisms underlying an association between early cannabis use and educational attainment include the possibility that cannabis use induces an ‘amotivational syndrome’ or that cannabis use causes cognitive impairment. However, there appears to be relatively little empirical support for these hypotheses. It is proposed that the link between early cannabis use and educational attainment arises because of the social context within which cannabis is used. In particular, early cannabis use appears to be associated with the adoption of an anti-conventional lifestyle characterized by affiliations with delinquent and substance using peers, and the precocious adoption of adult roles including early school leaving, leaving the parental home and early parenthood.
www.blackwell-science.com/add
The nature of benzodiazepine dependence among heroin users in Sydney, Australia
Addiction 95, 1785-1793
Joanne Ross and Shane Darke
Aims: To determine the extent to which heroin users meet criteria for benzodiazepine dependence, to examine the appropriateness of these criteria for assessing benzodiazepine dependence among this population, and to assess what other substance use, depressive and anxiety disorders are associated with benzodiazepine dependence.
Design: Cross-sectional survey.
Setting: Sydney, Australia.
Participants: Two hundred and twenty-two heroin injectors recruited through advertisements, needle exchanges, methadone maintenance clinics and by word of mouth.
Findings: Twenty six percent (52/202) of those who had used benzodiazepines received a lifetime diagnosis of benzodiazepine dependence, with 22% of current benzodiazepine users being dependent. A principal components analysis revealed that a unidimensional construct underlies the benzodiazepine dependence syndrome. Those respondents with lifetime benzodiazepine dependence were more likely than others to meet criteria for anxiety or depressive disorders.
Conclusions: The inclusion of the benzodiazepine dependence syndrome in DSM-III-R (and DSM-IV) is justified. A disturbingly high proportion of heroin users meet the criteria for benzodiazepine dependence, a condition that should be regarded as a significant marker for comorbidity among this group.
www.blackwell-science.com/add
Cohort trends in the age of initiation of drug use in Australia
Australian and New Zealand Journal of Public Health 24, 421-426
Louisa Degenhardt, Wayne Hall and Michael Lynskey
Objectives: To examine birth cohort trends in the prevalence of use and the age of initiation of use of: alcohol, tobacco, cannabis, amphetamines, LSD, and heroin.
Method: Data were taken from the 1998 National Drug Strategy Household Survey, a survey of a representative sample of Australians aged 14 years and over. Nine five-year cohorts were examined among persons born between 1940 and 1984. The weighted prevalence of use by ages 15 years, 21 years, and lifetime use, was estimated, as was the average age of first use among users. The significance of trends was tested using logistic regression (for lifetime use, use by 15 and 21 years) and linear regression (for age of first use).
Results: Lifetime prevalence of alcohol and tobacco use was similar among all birth cohorts. The prevalence of illicit drug use – cannabis, amphetamines, LSD and heroin – increased with successive birth cohorts. More recent birth cohorts reported using licit and illicit drugs at a younger age.
Conclusions: More recent cohorts are more likely to use illicit drugs at some point in their lives, and to use licit and illicit drugs at younger ages.
Implications: Greater numbers of Australians from more recent birth cohorts may be at risk of developing substance-related problems.
Heroin-related deaths in New South Wales, Australia, 1992-1996
Drug and Alcohol Dependence 60, 141-150
Shane Darke, Joanne Ross, Deborah Zador and Sandra Sunjic
The coronial files of all heroin-related fatalities that occurred in New South Wales (NSW) over the period 1992-1996 were inspected. There were 953 heroin-related fatalities in NSW over the study period. There was a substantial, statistically significant increase in heroin-related fatalities over the study period, from 152 deaths in 1992 to 226 during 1996. The mean age of cases was 31.0 years, 85% were males and 85% were classified as dependent on heroin at the time of death. There was a significant increase in the age of cases over the study period and the proportion of cases that were employed. Fatalities predominantly occurred in home settings (61%). No intervention occurred in 79% of cases. Fifty deaths (5%) occurred in the month following release from prison. 16 of which occurred the first 24 hours after release. Morphine concentrations rose from 0.24 mg/l in 1992 to 0.38 mg/l in 1996. Seventy six percent of cases involved heroin in combination with other drugs: alcohol (46%) benzodiazepines (27%) antidepressants (7%) and cocaine (7%). In only 24% of cases was morphine the sole drug detected. Males were significantly more likely to have alcohol detected at autopsy (49 vs. 24%), while females were more likely to have benzodiazepines detected (41 vs. 17%). The median blood morphine concentration among cases in which alcohol was detected was significantly lower than other cases (0.27 vs. 0.39 mg/l). It is concluded that heroin-related deaths continued to rise throughout the study period, and that deaths were predominant among older, untreated males. Despite the rise in blood morphine concentrations, polydrug use remained the predominant toxicological pattern.
www.elsevier.com/locate/drugalcdep
Australia’s mental health: an overview of the general population survey
Australian and New Zealand Journal of Psychiatry 34, 197-205
Scott Henderson, Gavin Andrews and Wayne Hall
Objectives: The objectives of this study were to estimate the 1-month and 1-year prevalence of mental disorders in the Australian adult population; to determine the amount of disablement associated with this; and to determine the use of health and other services by persons with common mental disorders.
Method: For the Adult Survey, a household sample of 10600 persons aged 18 years and over were interviewed across Australia by experienced field staff of the Australian Bureau of Statistics. This was 78% of the target sample. The interview consisted of the composite international diagnostic interview in its automated presentation (CIDI-A) and other components to determine disablement, use of services and satisfaction with services received. The diagnostic classifications used in the analyses were both ICD-10 and DSM-IV. Only the results from ICD-10 are reported here.
Results: A total of 17.7% of the sample had one or more common mental disorders, anxiety, depression, alcohol or substance abuse and neurasthenia. This morbidity was associated with considerable disablement in daily life: 3 days of impaired social role performance in the previous 4 weeks, compared with 1 day for the general population. Of all cases, 64.6% had had no contact with health services in the previous year; 29.4% had seen GPs and 7.5% had seen psychiatrists.
Conclusion: Australia now has its own national estimates of psychiatric morbidity. The morbidity is associated with considerable disablement, but most of it is untreated. General practitioners encounter by far the largest proportion of those reaching services.
Alcohol and drug-use disorders in Australia: implications of the National Survey of Mental Health and Wellbeing
Australian and New Zealand Journal of Psychiatry 34, 206-213
Maree Teesson, Wayne Hall, Michael Lynskey and Louisa Degenhardt
Objectives: This study reports the prevalence and correlates of ICD-10 alcohol and drug-use disorders in the National Survey of Mental Health and Wellbeing (NSMHWB) and discusses their implications for treatment.
Method: The NSMHWB was a nationally representative household survey of 10641 Australian adults that assessed participants for symptoms of the most prevalent ICD-10 and DSM-IV mental disorders, including alcohol and drug-use disorders.
Results: In the past 12 months 6.5% of Australian adults met criteria for and ICD-10 alcohol and drug-use disorder and 2.2% had another ICD-10 drug-use disorder. Men were at higher risk than women of developing alcohol and drug-use disorders and the prevalence of both disorders decreased with increasing age. There were higher rates of comorbidity between alcohol and drug-use disorders and mental disorders and low rates of treatment seeking. Conclusion: Alcohol-use disorders are a major mental health and public health issue in Australia. Drug-use disorders are less common than alcohol-use disorders, but still affect a substantial minority of Australian adults. Treatment seeking among persons with alcohol and other drug-use disorders is low. A range of public health strategies (including improved specialist treatment services) are needed to reduce the prevalence of these disorders.
Prevalence of cognitive impairment among homeless people in inner Sydney
Psychiatric Services 51, 520-521
Neil Buhrich, Tracey Hodder and Maree Teesson
The prevalence of cognitive impairment was assessed among a cohort of homeless men and women selected randomly from the dining rooms of the seven largest hostels offering emergency shelter in inner Sydney. They were interviewed using sections of the Composite International Diagnostic Interview 2.0. A total of 204 subjects (155 men and 49 women) were interviewed, of whom 20 (10 percent) showed evidence of cognitive impairment as assessed by the Mini Mental State Examination. Subjects with cognitive impairment were significantly older than those without impairment (mean ages of 57 and 41, respectively). Reasons for cognitive impairment among homeless individuals are complex an remain to be elucidated.
Interventions for people with alcohol use disorders and an intellectual disability: a review of the literature
Journal of Intellectual and Developmental Disability 25, 2, 135-146
Louisa Degenhardt
Alcohol is the most commonly used psychoactive substance in the general population, and alcohol use disorders are among the most common forms of mental illness. Prolonged heavy drinking can cause cognitive and physical impairment, and is associated with other mental disorders. There are a number of additional issues concerning problematic alcohol use that are of particular significance to those with an intellectual disability, particularly concerning the unique medical and psychological effects of prolonged alcohol use occurs. This paper presents an outline of the intervention that may be appropriate for an adult with an alcohol use disorder and an intellectual disability. Future research is needed to evaluate the efficacy of interventions with this client group.
Cognitive impairment among methadone maintenance patients
Addiction 5, 687-696
Shane Darke, Jamie Sims, Skye McDonald and Wendy Wickes
Aims: To compare the cognitive performance of methadone maintenance patients (MMPs) and a matched sample of non-heroin-using control subjects, and to ascertain risk factors for poorer cognitive performance.
Design: Matched control study
Setting: Sydney, Australia
Participants: 30 MMPs and 30 non-heroin using controls, matched for age, gender and education.
Findings: The MMP group had significantly higher rates than controls of alcohol dependence, heroin overdose and head injury. There was no difference between the groups on premorbid functioning. The MMP group performed significantly poorer than controls on all of the neuropsychological domains measured: information processing, attention, short-term visual memory, delayed visual memory, short-term verbal memory, long-term verbal memory and problem solving. A lifetime diagnosis of alcohol dependence and the number of non-fatal heroin overdoses were independent significant predictors of poorer cognitive performance.
Conclusions: In addition to high rates of psychiatric morbidity, MMPs also show cognitive deficits compared to matched controls. A history of alcohol dependence and repeated exposure to overdose increase the likelihood of cognitive impairment. The current study does not rule out the possibility of other factors, that were not measured, that may contribute to cognitive impairment among this MMPs.
www.blackwell-science.com/add
Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia
Drug and Alcohol Review 19, 337-346
Kate Dolan, Jo Kimber, Craig Fry, John Fitzgerald, David McDonald and Franz Trautmann
Rooms set aside for the consumption of illicit drugs have been referred to as drug consumption facilities, or rooms, health rooms or injecting rooms in Europe. Terms used in the Australian context include medically supervised injecting centres (in NSW), supervised injecting place (in the ACT) and off-street injecting facilities (in Victoria) among others. In this article the term ‘supervised injecting centre’ or 'Centre' will be used to denote the facility as a whole and ‘injecting or smoking room’ will be used to refer to the actual space in which drug consumption occurs.
These supervised injecting centres differ from illegal shooting galleries which operated in New York in the 1980s and in Sydney in the 1990s. These galleries operate for a profit and with little regard for the health and safety of patrons. In contrast, supervised injecting centres are sanctioned and professionally staffed health and welfare services. The four main expected benefits of supervised injecting centres are: reduction in public nuisance; reduction in opioid-related overdoses (both fatal and non-fatal); reduction in blood-borne virus transmission and improved access of health and other welfare services. Common objections to these Centres include; sending the 'wrong message' or condoning drug use, the 'honey pot effect' - the congregation of drug users and drug dealers, and delayed entry to drug treatment.
The purpose of this paper is to draw together available information on supervised injecting centres. We describe Centres in the Netherlands, Switzerland and Germany and then review available literature. Recent events within three Australian jurisdictions that plan to trial these facilities – NSW, Victoria and the Australian Capital Territory - are outlined.
www.apsad.org.au/danda_fs.html
Heroin-related deaths in regional New South Wales, 1992-96
Drug and Alcohol Review 19, 35-40
Shane Darke and Joanne Ross
The coronial files of all 188 heroin-related fatalities that occurred in regional New South Wales between 1992 and 1996 were inspected. There was a significant increase in fatalities, rising from 23 deaths in 1992 to 53 during 1996. The regions in which the most deaths occurred were Wollongong /Illawarra (43 deaths), Newcastle/hunter (35) and the far north coast (25). The mean age of cases was 31.5 years and 83% were males, and there were no significant trends in demographic characteristics of cases over the study period. the medium blood morphine concentration of cases was 0.39 mg/1 (range 0.05-4.5 mg/1). Alcohol was detected in 50% of cases and benzodiazepines in concentrations ranging from 0.25 mg/1 among south coast cases to 0.56 mg/1 in mid-western New South Wales. Compared to Sydney metropolitan cases, regional cases had a higher median blood morphine concentration, were less likely to have cocaine detected, were more likely to have died in a home environment and to have been born in Australia.
www.apsad.org.au/danda_fs.html
Fatal heroin overdoses resulting from non-injecting routes of administration, NSW, Australia, 1992-1996
Addiction 95(4), 569-573
Shane Darke and Joanne Ross
Aims: To document cases of fatal heroin overdose in New South Wales by non-injecting routes of administration, and to compare the characteristics and toxicology of these cases with injecting fatalities.
Design: Examination of coronial files.
Settings: New South Wales, Australia.
Participants: All fatal heroin overdose cases in NSW between 1992 and 1996.
Findings: There were 10 cases of death resulting from non-injecting routes of heroin administration between 1992 and 1996, representing 1% of cases. In three cases the route of administration was by inhalation, in five cases by nasal administration and in two cases by swallowing. The mean age of cases was 29.6 years, and nine of the cases were male. The median blood morphine concentration of non-injectors was 0.31 mg/l (range 0.06-0.99 mg/l). Drugs other than morphine were also detected in seven cases.
Conclusions: Heroin overdose deaths are not restricted to the injection of heroin. While injection may constitute a greater overdose risk-factor, there is no safe, overdose-free way to use heroin.
www.blackwell-science.com/add
The use of antidepressants among injecting drug users in Sydney, Australia
Addiction 95(3), 407-417
Shane Darke and Joanne Ross
Aims: To ascertain the prevalence and patters of antidepressant use among IDU in Sydney and to determine any harm associated with antidepressant use.
Design: Cross-sectional survey.
Setting: Sydney, Australia.
Participants: Two hundred and one Sydney injecting drug users (IDU) recruited through advertisements, needle exchanges, methadone maintenance clinics and by word of mouth.
Findings: Forty per cent of subjects had used antidepressants, 21% in the preceding 6 months. Similar proportions of subjects had used tricyclics (26%) and selective serotonin reuptake inhibitors (SSRIs) (24%) with 8% reporting use of a monoamine oxidase inhibitor. Recent use favoured the SSRIs: however, there was still widespread of tricyclics. The injection of antidepressant was rare, with only three subjects reporting ever having injected the drugs. Antidepressant use was associated with higher levels of polydrug use, poorer health, higher levels of psychiatric distress and a greater risk of heroin overdose. The excess risk of overdose was specifically associated with tricyclics, rather than SSRIs.
Conclusions: The study confirmed that, like other pharmaceutical products, the use of antidepressants was common among IDU in Sydney. The prescription of tricyclics to heroin users would appear to increase their risk of overdose. if it is considered appropriate to prescribe antidepressants to IDU, it would appear safer to prescribe SSRIs.
www.blackwell-science.com/add
Trends in opiate-related deaths in the United Kingdom and Australia, 1985-1995
Drug and Alcohol Dependence, 57, 247-254
Wayne Hall, Michael Lynskey and Louisa Degenhardt
This paper compares data on rates of opiate overdose mortality in the UK and Australia between 1985 and 1995. Data on rates if ICD 9-coded overdose mortality were obtained from the Office of National Statistics in the UK and from the Australian Bureau of Statistics mortality register. The proportion of all deaths attributed to opioid overdose increased in both countries between 1985 and 1995. The proportion of all deaths attributed to opioid was substantially higher in Australia than in the UK, both methadone appeared to contribute to more opioid overdose deaths in the UK (50%) than in Australia (18%). Given deficiencies in the available data, the reasons for these differences between the two countries are uncertain but a plausible hypothesis is that the greater availability and ease of access to methadone maintenance in the UK contributes to both the lower rate of opioid overdose mortality and the greater apparent contribution that methadone makes to opioid overdose deaths in that country.
www.elsevier.com/locate/drugalcdep
Causes and correlates of adolescent drug abuse and implications for treatment
Drug and Alcohol Review 18, 453-475
Catherine Spooner
On the basis of the literature, the following risk factors for drug abuse by adolescents were identified: biological predisposition to drug abuse; personality traits that reflect a lack of social bonding; a history of low quality and consistency of family management, family communication, family relationships and parental role-modelling, a history of being abused or neglected; low socio-economic status; emotional or psychiatric problems; significant stressors and/or inadequate coping skills and social supports; inadequate social skills; history of associating with drug-using peers, rejection by prosocial peers due to poor social skills; a history of low commitment to education, failure at school; a history of anti-social behaviour and delinquency and early initiation to drug use. Models for conceptualising the aetiology of drug abuse are discussed, namely Jessor’s problem behaviour syndrome and Rhodes & Jason’s Social Stress Model. It is clear that the path to drug abuse is complex, so simple solutions to the problem are unlikely to be effective.
www.apsad.org.au/danda_fs.html
Hepatitis C virus antibody prevalence among injecting drug users at selected needle and syringe programs in Australia, 1995-1997
Medical Journal of Australia 172, 57-61
Margaret A MacDonald, Alex D Wodak, Kate A Dolan, Ingrid van Beek, Philip H Cunningham, and John M Kaldor
Objectives: To describe point prevalence of HCV antibody and relevant risk behaviour among people who inject drugs and who attended selected needle and syringe programs throughout Australia in 1995, 1996 and 1997.
Design and setting: Repeated cross-sectional surveys of one week’s were carried out in 21, 20 and 23 needle and syringe program sites throughout Australia in 1995, 1996 and 1997, respectively.
Participants: All clients attending participating sites during the designated survey week were asked to complete a self-administered questionnaire and provide a finger-prick blood sample for HCV antibody testing.
Main Outcome measure: Prevalence of HCV antibody.
Results: Survey response was 41% (n=979) in 1995, 51% (n=1463) in 196 and 48% (n=1699) in 1997. HCV prevalence declined significantly from 63% in 1995 to 51% in 1996 and 50% in 1997 (p< 0.001). Among respondents who reported injecting for less than three years, prevalence declined from 22% in 1995 to 13% in 1996 and 1997 (P<0.001). Reported use of needles and syringes after someone else in the previous month declined from 31% in 1995 and 28% in 1996 to 15% in 1997 (P< 0.001).
Conclusions: Despite an apparent decline in HVC prevalence, carriage rates of HCV antibody remain high.
Cannabis use and psychosis: a review of clinical and epidemiological evidence
Australian and New Zealand Journal of Psychiatry 2000: 34:26-34>
Wayne Hall and Louisa Degenhardt
Objective: This paper evaluates evidence for two hypotheses about the relationship between cannabis use and psychosis: (i) that heavy cannabis use causes a ‘cannabis psychosis’, ie a psychotic disorder that would not have occurred in the absence of cannabis use and which can be recognised by its pattern of symptoms and their relationship to cannabis use; and (ii) that cannabis use may precipitate schizophrenia, or exacerbate its symptoms.
Method: literature relevant to drug use and schizophrenia is reviewed.
Results: There is limited clinical evidence for the first hypothesis. If ‘cannabis psychoses’ exist, they seem to be rare, because they require very high doses of existing (but as yet unspecified) vulnerability, or both. There is more support for the second hypothesis in that a large prospective study has shown a linear relationship between the frequency with which cannabis had been used by age 18 and the risk over the subsequent 15 years of receiving a diagnosis of schizophrenia.
Conclusion: It is still unclear whether this means that cannabis use precipitates schizophrenia, whether cannabis use is a form of ‘self-medication’, or whether the association is due to the use of other drugs, such as amphetamines, which heavy cannabis users are more likely to use. There is better clinical and epidemiological evidence that cannabis use can exacerbate the symptoms of schizophrenia.
Event-related potential indices of auditory selective attention in dependent amphetamine users
Biological Psychiatry 45, 1488-1497
Rebecca McKetin and Nadia Solowij
Background: The aim of the present study was to further investigate a previously reported attention-related impairment in dependent amphetamine users using event-related potential (ERP) indices of selective attention.
Methods: ERPs were recorded during an auditory selective attention task (SAT) that involved detecting infrequent long-duration target tones presented among short-duration tones that varied in location (left vs right ear) and pitch (low vs high). Amphetamine users (n=19) were divided into two groups, high dependence (n=10) and low dependence (n=10), based on amphetamine Severity of Dependence Scale scores, and compared to an age-matched control group (n=9).
Results: The high-dependence group showed slowed reaction time and reduced early processing negativity and peak N1 amplitude to location-relevant nontarget stimuli. Poor performance on the SAT was highly correlated with deficits in early processing, which were also related to poor performance on the Wechsler Memory Scale Attention/Concentration index.
Conclusions: It is suggested that severely dependent users suffer an inability to selectively enhance the sensory processing of relevant auditory information. This may produce poor automatic preferential processing of relevant information and increase load on limited attentional resources.
Opioid overdose mortality in Australia, 1964-1997: birth-cohort trends
Medical Journal of Australia 171, 1, 34-37
Wayne Hall, Louisa Degenhardt and Michael Lynskey
Objective: To examine trends in rates of opioid overdose deaths from 1964 to 1997 in different birth conhorts
Design: Age-period-cohort analysis of national data from the Australian Bureau of Statistics.
Main outcome measures: Annual population rates of death attributed to opioid dependence or accidental opioid poisoning in people aged 15-44 years, by sex and birth cohort (in five-year intervals, 1940-1944 to 1975-1979).
Results: The rate of opioid overdose deaths increased 55-fold between 1964 and 1997, from 1.3 to 71.5 per million population aged 15-44 years. The rate of opioid overdose deaths also increased substantially over the eight birth cohorts, with an incidence rate ratio of 20.70 (95% confidence interval, 13.60-31.46) in the 1975-1979 cohort compared with the 1940-1944 cohort. The age at which the cumulative rate of opioid overdose deaths reached 300 per million fell in successive cohorts (for men, from 28 years among those born 1955-1959 to 22 years among those born 1965-1974; for women, from 33 years among those born 1955-1959 to 27 years among those born 1965-1969).
<B>Conclusions:<B> Heroin use in Australia largely began in the early 1970s and rates of heroin use have markedly increased in birth cohorts born since 1950.
HIV transmission in a prison system in an Australian State
Medical Journal of Australia 171, 1, 14-17
Kate Dolan and Alex Wodak
Objective: To investigate possible HIV transmission among prison inmates.
Setting: A prison system in an Australian State.
Participants: 13 ex-prisoners and their prison contacts.
Methods: Ex-prisoners who claimed to have been infected with HIV in prison and their prison contacts were interviewed about HIV risk behaviour. Entries in prison and community medical records were used by a three-member expert panel to establish the likelihood of primary HIV infection and its possible timing and location.
Main outcome measures: Determination of whether HIV infection probably occurred in prison.
Results: There was a very high probability that at least four of 13 ex-prisoners investigated acquired HIV in prison from shared injection equipment. Another two ex-prisoners most probably acquired HIV infection outside prison. The location of infection for the remaining seven could not be deternmined.
Conclusions: HIV transmission in prison has substantial public health implications as most drug-using prisoners soon return to the community. HIV prevention strategies known to be effective in community settings, such as methadone maintenance treatment and syringe exchange scheme, should be considered for prisoners.
Ecstasy use in Australia: patterns of use and associated harm
Drug and Alcohol Dependence 55, 105-115
Libby Topp, Julie Hando, Paul Dillon, Ann Roche and Nadia Solowij
This study explored patterns of ecstasy use and associated harm through the administration of a structured interview schedule to 329 ecstasy users, recruited from three Australian cities. A broad range of ecstasy users were interviewed, but on the whole, the sample was young, relatively well educated and most were employed or students. Patterns of use were varied, although extensive polydrug use was the norm. High rates of intravenous drug use were recorded, which may relate to an over-representation of chaotic intravenous polydrug users. Subjects had experienced an average of eight physical and four psychological side-effects, which they attributed to their ecstasy use in the preceding 6 months. Approximately 40% of the sample also reported financial, relationship and occupational problems. Young, female, polydrug users and those who binged on ecstasy for 48 hours or more appeared most at risk of experiencing harm that they related to their ecstasy use. One-fifth of the sample had received treatment for an ecstasy-related problem, most often from a GP or natural therapist, and 7% were currently in treatment. One quarter wanted to reduce their use because of financial, relationship and psychological problems. A total of 15% wanted formal treatment for an ecstasy-related problem and 85% requested more information. These results have implications for the development of policies to respond to drug use among this population.
www.elsevier.com/locate/drugalcdep
HIV risk behaviour and prevention in prison: a bleach programme for inmates in NSW
Drug and Alcohol Review 18, 139-143
Kate Dolan, Alex Wodak and Wayne Hall
One hundred and eighty-one inmates in AIDS education courses were surveyed about their risk behaviour and access to disinfectants for syringe cleaning in 1993. Overall, 40% of respondents reported HIV risk behaviour in prison. One-quarter of respondents reported injecting, of whom three-quarters reported sharing syringes in prison. Most respondents who shared syringes reported cleaning them with disinfectant (96%), even though only one-third reported having easy access to disinfectants. One-sixth of respondents reported sharing tattooing equipment, of whom two-thirds reported using a disinfectant to clean the tattoo needle. Few respondents reported fellatio (8%) or anal intercourse (4%) in prison. Although some respondents faced difficulty in obtaining disinfectants, almost all respondents cleaned syringes with bleach when sharing. High levels of risk behaviour in prison might be reduced by methadone maintenance and condom programmes. A trial of strict one-for-one syringe exchange warrants consideration.
www.apsad.org.au/danda_fs.html
Sexual behaviour of ecstasy users in Sydney, Australia
Culture, Health and Sexuality 1, 2, 147-159
Libby Topp, Julie Hando and Paul Dillon
Although ecstasy has enjoyed a reputation as an enhancer of sexual performance in the media, little research has examined the effects it has on sexual behaviour. As part of a larger survey involving personal interviews with 213 ecstasy users, the HIV Risk-Taking Behaviour Scale (HRBS) was administered to examine extent of sexual risk-taking while intoxicated and not, along with items concerning the effects of ecstasy on sex. Results indicated that 77% of the sample had engaged in penetrative sex in the preceding month and that 49% had had sex while intoxicated in the preceding six months. There was a tendency to use condoms less often with casual partners while intoxicated than while not. Ecstasy use and age were more consistent predictors of sexual risk-taking than gender and sexual identity. Most subjects reported that ecstasy improved sex (70%) and lowered inhibitions (67%). However, 45% also reported that ecstasy inhibited arousal and/or climax. Twelve percent reported a loss of sex urge related to ecstasy use in the preceding six months, lasting for an average of 48 hours. Results suggested that the effects of ecstasy on sex are idiosyncratic and that better education on the risks of unsafe sexual activity for ecstasy users is warranted.
Exploring the relationship between male homo-bisexuality, body image and steroid use
Culture, Health and Sexuality 1, 4, 317-327
Paul Dillon, Jan Copeland and Richard Peters
This study aimed to determine the characteristics of anabolic-androgenic steroid (AAS) users to determine their motivations for use, and to examine the patterns and correlates of AAS use, with particular attention to homo/bisexual men. A personal interview was conducted with 100 current AAS users in New South Wales, Australia using a structured questionnaire divided into ten separate sections: demographics; patterns of AAS use; reasons for AAS use; opinions and attitudes concerning AAS; training activity; sources of steroids; AAS information sources; effects of AAS; lifestyle issues including legal and illegal drug use; and deterrents to AAS use. This predominantly male sample (94%) included 27% homo/bisexual men. Homo/bisexual users reported a different pattern of AAS use from the heterosexual users. They started using at a later age and used smaller quantities less frequently. Homo/bisexual users were also more likely to identify as body image users and indicate their motivation to use AAS on their first and most recent occasion was to improve appearance, although there were no significant differences between homo/bisexuals and heterosexuals in relationship to perceptions of body shape. The homo/bisexual men in this sample were also far more likely to have used a wide range of illicit drugs.
Community-based drug and alcohol counselling: who attends and why?
Drug and Alcohol Review 21, 153-162
Anthony Shakeshaft, Jenny Bowman and Rob Sanson-Fisher
In order to develop and tailor treatment approaches in drug and alcohol counselling accurately, it is necessary to identify characteristics of the relevant client group. This study describes the demographic and substance use characteristics of 1,212 community-based drug and alcohol counselling clients from a regional Area Health Service in NSW, Australia. Findings identify these clients as predominantly young, unmarried, unemployed, males with low incomes. Alcohol use is characterised by binge consumption (83%) and alcohol-related problems (94%). A substantial proportion use tobacco (74%), cannabis (61%), opiates (15%) and amphetamines (22%). Of those using illicit drugs other than marijuana, the incidence of sharing syringes (10%) is of concern. These data differ from those reported by both general practice patients in the same geographical area, as a treatment seeking population in an alternative community-based setting, and a general community sample. It is argued that there is a need for interventions delivered in community-based drug and alcohol settings that are aimed specifically at poly-drug use, attempt to minimise drug related harm and are relevant to those of lower socio-economic status.
www.apsad.org.au/danda_fs.html
Accidental fatalities among heroin users in South Australia, 1994-1997: toxicological findings and circumstances of death
Addiction Research and Theory 10, 335-346
Catherine McGregor, Robert Ali, Robert Lokan, Paul Christie and Shane Darke
A total of 101 accidental deaths were identified among heroin users in South Australia for the period 1994-1997. Mean age at death was 29.9 years. Cases typically involved a single, unemployed, Caucasian male in his late twenties with a history of heroin and other drug use. Two or more drug types were detected in 80% of cases. The total number of substance types identified increased significantly with age. In comparison to younger fatalities, alcohol and benzodiazepines were identified in more of those 27 years of age and over. Thirteen deaths occurred within four weeks of release from prison and in nine cases tricyclic anti-depressants were found. The majority of deaths occurred in a private home and in the presence (or near proximity) of others. Identified risk factors included: being male, being a long-term heroin user; recent release from prison; use of tricyclic antidepressants and/or other central nervous system depressants.
Hair morphine concentration of fatal heroin overdose cases and living heroin users
Addiction 97. 977-984
Shane Darke, Wayne Hall, Sharlene Kaye, Joanne Ross and Johan Dulfou
Aims To compare heroin and other opiate use of heroin overdose fatalities, current street heroin users and drug-free therapeutic community clients.
Design Hair morphine concentrations that assess heroin use and other opiate use in the 2 months preceding interview or death were compared between heroin overdose fatalities diagnosed by forensic pathologists (FOD) (n = 42), current street heroin users (CU) (n = 100) and presumably abstinent heroin users in a drug-free therapeutic community (TC) (n = 50).
Settings Sydney, Australia.
Findings The mean age and gender breakdown of the three samples were 32.3 years, 83% male (FOD), 28.7 years, 58% male (CU) and 28.6 years, 60% male (TC). The median blood morphine concentration among the FOD cases was 0.35mg/l, and 82% also had other drugs detected. There were large differences between the three groups in hair morphine concentrations, with the CU group (2.10 ng/mg) having concentration approximately four times that of the FOD group (0.53 ng/mg), which in turn had a concentration approximately six times that of the TC group (0.09 ng/mg). There were no significant differences between males and females in hair concentrations within any of the groups. Hair morphine concentrations were correlated significantly with blood morphine concentrations among FOD cases (r=0.54), and self-reported heroin use among living participants (r=0.57).
Conclusions The results indicate that fatal cases had a lower degree of chronic opiate intake that the active street users, but they were not abstinent during this period.
www.blackwell-science.com/add
Morbidity associated with non-fatal heroin overdose
Addiction 97, 963-967
Matthew Warner-Smith, Shane Darke & Carolyn Day
Aims To estimate the range and severity of heroin overdose related morbidity.
Design Cross-sectional survey.
Setting Sydney, Australia.
Participants 198 heroin users.
Findings Sixty-nine per cent had experienced a heroin overdose, 28% in the preceding 12 months. Of those who had overdosed, 79% had experienced at least one overdose-related morbidity symptom. An ambulance had attended overdoses for 59% of subjects, 33% had required hospital treatment for overdose, and 14% had experienced overdose-related complications of sufficient severity to be admitted to a hospital ward. Indirect overdose-related morbidity included: physical injury sustained when falling at overdose (40%), burns (24%) and assault while unconscious (14%). Direct overdose-related morbidity included: peripheral neuropathy (49%), vomiting (33%), temporary paralysis of limbs (26%), chest infections (13%) and seizure (2%).
Conclusions There appears to be extensive morbidity associated with non-fatal overdose. This is clearly an area that requires more research to document the prevalence and nature of these harms, and factors associated with them.
www.blackwell-science.com/add
Results from the 4th National Clients of Treatment Service Agencies census: changes in clients' substance use and other characteristics
Australia and New Zealand Journal of Public Health 26,
Fiona Shand and Richard Mattick
Objective: The 2001 Clients of Treatment Service Agencies (COSTA) census, the fourth since 1990, was conducted to enable a comparison of the drug and alcohol-related problems being treated over an 11-year period.
Method: The 24-hour census was conducted on Wednesday 2 May 2001 in all Australian States and Territories. All agencies providing treatment for drug and alcohol problems in Australia were asked to provide demographic, treatment and substance use information about all clients treated on census day. The data were analysed with frequencies and basic descriptive statistics.
Results: Of the agencies surveyed, 90.3% responded. The census suggests that, among the treatment population, the mean age of substance users has decreased and the proportion of clients who are women has increased. Treatment for opiate, cannabis and amphetamine problems increased; treatment for alcohol problems decreased. Substance use patterns differed according to sex, age, size of the population centre, and Indigenous status.
Conclusions and Implications: Changes among the treatment population reflect changes in demographics and substance use among the broader drug-using community, with the exception of the presentation of alcohol problems for treatment. The reasons for the apparent decline in treatment for alcohol problems are not clear, although a number of factors, such as changes in treatment strategies and facilities and relative increases in other substance use problems, are considered. Any decrease in treatment for a significant health problem such as alcohol use disorder will have considerable public health implications.
Substitution therapy for amphetamine users
Drug and Alcohol Review 21, 179-185
James Shearer, John Sherman, Alex Wodak and Ingrid Van Beek
At the commencement of the third millennium, the illicit use of amphetamines continues to be a growing problem in many countries around the world, yet treatment responses remain in need of further development. This is particularly true with regards to pharmacotherapy for amphetamine dependence. In this Harm Reduction Digest four authors who bring together considerable research and clinical experience in this area describe the nature of amphetamine-related problems and consider the role of amphetamine agonists in substitution therapy for amphetamine dependence. This is a timely paper which should be of interest to clinicians, researchers and regulators.
www.apsad.org.au/danda_fs.html
‘Diagnostic orphans’ among young adult cannabis users: persons who report dependence symptoms but do not meet diagnostic criteria
Drug and Alcohol Dependence 67, 205-212
Louisa Degenhardt, Michael Lynskey, Carolyn Coffey and George Patton
Objective: To examine the characteristics of ‘diagnostic orphans’ among cannabis users-those who report one or two symptoms of DSM-IV dependence but do not meet diagnostic criteria for DSM-IV abuse or dependence.
Method: Data were collected from a representative population cohort of 1601 young adults aged 20-21 years. Those who reported that they had used cannabis at least weekly at some point within the past year were assessed for symptoms of DSM-IV cannabis abuse and dependence using the Composite International Diagnostic Interview.
Results: Approximately 2.8% of the cohort could be classified as diagnostic orphans, with another 3.0 and 7.5% meeting criteria for abuse and dependence, respectively. Diagnostic orphans were: similar to those who met criteria for cannabis abuse or dependence in terms of demographic characteristics, similar to those who met criteria for cannabis abuse in terms of cannabis use patterns: and similar to those who met criteria for abuse and dependence in the rates of heavy alcohol use and DSM-IV alcohol dependence. However, they did not appear to have elevated rates of illicit drug use or mental health problems compared to non users.
Conclusions: Diagnostic orphans reported using cannabis in a manner similar to persons meeting criteria for cannabis abuse, and had similar rates of alcohol dependence and other illicit drug use. Strict adherence to DSM-IV diagnoses of abuse and dependence may overlook a substantial proportion of young persons who experience cannabis-related problems. There is a need to consider (a) subthreshold levels of cannabis-related problems among those seeking treatment for other problems: and (b) interventions for this group to prevent escalation of such problems.
www.elsevier.com/locate/drugalcdep
Determining a diagnostic cut-off on the Severity of Dependence Scale (SDS) for cocaine dependence
Addiction 97, 727-731
Sharlene Kaye and Shane Darke
Aim The study aimed to assess the efficacy of the Severity of Dependence Scale (SDS) as a diagnostic measure of cocaine dependence and determine the cut-off score that best discriminates between the presence and absence of a DSM-IV diagnosis of cocaine dependence.
Design Cross-sectional survey.
Setting Sydney, Australia.
Participants One hundred and forty-two cocaine users.
Measurements The diagnostic performance of the SDS was measured via ROC analysis against DSM-IV diagnoses of cocaine dependence, as measured by Composite International Diagnostic Interview (CIDI).
Findings ROC analysis revealed the SDS to be a test of high diagnostic utility for the measurement of cocaine dependence. The cut-off point on the SDS at which there is optimal discrimination between the presence and absence of a DSM-IV diagnosis of cocaine dependence was found to be 3 (i.e. a score of 3 or more).
Conclusions The study statistically validated the utility of the SDS as a diagnostic measure of cocaine dependence and has determined an appropriate cut off point. The SDS is recommended as a brief screening instrument for cocaine dependence that can be used in addition to more comprehensive measures such as the CIDI.
www.blackwell-science.com/add
Cocaine use in New South Wales, Australia, 1996-2000: 5 year monitoring of trends in price, purity, availability and use from the illicit drug reporting system
Drug and Alcohol Dependence 6, 81-88
Shane Darke, Sharlene Kaye and Libby Topp
This paper describes trends in the price, purity availability and use of cocaine in Sydney, Australia monitored by the Illicit Drug Reporting System (IDRS) between 1996-2000. The IDRS monitors illicit drug trends by means of triangulation of data from interviews with injecting drug users (IDU), reports of key informants, and analysis of indicator data. The price of a ‘cap’ of cocaine fell from A$80 in 1997 to A$50 in 1998, and remained at the lower price in subsequent years. Cocaine purity was high in all years (range 50-64%), and was highest in the 1997-1998 period. The availability of cocaine and its use by IDU increased substantially, 1997 and 1998, and remained high in subsequent years. The median number of cocaine use days also increased substantially between 1997 (4 days) and 1998 (25 days), and remained at higher levels than prior to 1998 in subsequent years. Cocaine use was primarily of powder, by injection, and strongly associated with existing heroin injectors. The availability and use of crack remained rare in Sydney. Use of cocaine among IDU was associated with more frequent injections, more injection-related health problems, higher levels of needle sharing, and higher levels of criminality. It is concluded that the use and availability of cocaine in Sydney increased substantially between 1997 and 1998, and has remained entrenched in the Sydney illicit drug market. The regular and formal monitoring of illicit drug trends enabled substantial changes in the cocaine market in Sydney to be detected, and the information to be fed back to the health and law enforcement sectors.
www.elsevier.com/locate/drugalcdep
GHB use among Australians: characteristics, use patterns and associated harm
Drug and Alcohol Dependence 67, 89-94
Louisa Degenhardt, Shane Darke and Paul Dillon
The aim of this study was to examine the characteristics of gamma-hydroxybutyrate (GHB) users, their GHB and other drug use patterns, and the harms associated with GHB use. Seventy-six GHB users were recruited and administered a structured interview on GHB use and related harms. GHB users appeared to be a stable, high educated and well-functioning group. They had had extensive experience with a range of drugs, and GHB was typically used in conjunction with other drugs. Despite the fact that most GHB users had not had a long or extensive experience with GHB use, the proportion reporting significant negative side effects when using GHB was high (99% reported at least one), and the mean number of side effects ever experienced was 6.5. Notably, half (52%) reported becoming unconscious, 53% reported vomiting, 58% reported profuse sweating, and 8% reported having a fit or seizure. The high rate of problems reported by a group with limited use of this drug suggests that in a context of polydrug use, GHB use is associated with significant risks to users.
www.elsevier.com/locate/drugalcdep
Young people’s drug use when heroin is less available
Youth Studies Australia 21, 11-16
Louisa Degenhardt, Michael Gascoigne and John Howard
A study of the effects of a heroin shortage on the demand for drug treatment services found that there were no significant changes in either demand for treatment or in the demographic characteristics of adolescents admitted to the program. However, the proportion reporting regular heroin use declined over the period, while the proportion reporting regular cannabis use and recent psychostimulant use increased. There was also a decrease in the proportion reporting recent injecting drug use. It is possible that increased use of these drugs poses a risk to young persons vulnerable to developing psychosis, and that increased psychostimulant use, particularly when combined with alcohol, is associated with greater aggressive behaviour. These possibilities need to be taken into account by persons working with this group of drug users.
Substance use disorders in an Australian community survey
Drug and Alcohol Review 21, 275-280
Maree Teesson, Uta Dietrich, Louisa Degenhardt, Michael Lynskey and John Beard
A community survey of the common mental disorders in a geographically defined treatment service area was used to explore the socio-demographic correlates and service utilization of people with alcohol and drug use disorders living in the area. These data represent the most comprehensive data on substance use disorders in a defined geographic region in Australia. Alcohol and drug use disorders were most likely to be found in the young, with those aged 18-34 years being three times more likely to have an alcohol use disorder than those aged 55 years and over. A third (33%) of those people with an alcohol use disorder and 42% of those with a drug use disorder had consulted a health professional in the past 12 months for their substance use disorder.
www.apsad.org.au/danda_fs.html
Who seeks treatment for alcohol dependence? Finding from the Australian National Survey of Mental Health and Wellbeing
Social Psychiatry and Psychiatric Epidemiology 37, 451-456
Heather Proudfoot and Maree Teesson
Background This paper presents findings from the Australian National Survey of Mental Health and Wellbeing (NSMHWB) regarding prevalence and treatment seeking for Australians with DSM-IV alcohol dependence and examines the influence of alcohol use variables on treatment seeking.
Method A standardised interview (including CIDI 2.1) was administered to a stratified random sample of 10,641 Australians aged 18 years and over. Demographic variables, common DSM-IV mental disorders, physical health status, perceived disability and treatment-seeking behaviour were assessed. Multi logistic regression was used to ascertain the independent effects of all variables considered.
Results The prevalence of DSM-IV alcohol dependence was 4.1% in this population, with 75% being male and nearly 60% in the 18-34 year age group. Variables that correlated independently with alcohol dependence were sex (male), age (young), not being in a married or de facto relationship and having any affective, anxiety or other substance use disorder. Functional disability did not correlate with a dependence diagnosis. Correlates of treatment seeking for those with dependence were sex (female) and having a comorbid affective disorder. Having a diagnosis of dependence and /or abuse and having more dependence symptoms did not predict treatment seeking. However, meeting either of two criteria assessing psychological, physical or social problems due to alcohol use tended to increase service use.
Conclusions People with alcohol dependence do not perceive themselves as disabled and do not seek treatment. However, having a comorbid affective disorder or other problems directly attributable to alcohol use increases the likelihood that such individuals will seek treatment. Efforts should be made at the primary care level to encourage those engaged in harmful drinking practices to recognise the risks of such drinking and reduce it or seek treatment. Similarly, it is recommended that integrated services are enhanced at both primary and specialist levels in order that those with multiple problems are refine measurement of disability and diagnoses of alcohol use disorders and to examine the relationship between disability and alcohol use.
Sex, drugs and just say no: a media perspective
The International Journal of Drug Policy 7, 183-186
Paul Dillon, Linda Goldspink-Lord and Nicholas Parkhill
The tragic death of a young person who died in Sydney after taking an ecstasy tablet has brought the policy of harm reduction under the media microscope. The extraordinary public comment surrounding the death of this young person has impacted not only on drug education policy but on the public perception of drug education and harm reduction. This paper will highlight this issue as a case study to illustrate how current harm reduction policy can be ‘framed’ by the media to add to the value of a news story. It will analyse what motivates this construction and look at what impact this has had on drug and alcohol projects and resources in NSW and nationally. Case studies will be presented of strategies to counteract possible negative impact.
Proactive or sensationalist?: the media and harm reduction
The International Journal of Drug Policy 9, 175-179
Paul Dillon
It is widely accepted amongst workers in the drug and alcohol field that one of harm reduction’s greatest barriers is media misrepresentation. Too often workers face the dilemma of whether to be proactive and actively discuss harm reduction messages or quietly continue with their work hoping that valuable messages will be disseminated effectively, with little controversy. Agencies that decide to actively seek press coverage for their work are often criticised for contributing to the ‘media frenzy’ that surrounds basic harm reduction principles. This paper will highlight the question of where do we cease to be proactive and enter the realm of sensationalism? Three Australian case studies will be used to highlight a variety of media strategies which were proactive in their approach to harm reduction. The degree to which they were successful will also be examined.
Overdose among heroin users in Sydney, Australia: II. Responses to overdose
Addiction 91(3), 413-417
Shane Darke, Joanne Ross and Wayne Hall
A sample of 329 heroin users were interviewed about their experiences at other people’s heroin overdoses. The overwhelming majority (86%) had witnessed a heroin overdose, on a median of six occasions. Heroin users were reluctant to seek medical attention, with an ambulance being called on only half (56%) of the most recent overdose occasions. At only 17% of most recent overdoses was calling an ambulance the first action taken. Males reported taking significantly longer than females to call an ambulance. Nearly half (44%) of subjects reported that there were factors that had delayed or stopped them seeking medical assistance, the most common impediment being a fear of police involvement. The importance of interventions to encourage help-seeking at overdoses are discussed.
www.blackwell-science.com/add
Anti-social personality disorder and response to methadone maintenance treatment
Drug and Alcohol Review 15, 271-276
Shane Darke, Robert Finlay-Jones, Sharlene Kaye and Teeya Blatt
A sample of 183 current methadone maintenance patients were interviewed on their drug use history, criminal history, current drug use, and symptoms of Anti-social Personality Disorder (ASPD). Thirty-nine percent of patients met the DSM-III-R criteria for a diagnosis of ASPD. ASPD patients had an earlier onset of drug use, drug injecting, heroin use, had wider polydrug using histories and had been arrested earlier and more frequently than other patients. Despite the different pre-treatment histories of ASPD and other patients, there were no differences between the two groups in retention in treatment, methadone dosage or heroin use. It is concluded that heroin-dependent ASPD patients can be successfully retained in methadone treatment, on similar methadone doses and with similar in-treatment drug use patterns as those of non-ASPD heroin dependent patients.
www.apsad.org.au/danda_fs.html
A comparison of blood toxicology of heroin-related deaths and current heroin users in Sydney, Australia
Drug and Alcohol Dependence 47, 45-53
Shane Darke, Sandra Sunjic, Deborah Zador, and Tania Prolov
Blood toxicology results for deaths attributed to heroin overdose during 1995 in the South Western Sydney (SWS) region (n = 9) were compared with those of a sample of 100 current SWS heroin users who had injected within the preceding 24 h. Heroin-related deaths had a higher median concentration of morphine than current heroin users (0.35 versus 0.09 mg/l). However, there was substantial overlap between the blood morphine concentrations of the two groups, ranging from 0.08-1.45 mg/l. This range incorporated 90% of heroin-related deaths. A third of current users had morphine concentrations over twice the toxic blood morphine concentration employed by the analytical laboratories, and 7% had morphine levels higher than the median recorded for fatal cases. Alcohol was detected in 51% of fatal cases (median = 0.10 g/100 ml) compared with 1% of current heroin user. There was a significant negative correlation among fatal cases between blood morphine and blood alcohol concentrations (rs= -0.41). There was no significant difference between groups in the proportions of subjects positive for blood benzo-diazepines. The results raise questions about the mechanisms of death in what are termed overdoses, and about the role of alcohol in these fatalities.
www.elsevier.com/locate/drugalcdep
Antisocial personality disorder, psychopathy and injecting heroin use
Drug and Alcohol Dependence 52, 63-69
Shane Darke, Sharlene Kaye, and Robert Finlay-Jones
Two hundred community-based methadone patients (CM); 200 prison inmates enrolled in prison methadone programs (PM); and 150 prison inmates with no history of heroin use (PNH) were interviewed to obtain diagnoses of antisocial personality disorder (ASPD) and Psychopathy Checklist-defined psychopathy. Large proportions of subjects in all three groups met the criteria for a diagnosis of ASPD (CM 44%, PM 65%, PHN 31%), with the two methadone groups having significantly higher proportions of ASPD diagnosis than non-heroin users. There were no differences between groups in the proportions diagnosed as psychopathic (CM 4%, PM 9%, PNH 4%). For each group, the proportions diagnosed as ASPD were significantly higher than the proportions diagnosed as psychopathic. Implications for the diagnosis of ASPD are discussed.
www.elsevier.com/locate/drugalcdep
Overdose among heroin users in Sydney, Australia: I. Prevalence and correlates of non-fatal overdose
Addiction (1996) 91(3), 405-411
Shane Darke, Joanne Ross & Wayne Hall
A sample of 329 heroin users were interviewed regarding their personal experience of non-fatal heroin overdose. Experience of overdose was widespread, with two-thirds of subjects (68%) reporting having overdosed. The median number of life-time overdoses was three, with males and females equally likely to have overdosed. The majority (62%) of most recent heroin overdoses occurred in conjunction with the consumption of other central nervous system depressants (alcohol, benzodiazepines and other opioids). Logistic regression analyses indicated three independent factors associated with having overdosed: longer heroin using careers, greater heroin dependence and higher levels of alcohol consumption. Implications for the reduction in the prevalence and frequency of overdose are discussed.
www.blackwell-science.com/add
Implications of gender for alcohol treatment research: a quantitative and qualitative review
British Journal of Addiction 87, 1249-1261
Tracey Jarvis
Previous reviews of alcohol treatment research have indicated that in the majority of studies there are not sex differences in treatment outcome. The current met-analysis was used to measure the magnitude and direction of trends of sex difference in treatment outcome. The results indicated that women had better treatment outcomes than men in the first 12 months after treatment while men showed greater improvement than women in follow-ups after 12 months. However, the estimated differences were small and derived from a heterogeneous sample of studies. Evidence from the studies in the meta-analysis is used to highlight the importance of gender-related factors which may impact on the processes and outcomes of treatment. In particular, sex differences in physiological responses to alcohol, in social norms for alcohol, and in socio-cultural experiences are considered important areas for future investigation in alcohol treatment research.
Differential impairments of selective attention due to frequency and duration of cannabis use
Biological Psychiatry 37, 731-739
Nadia Solowij, Patricia Michie and Allison Fox
The evidence for long-term cognitive impairments associated with chronic use of cannabis has been inconclusive. We report the results of a brain event-related potential (ERP) study of selective attention in long term cannabis users in the unintoxicated state. Two ERP measures known to reflect distinct components of attention were found to be affected differentially by duration and frequency of cannabis use. The ability to focus attention and filter out irrelevant information, measured by frontal processing negativity to irrelevant stimuli, was impaired progressively with the number of years of use but was unrelated to frequency of use. The speed of information processing, measured by the latency of parietal P300, was delayed significantly with increasing frequency of use but was unaffected by duration of use. The results suggest that a chronic build up of cannabinoids produces both short- and long-term cognitive impairments.
Ecstasy (3,4-methylenedioxymethamphetamine)
Current Opinion in Psychiatry 1993 6, 411-415
Nadia Solowij
This review summarizes the recent literature pertinent to the popular drug Ecstasy (MDMA). Three priority areas have emerged with regard to this substance: the importance of large-scale naturalistic studies of users; the growing number of reports of adverse reactions; and the continued research into serotonergic neurotoxicity produced by MDMA or its metabolites.
Biopsychosocial changes associated with cessation of cannabis use: a single case study of acute and chronic cognitive effects, withdrawal and treatment
Life Sciences 56, 2127-2134
Nadia Solowij, Brin F.S. Grenyer, Gregory Chesher, and John Lewis
A 35 year old male was cognitively assessed prior to cessation of 18 years of daily cannabis use and monitored for several weeks post cessation. Brain event-related potential (ERP) measures of selective attention reflecting a difficulty in filtering out complex irrelevant infomation showed no indication of improvement over 6 weeks of abstinence. In contrast, when tested in the acutely intoxicated state prior to cessation of use, a dramatic normalisation of the ERP signature of this individual was observed. A treatment program based on supportive-expressive psychotherapy was administered and depression, anxiety and general psychological health were monitored over the course of withdrawal from cannabis.
The effects of partial decriminalisation on cannabis use in South Australia, 1985 to 1993
Australian Journal of Public Health 19, 281-287
Neil Donnelly, Wayne Hall and Paul Christie
In 1987 the Cannabis Expiation Notice scheme decreased penalties for the personal use of cannabis in South Australia. Data from four National Campaign Against Drug Abuse (NCADA) household drug-use surveys covering the period 1985 to 1993 were analysed to measure the effect of the decriminalisation on cannabis and current weekly use. Logistic regression was used to control for the potentially confounding effects of age and sex. Other outcomes were rates of having ever been offered cannabis and willingness to use cannabis if offered it. Between 1985 and 1993 the adjusted prevalence rate of ever having used cannabis increased in South Australia from 26 per cent to 38 per cent. There were also significant increases in Victoria and Tasmania, and to a lesser extent in New South Wales. The increase in South Australia was not significantly greater than the average increase (p = 0.1). Adjusted rates of weekly use increased between 1988 and 1991 in South Australia, but did not change through 1993. Although the effect was in the direction of a greater increase in South Australia, this was not statistically significant when compared to increases in the rest of Australia (p = 0.07). The greatest increase in adjusted weekly use occurred in Tasmania between 1991 and 1993, from 2 per cent to 7 per cent. Although the NCADA survey data indicate that there were increases in cannabis use in South Australia in 1985-1993, they cannot be attributed to the effects of partial decriminalisation, because similar increases occurred in other states.
Do cognitive impairments recover following cessation of cannabis use?
Life Sciences 56, 2119-2126
Our previous research with long term cannabis users established an impaired ability to focus attention and filter out irrelevant information, which was progressive with the cumulative duration of exposure to cannabis. The current study examined these processes in a group of ex-cannabis users. The results suggested a partial recovery of function but the past duration of cannabis use continued to have an adverse effect of the ability to effectively reject complex irrelevant information. There was no indication of improvement with increasing length of abstinence. Whilst relatively subtle in nature, the consequences of such an enduring deficit associated with cannabis use are worthy of further investigation.
|
Patterns of use and harms associated with non-ketamine use
Drug and Alcohol Dependence 69, 23-28
Paul Dillon, Jan Copeland and Karl Jansen
Aim: To 1) identify current patterns of non-medical ketamine use; and 2) identify potential harms associated with non-medical ketamine use.
Design: Cross sectional survey of lifetime ketamine users.
Setting: Semi-structured interviews took place in public and private settings in Sydney Australia.
Participants: 100 ketamine users.
Measurements: Self-reported experiences with and attitudes towards ketamine use.
Findings: Ketamine appeared to be added to an already extensive drug use repertoire of a well-educated and informed sample. Many users reported regularly experiencing effects such as an inability to speak, blurred vision, lack of co-ordination and increased body temperature, which resulted in some either reducing their dose or stopping use.
Conclusions: Many users had experienced significant negative effects, such that some had either reduced their dose or stopped use altogether and expressed concerns over some others. This study reinforces the need to develop harm minimisation campaigns that match the experiences and attitudes of their target group through careful needs assessment and appropriate evaluation.
Alcohol and other drug use disorders among homeless people in Australia
Substance Use and Misuse 38, 465-476
Maree Teesson, Tracey Hodder and Neil Buhrich
This paper describes alcohol and drug-use disorders among 210 homeless people in Australia, and compares the Australian findings with the international literature. While the prevalence of alcohol-use disorders among people who are homeless in Australia is comparable with other international studies, drug-use disorders appear to be more prevalent among Australian homeless than comparable international studies. Reasons for this difference are explored.
Schizophrenia among homeless people in inner-Sydney: current prevalence and historical trends
Journal of Mental Health 12, 51-57
Neil Buhrich, Tracey Hodder and Maree Teesson
Background: There are high prevalence rates of schizophrenia among people who are homeless. Whether the prevalence has increased over the past two decades remains unclear.
Aims: To assess the prevalence of schizophrenia among people who use refuges for the homeless, and to compare the current prevalence to prevalence rates in the same refuges since 1983.
Method: Two hundred and ten homeless men and women residing at or visiting the seven largest refuges in inner-Sydney were screened for possible psychosis. Persons who screened positive for psychosis were referred to the psychiatrist for diagnosis of possible or definite schizophrenia. The BPRS-E (expanded Brief Psychiatric rating scale) was completed for all participants with possible or definite schizophrenia.
Results: The prevalence rate for possible or definite schizophrenia among the men was 23% to 30%. This compares to 16% in 1983 and 26% in 1988. The current prevalence for women was 46% to 50% which compares to 33% in 1989; a difference which is not significant. The majority of participants with schizophrenia were scored as having ‘non-pathological symptoms’ on the BPRS-E.
Conclusions: The prevalence of schizophrenia has remained relatively stable over the past two decades despite deinstitutionalisation continuing over the same period.
The emergence of potent forms of methamphetamine in Sydney, Australia: a case study of the IDRS as a strategic early warning system
Drug and Alcohol Review 21, 341-348
Libby Topp, Louisa Degenhardt, Sharlene Kaye and Shane Darke
A striking finding of the Illicit Drug Reporting System (IDRS) in recent years has concerned the emergence in Sydney of a number of different forms of potent methamphetamine. This paper demonstrates the operation of the IDRS in detecting and documenting an increase in both the availability and use of these forms of methamphetamine in Sydney, and Australia more widely, since 1998. Data from different components of the IDRS are utilised to propose that there are currently at least three forms of methamphetamine available in Sydney that are considered by the market to be distinct commodities: methamphetamine powder (‘speed’), base methamphetamine (‘base’) and crystalline methamphetamine (‘ice’/’shabu’/’crystal meth’). Base and ice are more potent forms of methamphetamine than speed, and international experience, along with preliminary data obtained from the IDRS, suggest that their use is associated with harms in a number of domains.
Patterns of co-morbidity between alcohol use and other substance use in the Australian population
Drug and Alcohol Review 22, 7-13
Louisa Degenhardt and Wayne Hall
The present study describes patterns of co-morbidity between alcohol use and other substance use problems in the Australian population using data from the 1997 National Survey of Mental Health and Well Being. Multiple regression analyses examined whether the observed associations between alcohol and other drug use disorders were explained by other variables, including demographic characteristics and neuroticism. We also assessed whether the presence of co-morbid substance use disorders affected treatment seeking for a mental health problem. Alcohol use was related strongly to the use of other substances. Those who did not report alcohol use within the past 12 months were less likely to report using tobacco, cannabis, sedatives, stimulants or opiates. Higher rates again were observed among those with alcohol use disorders: half (51%) of those who were alcohol-dependent were regular tobacco smokers, one-third had used cannabis (32%); 15% reported other drug use; 15% met criteria for a cannabis use disorder and 7% met criteria for another drug use disorder. These associations were not accounted for by the demographic and other variables considered here. Co-morbid substance use disorders (sedative, stimulants or opioids) predicted a high likelihood of seeking treatment for a mental health problem among alcohol-dependent people.
Prison-based syringe exchange programmes: a review of international research and development
Addiction 98, 153-158
Kate Dolan, Scott Rutter and Alex Wodak
Journal publication and conference presentations on prison-based syringe exchange (PSE) programmes were identified by a comprehensive search of electronic databases. Experts involved with development and evaluation of current PSE programmes or policy were contacted for reports, documents and unpublished material. Spanish information on PSE was translated for this review. We identified 14 papers specifically on PSE programmes in Switzerland (six papers), Germany (four) and Spain (four). The first PSE programme started in 1992 in Switzerland. As of December 2000, seven PSEs were operating in Switzerland, seven in Germany and five in Spain. There have been six evaluations of prison syringe exchange programmes and all have been favourable. Reports of drug use decreased or remained stable over time. Reports of syringe sharing declined dramatically. No new cases of HIV, hepatitis B or hepatitis C transmission were reported. The evaluations found on reports of serious unintended negative events, such as initiation of injection or of the use of needles as weapons. Staff attitudes were generally positive but response rates to these surveys varied. Overall, this review indicated that prison syringe exchange programmes are feasible and do provide benefit in the reduction of risk behaviour and the transmission of blood-borne infection without any unintended negative consequences.
The prevalence and correlates of gamma-hydroxybutyrate (GHB) overdose among Australian users
Addiction 98, 199-204
Louisa Degenhardt, Shane Darke and Paul Dillon
Aim The aim of this study was to examine the correlates, context and risk perceptions regarding gamma-hydroxybutyrate (GHB) overdose among a sample of recreational GHB users in Australia
Design A cross-sectional survey of 76 GHB users who were administered a structured interview on GHB use. They were asked a series of questions regarding whether they had ever experienced a GHB overdose, the context of their most recent GHB overdose, and about their perceptions of the risks of GHB overdose.
Findings This sample of GHB users had not had a long or extensive experience with GHB use; despite this, half (53%) had experienced a GHB overdose. This sample of GHB users appeared to be well-educated, employed and a history of either drug treatment of incarceration was uncommon. There were no differences between those who had or had not overdosed in terms of socio-demographic characteristics, extent of other drug use or typical patterns of other drug use when using GHB. However, those who had overdosed on GHB had used it more times during their life-time, and had been using it for a longer period of time.
Conclusions GHB-related overdoses were common among a sample of GHB users who had only recently begun using the drug. The only apparent distinguishing factor between those who had and had not overdosed on GHB was the amount of experience with GHB use.
Decreased heroin availability in Sydney in early 2001
Addiction 98, 93-95
Carolyn Day, Libby Topp, David Rouen, Shane Darke, Wayne Hall and Kate Dolan
Aim To examine the veracity of reports of a substantial decrease in the availability of heroin in Sydney in January 2001
Design Cross-sectional survey.
Setting Sydney, Australia.
Participants Forty-one injecting drug users (IDUs) and 10 key informants (KIs).
Findings Almost all IDUs (93%) reported that heroin was harder to obtain at the time of interview (mid-February 2001) than it was before Christmas 2000 and KIs concurred. IDUs (83%) and KIs (70%) also reported that the price of heroin had increased since Christmas, and that the purity of heroin had decreased (IDUs 73%; KIs 80%). Almost all IDUs reported a reduction in their heroin use and a subsequent increase in other drug use, particularly cocaine, benzodiazepines and cannabis. Similar reports about IDUs came from nine of the 10 KIs. Over half the KIs reported an increase in both property and violent crime as a result of the heroin shortage. This crime was reportedly occurring mainly between heroin suppliers and/or IDUs. Reports from other Australian jurisdictions suggest that the shortage was not specific to Sydney.
Conclusions The reduction in the availability of heroin provides a unique opportunity to investigate the impact of supply reduction.
‘Crystal meth’ use among polydrug users in Sydney’s dance party subculture: characteristics, use patterns and associated harms
International Journal of Drug Policy 14, 17-24
Louisa Degenhardt and Libby Topp
Aim: To examine the characteristics of a small sample of crystal methamphetamine users (‘crystal meth’) and their history of crystal meth and other drug use, to assess the extent and context of crystal meth use; and to document the perceived psychological and physical side effects of use.
Method: A sample of 45 persons reporting the use of crystal methamphetamine was recruited from a variety of sources and administered a structured interview regarding their methamphetamine use and related harms. Reports of side effects among this sample of methamphetamine users were compared with those reported by a sample of much heavier, longer-term and predominantly injecting amphetamine powder users, a related but less potent form of this class of drugs.
Findings: The sample was largely male, highly educated and employed. Most users had experience with a variety of party drugs, of which crystal methamphetamine was a relatively recent addition. Many users had not had extensive experience with the drug; despite this, high rates of significant physical and psychological side effects were reported. Comparison with amphetamine users revealed that similar proportions of both groups reported most symptoms. Symptoms reflecting high doses of amphetamines (such as chest pains, heart palpitations, panic attacks) were reported by higher proportions of crystal methamphetamine user, whereas amphetamine users were more likely to report violent behaviour, hallucination, and headaches.
Conclusions: Despite relatively recent and infrequent use of crystal methamphetamine users were highly likely to report a wide range of significant side effects
Drug use and its correlates in an Australian Prisoner Population
Addiction Research and Theory 11, 89-101
Tony Butler, Michael Levy, Kate Dolan and John Kaldor
The prevalence of past and present tobacco, alcohol, and illicit drug use is examined in a cross sectional random sample of prisoners. 789 male and female prisoners from 27 correctional centres across New South Wales (NSW) participated in the survey. Information was collected using a face-to-face interview on community and prison drug use, and intoxication while offending. Current tobacco use was reported by 72% of the sample. Use of alcohol by females was more likely than males to be classified as ‘safe’ according to the Alcohol Use Disorders Identification Test (39
vs. 26%). Overall, 64% of prisoners had used illicit drugs at some time in the past with cannabis and heroin the most common. Forty four percent of prisoners had a history of injecting drug use, with injecting prevalence significantly higher in females than males (64
vs. 40%) with approximately half of both male and female injectors reporting that they had injected while in prison. ‘Harmful’ or ‘hazardous’ use of alcohol was associated with imprisonment for violent crimes. Sixty two percent of property offenders had an injecting history. Correctional authorities need to ensure than drug treatment programmes are available to prisoners and consideration should be given to piloting needle and syringe exchange programmes in NSW prisons given the high levels of sharing injecting equipment in prison.
The relationship of conduct disorder to attempted suicide and drug use history among methadone maintenance patients
Drug and Alcohol Review 22, 21-25
Shane Darke, Joanne Ross and Michael Lynskey
In order to examine the effects of a diagnosis of childhood conduct disorder (CD) on history of attempted suicide and drug use, un-confounded by early onset heroin use, 181 methadone maintenance patients who commenced heroin use after the age of 15 were interviewed. CD was diagnosed in 54% of patients. Compared to other patients, CD patients were younger and less education. The onset of drug use, injecting drug use and heroin use occurred, on average, 2 years earlier than in other patients, and they had broader histories of injecting polydrug use. CD patients were more likely to have attempted suicide and to have been hospitalized after an attempt, and to have attempted suicide while enrolled in their current treatment. The current study indicates that a history of CD increases the risk of attempted suicide over and above the higher risks associated with injecting drug use per se.
The monitoring of drug trends in Australia
Drug and Alcohol Review 22, 61-72
Fiona Shand, Libby Topp, Shane Darke, Toni Makkai and Paul Griffiths
Recently, there has been increased recognition of the importance of drug information systems (DIS), highlighting the need for an internationally coordinated approach to data collection and advocating the regular assessment of a range of areas. Accurate information provides policy makers with the evidence to evaluate current strategies and to plan future strategies. An effective drug information system (DIS) must collect comprehensive, detailed and in-depth data, while also being sensitive to emergent trends and placing these changes into the context of longer-term trends. An integrated and comprehensive system combines both sensitive (or lead) and slower but more reliable lag indicators. This article reviews conceptual frameworks for DIS and developments in international systems. It then considers the range of DIS in Australia and then describes two integrated monitoring systems with an early warning function: the Illicit Drug Reporting System (IDRS) and the Drug Use Monitoring Australia (DUMA) Programme. Both systems collate sensitive lead indicators, and provide timely information about emerging drug trends in Australia. Together, these two systems are best-placed to provide effective early warning of new trends in illicit drug markets, and constitute an important component of the overall approach to the monitoring of drug use and associated harms in Australia.
www.apsad.org.au/danda_fs.html
Patterns and correlates of substance use amongst juvenile detainees in New South Wales 1989-99
Drug and Alcohol Review 22, 15-20
Jan Copeland, John Howard, Tim Keogh and Katie Seidler
In the decade 1989-99 there have been significant changes in the patterns of substance use in the Australian community. Juvenile offenders have been a sentinel population of these emerging trends. The social and personal costs associated with adolescent substance abuse, especially where it leads to increased criminal offending requires urgent attention. This study was a replication of the 1989 and 1994 surveys of young people in detention in New South Wales, Australia. The 300 voluntary participants from nine detention centres had a similar demographic profile to participants in previous surveys. They were predominantly male (90%) with a mean age of 16.5 years and an over-representation of Aboriginal and Torres Straits Islander peoples. The patterns of a lifetime alcohol and tobacco use were stable over the decade, with particular increases in amphetamine, opioid and cocaine use since 1994. The more concerning pattern of at least weekly substance use revealed significant increases in high levels of negative health and psychosocial consequences of substance use, including overdose, among this group. High levels of self-reported depression and suicidal behaviours, family and gender issues are also discussed. Encouragingly, there was a relatively high level of self-recognized treatment need for substance use and mental health problems among the sample. This highlights further the growing need for the development and dissemination of novel interventions that harness this willingness and actively engage, motivate and maintain these young people in accessible, appropriate and effective interventions.
www.apsad.org.au/danda_fs.html
Pilot randomised double blind placebo controlled study of dexamphetamine for cocaine dependence
Addiction 98, 1137-1141
James Shearer, Alex Wodak, Ingrid van Beek, Richard Mattick, and John Lewis
Aims: To establish the feasibility of conducting a placebo-controlled clinical trial of dexamphetamine replacement therapy for cocaine dependence and to obtain preliminary data.
Design: Double-blind randomised placebo-controlled trial.
Participants: Thirty cocaine-dependent injecting drug users.
Intervention: Subjects were assigned randomly to receive 60 mg/day dexamphetamine (n = 16) or placebo (n = 14) for 14 weeks.
Measurements: Immunoassay and mass spectrometric techniques were used to identify cocaine metabolites in urine. Subjects were screened using the Composite International Diagnostic Interview and DSM-IV. The Opiate Treatment Index, Brief Symptom Inventory. Severity of Dependence Scale and visual analogue craving scales were used to collect pre- and post-self report data.
Findings: Treatment retention was equivalent between groups; however, outcomes favoured the treatment group with no improvements observed in the placebo control group. The proportion of cocaine-positive urine samples detected in the treatment group declined from 94% to 56% compared to no change in the placebo group (79% positive). While the improvements were not significant between groups, within group analysis revealed that the treatment group reduced self-reported cocaine use (P = 0.02), reduced criminal activity (P = 0.04), reduced cravings (P < 0.01) and reduced severity of cocaine dependence (P < 0.01) with no within-group improvements found in the placebo group.
Conclusions: A definitive evaluation of the utility of dexamphetamine in the management of cocaine dependence is feasible and warranted.
www.blackwell-science.com/add
A Comparison of buprenorphine treatment in clinic and primary care settings: a randomised trial
Medical Journal of Australia 179, 38-42
Amy E. Gibson, Christopher M. Doran, James R. Bell, Anni Ryan and Nicholas Lintzeris
Objective: To compare outcomes, costs and incremental cost-effectiveness of heroin detoxification performed in a specialist clinic and in general practice.
Design and Setting: Randomised controlled trial set in a specialist outpatient drug treatment centre and six office-based general practices in inner city Sydney, Australia.
Participants: 115 people seeking treatment for heroin dependence, of whom 97 (84%) were reinterviewed at Day 8, and 78 (68%) at day 91.
Interventions: Participants were randomly allocated to primary care or a specialist clinic, and received buprenorphine for 5 days for detoxification, then were offered either maintenance therapy with methadone or buprenorphine, relapse prevention with naltrexone, or counselling alone.
Main outcome measures: Completion of detoxification, engagement in post-detoxification treatment, and heroin use assessed at Day 8 and Day 91. Costs relevant to providing treatment, including staff time, medication use and diagnostic procedures, with abstinence from heroin use on Day 8 as the primary outcome measure.
Results: There were no significant differences in the proportions completing detoxification (40/56 [71%] primary care v 46/59 [78%] clinic), participating in postwithdrawal treatment (28/56 [50%] primary care v 36/59 [61%] clinic), reporting no opiate use during the withdrawal period (13/56 [23%] primary care v 13/59 [22%] clinic), and in duration of postwithdrawal treatment by survival analysis. Most participants in both groups entered postwithdrawal buprenorphine maintenance. On an intention-to-treat basis, self-reported heroin use in the month before the Day 91 interview was significantly lower than at baseline (27 days/month at baseline, 14 days/month at Day 91;
P < 0.0005) and did not differ between groups. Buprenorphine detoxification in primary care was estimated to be $24 more expensive per patient than treatment at the clinic. The incremental cost-effectiveness ratio reveals that, in this context, it costs $20 to achieve a 1% improvement in outcome in primary care.
Conclusions: Buprenorphine-assisted detoxification from heroin in specialist clinic and primary care settings were similar in efficacy and cost-effectiveness. Buprenorphine treatment can be initiated safely in primary care settings by trained GPs.
Changes in patterns of drug injection concurrent with a sustained reduction in the availability of heroin in Australia
Drug and Alcohol Dependence 70, 275-286
Lippy Topp, Carolyn Day and Louisa Degenhardt
Between 1996 and 2000, heroin was the drug most frequently injected in Australia, and viable heroin markets existed in six of Australia’s eight jurisdictions. In 2001, there was a dramatic and sustained reduction in the availability of heroin that was accompanied by a substantial increase in its price, and a 14% decline in the average purity of seizure analysed by forensic laboratories. The shortage of heroin constitutes a unique natural experiment within which to examine the impact of supply reduction. This paper reviews one important correlate of the shortage, namely changes in patterns of illicit drug injection. A number of studies have consistently suggested that between 2000 and 2001, there was a sizable decrease in both prevalence and frequency of stimulant injection. Cocaine was favoured in NSW, the sole jurisdiction in which a cocaine market was established prior to the heroin shortage; whereas methamphetamine predominated in other jurisdictions. Some data suggest that, at least in the short-term, some drug injectors left the market altogether subsequent to the reduced heroin availability. However, the findings that (1) some former heroin users switch their drug preference to s stimulant; and (2) subsequently attributed this change to the reduced availability of heroin suggests that reducing the supply of one drug may serve to increase the use of others. Given the differential harms associated with the use of stimulants and opiates, this possibility has grave implication for Australia, where the intervention and treatment system is designed primarily to accommodate opiate use and dependence.
www.elsevier.com/locate/drugalcdep
Testing hypotheses about the relationship between cannabis use and psychosis
Drug and Alcohol Dependence 71, 37-48
Louisa Degenhardt, Wayne Hall and Michael Lynskey
Aim: To model the impact of rising rates of cannabis use on the incidence and prevalence of psychosis under four hypotheses about the relationship between cannabis use and psychosis.
Methods: The study modelled the effects on the prevalence of schizophrenia over the lifespan of cannabis in eight birth cohorts: 1940–1944, 1945–1949, 1950–1954, 1955–1959, 1960–1964, 1965–1969, 1970–1974, 1975–1979. It derived predictions as to the number of cases of schizophrenia that would be observed in these birth cohorts, given the following four hypotheses: (1) that there is a causal relationship between cannabis use and schizophrenia; (2) that cannabis use precipitates schizophrenia in vulnerable persons; (3) that cannabis use exacerbates schizophrenia; and (4) that persons with schizophrenia are more liable to become regular cannabis users.
Results: There was a steep rise in the prevalence of cannabis use in Australia over the past 30 years and a corresponding decrease in the age of initiation of cannabis use. There was no evidence of a significant increase in the incidence of schizophrenia over the past 30 years. Data on trends the age of onset of schizophrenia did not show a clear pattern. Cannabis use among persons with schizophrenia has consistently been found to be more common than in the general population.
Conclusions: Cannabis use does not appear to be causally related to the incidence of schizophrenia, but its use may precipitate disorders in persons who are vulnerable to developing psychosis and worsen the course of the disorder among those who have already developed it.
www.elsevier.com/locate/drugalcdep
Cessation of methadone maintenance treatment using buprenorphine: transfer from methadone to buprenorphine and subsequent buprenorphine reductions
Drug and Alcohol Dependence 71,49-55
Courtney Breen, Simon Harris, Nicholas Lintzeris, Richard Mattick, Lynn Hawken, James Bell, Alison Ritter, Michael Lenné and Elizabeth Mendoza
Background: Buprenorphine is used in the treatment of opioid dependence. Due to its pharmacology, the transfer from methadone to buprenorphine may precipitate withdrawal symptoms.
Methods: Methadone maintained patients with clinical indicators of stability who were seeking withdrawal from methadone were recruited from three Australian states. Patients on methadone doses between 30 and 40 mg were randomised to transfer to buprenorphine by a fixed dose (
transfer at 30 mg methadone) or by a variable dose induction (
transfer when `uncomfortable'). A third group of patients with methadone doses less than 30 mg were transferred to buprenorphine at their entry methadone dose. Fifty-one patients were inducted onto buprenorphine using the same dosing protocol with the first dose of 4 mg buprenorphine. Following stabilisation on buprenorphine, patients gradually reduced the buprenorphine dose to 0 mg. Withdrawal severity and drug use was monitored.
Results: There were no significant difference between the
transfer at 30 mg and
transfer when `uncomfortable' dosing protocols in severity of withdrawal on transfer from methadone to buprenorphine. Those on doses less than 30 mg reported significantly less withdrawal discomfort at transfer. All but one patient stabilised on buprenorphine. Thirty-eight of the 51 patients inducted onto buprenorphine reached 0 mg.
Conclusions: Transfer from methadone to buprenorphine can safely occur from doses of around 30 mg of methadone. Buprenorphine dose reductions were well tolerated. Thirty-one percent of patients were not using heroin or methadone at 1-month follow-up.
www.elsevier.com/locate/drugalcdep
Prevalence and correlates of intravenous methadone syrup administration in Adelaide, Australia
Addiction 98, 413-418
Rachel Humeniuk, Robert Ali, Catherine McGregor, and Shane Darke
Aims: The aims of this study were to determine the prevalence of methadone syrup injecting in Adelaide, South Australia and to characterize methadone injectors, including their heroin use and risk behaviours associated with heroin overdose.
Design: Cross-sectional design
Setting: Community setting, principally metropolitan Adelaide.
Participants: Current heroin users (used heroin in the last 6 months), recruited through snowballing.
Measurements: Structured questionnaire.
Findings: Of 365 participants, 18.4% reported having ever injected methadone syrup and 11.0% had injected methadone in the last 6 months. Those that had injected methadone were more likely to be male, and were more likely to be receiving methadone maintenance. They were also maintained on higher doses of methadone than subjects not injecting methadone. A history of methadone injection was associated with more heroin overdoses experiences and greater dependence on heroin. Methadone injectors were also more likely to engage in risky behaviours associated with heroin overdose, including using heroin when no other people were present, not trial-tasting new batches of heroin and poly-drug use.
Conclusions: Methadone syrup injectors appear to be at greater risk of a series of harms than subjects not injecting methadone. The prevalence of methadone syrup injecting in Adelaide, South Australia was 11% which was lower than prevalence in Sydney, New South Wales, but higher than in Melbourne, Victoria. Jurisdictional differences concerning the prevalence of methadone syrup injecting may reflect differing policies by each state to methadone dispensing.
www.blackwell-science.com/add
Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients
Addiction, 98, 441-452
Richard P. Mattick, Robert Ali, Jason M. White, Susannah O’Brien, Seija Wolk and Cath Danz
Abstract
Aims: To assess the efficacy of buprenorphine compared with methadone maintenance therapy for opioid dependence in a large sample using a flexible dosing regime and the marketed buprenorphine tablet.
Design: Patients were randomized to receive buprenorphine or methadone over a 13- week treatment period in a double-blind, double-dummy trial.
Setting: Three methadone clinics in Australia
Participants: Four hundred and five opioid-dependent patients seeking treatment.
Intervention: Patients received buprenorphine or methadone as indicated clinically using a flexible dosage regime. During weeks 1-6, patients were dosed daily. From weeks 7-13, buprenorphine patients received double their week 6 dose on alternate days.
Measurements: Retention in treatment, and illicit opioid use as determined by urinalysis. Self-reported drug use, psychological functioning, HIV-risk behaviour, general health and subjective ratings were secondary outcomes.
Findings: Intention-to-treat analyses revealed no significant difference in completion rates at 13 weeks. Methadone was superior to buprenorphine in time to termination over the 13-week period (Wald x ˛=4.371, df = 1, P= 0.037), but not separately for the single-day or alternate-day dosing phases. There were no significant between-group differences in morphine-positive urines, or in self-reported heroin or other illicit drug use. The majority (85%) of the buprenorphine patients transferred to alternate-day dosing were maintained in alternate-day dosing.
Conclusions: Buprenorphine did not differ from methadone in its ability to suppress heroin use, but retained approximately 10% fewer patients. This poorer retention was due possibly to too-slow induction onto buprenorphine. For the majority of patients, buprenorphine can be administered on alternate days.
www.blackwell-science.com/add
The Sydney Medically Supervised Injecting Centre: Client characteristics and predictors or frequent attendance during the first 12 months of operation
Journal of Drug Issues 0022-04, 639-648
Jo Kimber, Margaret MacDonald, Ingrid van Beek, John Kaldor, Don Weatherburn, Helen Lapsley, and Richard Mattick
This paper describes characteristics of clients registered in the first 12 months of the Sydney Medically Supervised Injecting Centre’s (MSIC) operation, as well as predictors of frequent attendance. The study is based on information collected from clients at their initial registration and subsequent service utilization. Most of the 2,719 were male (71%), almost half had previously experienced at least one non-fatal heroin overdose, and one quarter had accessed formal drug treatment in the previous 12 months. Characteristics associated with frequent attendance at the MSIC were reporting previous attendance at the local primary health service for injecting drug users (IDU), injecting drugs other than amphetamine, reporting sex work, injecting at least daily, and injecting in a public place in the month before registration.
Modelling hepatitis C virus incidence, prevalence and long-term sequelae in Australia, 2001
International Journal of Epidemiology 32, 717-724
Matthew Law, Gregory Dore, Nicky Bath, Sandra Thompson, Nick Crofts, Kate Dolan, Wendy Giles, Paul Gow, John Kaldor, Stuart Loveday, Elizabeth Powell, Jenean Spencer, and Alex Wodak
Background: To plan an appropriate public health response to the hepatitis C virus (HCV) epidemic requires that estimates of HCV incidence and prevalence, and projections of the long-term sequelae of infection, are as accurate as possible. In this paper, mathematical models are used to synthesize data on the epidemiology and natural history of HCV in Australia to estimate HCV incidence and prevalence in Australia to end 2001, and project future trends in the long-term sequelae of HCV infection.
Methods: Mathematical models of the HCV epidemic in Australia were developed based on estimates of the pattern of injecting drug use. Estimates of HCV infections due to injecting drug use were then adjusted to allow for HCV infections resulting from other transmission routes. Projections of the long-term sequelae of HCV infection were obtained by combining modelled HCV incidence with estimates of the progression rates to these outcomes.
Results: It was estimated that there were 210 000 (lower and upper limits of 157 000 and 252 000) people in Australia living with HCV antibodies at the end of 2001, with HCV incidence in 2001 estimated to be 16 000 (11 000-19 000). It was estimated that 6500 (5000-8000) people were living with HCV-related cirrhosis in 2001, that 175 (130-210) people developed HCV-associated liver failure, and that there were 50 (40-60) incident cases of HCV-related hepatocellular carcinoma (HCC). It was estimated that in 2001 22 500 quality adjusted life years were lost to chronic HCV infection, the majority (77%) in people with early (stage 0/1) liver disease.
Discussion: Model-based estimates were broadly consistent with other sources of information on the HCV epidemic in Australia. These models suggested that the prevalence of HCV-related cirrhosis and the incidence of HCV-related liver failure and HCC will more than triple in Australia by 2020.
Exploring the association between cannabis use and depression
Addiction, 98, 1493-1504
Louisa Degenhardt, Wayne Hall and Michael Lynskey
Aim: To examine the evidence on the association between cannabis and depression and evaluate competing explanations of the association.
Method A search of Medline, Psychinfo and EMBASE databases was conducted. All references in which the terms ‘cannabis’, ‘marijuana’ or ‘cannabinoid’, and in which the words ‘depression/depressive disorder/depressed’, ‘mood’, ‘mood disorder’ or dysthymia’ were collected. Only research studies were reviewed. Case reports are not discussed.
Results: There was a modest association between heavy or problematic cannabis use and depression in cohort studies and well-designed cross-sectional studies in the general population. Little evidence was found for an association between depression and infrequent cannabis use. A number of studies found a modest association between early-onset, regular cannabis use and later depression, which persisted after controlling for potential confounding variables. There was little evidence of an increased risk of later cannabis use among people with depression and hence little support for the self-medication hypothesis. There have been a limited number of studies that have controlled for potential depression. These have found that the risk much reduced by statistical control but a modest relationship remains.
Conclusions: Heavy cannabis use and depression are associated and evidence from longitudinal studies suggests that heavy cannabis use may increase depressive symptoms among some users. It is still too early, however, to rule out the hypothesis that the association is due to common social, family and contextual factors that increase risks of both heavy cannabis use and depression. Longitudinal studies and studies of twins discordant for heavy cannabis use and depression are needed to rule out common causes. If the relationship is causal, then on current patterns of cannabis use in the most developed societies cannabis use makes, at most, a modest contribution to the population prevalence of depression.
www.blackwell-science.com/add
A randomized controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system
Drug and Alcohol Dependence 72. 59-65.
Kate Dolan, James Shearer, Margaret MacDonald, Richard Mattick, Wayne Hall and Alex Wodak
Objectives: The aim was to determine whether methadone maintenance treatment reduced heroin use, syringe sharing and HIV or hepatitis C incidence among prisoners.
Methods: All eligible prisoners seeking drug treatment/s were randomized to methadone or a waitlist control group from 1997-1998 and followed up after 4 months. Heroin use was measured by hair analysis and self report; drugs used and injected and syringe sharing were measured by self report. Hepatitis C and HIV incidence was measured by serology.
Results: Of 593 eligible prisoners, 382 (64%) were randomized to MMT (n=191) or control (n=191). 129 treated and 124 control subjects were followed up at 5 months. Heroin use was significantly lower among treated than control subjects at follow up. There was no difference in HIV or hepatitis C incidence.
Conclusion: Consideration should be given to the introduction of prison methadone programs particular where community based programs exist.
www.elsevier.com/locate/drugalcdep
Medical marijuana initiatives. Are they justified? How successful are they likely to be?
CNS Drugs 17, 689-697.
Wayne Hall and Louisa Degenhardt
The principal constituent of cannabis, tetrahydrocannabinol (THC), is moderately effective in treating nausea and vomiting, appetite loss, and acute and chronic pain. Oral THC (dronabinol) and the synthetic cannabinoid, nabilone, have been registered for medical use in the US and UK, but they have not been widely used because patients find it difficult to titrate doses of these drugs. Advocates for the medical use of cannabis argue that patients should be allowed to smoke cannabis to relieve these above-mentioned symptoms.
Some US state governments have legislated to allow the medical prescription of cannabis, but the US federal government has tried to prevent patients from obtaining cannabis and threatened physicians who prescribe it with criminal prosecution or loss of their license to practice. In the UK and Australia, committees of inquiry have recommended medical prescription (UK) and exemption from criminal prosecution (New South Wales, Australia), but governments have not accepted these recommendations. The Canadian government allows an exemption from criminal prosecution to patients with specified medical conditions. It has recently legislated to provide cannabis on medical prescription to registered patients, but this scheme so far has not been implemented.
Some advocates argue that legalizing cannabis is the only way to ensure that patients can use it for medical purposes. However, this would be contrary to international drug control treaties and is electorally unpopular. The best prospects for the medical use of cannabinoids lie in finding ways to deliver THC that do not involve smoking and in developing synthetic cannabinoids that produce therapeutic effects with a minimum of psychoactive effects. While awaiting these developments, patients with specified medical conditions could be given exemptions from criminal prosecution to grow cannabis for their own use, at their own risk
Buprenorphine versus methadone maintenance: a cost effectiveness analysis
Drug and Alcohol Dependence 71, 295-302.
Chris Doran, Marian Shanahan, Richard Mattick, Robert Ali, Jason White and James Bell
This article presents the cost-effectiveness results of a randomised controlled trial conducted in two Australian cities. The trial was designed to assess the safety, efficacy and cost-effectiveness of buprenorphine versus methadone in the management of opioid dependence. The trial utilised a flexible dosing regime that was tailored to the clinical needs of the patients, with high maximum doses, using the marketed formulation, under double-blind conditions. A total of 405 subjects were randomised to a treatment at one of three specialist outpatient drug treatment centres in Adelaide and Sydney, Australia. The perspective of the cost-effectiveness analysis was that of the service provider and included costs relevant to the provision of treatment. The primary outcome measure used in the economic analysis was change in heroin-free days from baseline to the sixth month of treatment. Treatment with methadone was found to be both less expensive and more effective than treatment with buprenorphine, which suggests methadone dominates buprenorphine. However, statistical testing found that the observed difference between the cost-effectiveness of methadone and buprenorphine treatments was not statistically significant. The results of this study provide useful policy information on the costs and outcomes associated with the use of methadone and buprenorphine and indicate that buprenorphine provides a viable alternative to methadone in the treatment of opioid dependence.
www.elsevier.com/locate/drugalcdep
Health service utilization and benzodiazepine use among heroin users: findings from the Australian Treatment Outcome Study (ATOS)
Addiction, 98, 1129-1135.
Shane Darke, Joanne Ross, Maree Teesson, and Michael Lynskey
Aims: To determine levels of health service utilization among heroin users, the types of prescription drugs obtained by heroin users and the contribution of benzodiazepine use in health service utilization and prescribed drug use.
Design: Cross-sectional survey.
Setting: Sydney, Australia.
Participants: A total of 615 current heroin users recruited for the Australian Treatment Outcome Study (ATOS).
Findings: Sixty per cent of subjects had consulted a general practitioner (GP) and 7% a specialist in the preceding month. An ambulance had attended 11% of subjects in the preceding month. Forty-eight percent of subjects had prescriptions dispensed for medication in the preceding month. Thirty-nine per cent of participants had prescriptions dispensed for psychotropic medications, representing 80% of all prescriptions. Twenty per cent of subjects had prescriptions dispensed for non-psychotropic medications (20% of prescriptions). The most commonly prescribed drugs were benzodiazepine users had more GP and psychiatrist visits, were more likely to have had an ambulance attendance and had significantly more dispensed prescriptions.
Conclusions: There were high levels of health utilization among heroin users. Prescription drug use was common, and dominated by psychotropic drugs. Benzodiazepine use was a dominant factor in the use of services and in prescriptions dispensed. Despite increased awareness of the harms associated with benzodiazepines, they continue to be prescribed widely to heroin users.
www.blackwell-science.com/add
Heroin overdose: Research and evidence-based intervention
Journal of Urban Health: Bulletin of the New York Academy of Medicine 80, 189-199.
Shane Darke and Wayne Hall
Drug overdose is a major cause of premature death and morbidity among heroin users. This article examines recent research into heroin overdose to inform interventions that will reduce the rate of overdose death. The demographic characteristics of overdose cases are discussed, including factors associated with overdose: polydrug use, drug purity, drug tolerance, routes of administration, and suicide. Responses by heroin users at overdoses are also examined. Potential interventions to reduce the rate of overdose and overdose-related morbidity are examined in light of the emerging data in this field.
Hepatitis C-related discrimination among heroin users in Sydney: drug user or hepatitis C discrimination?
Drug and Alcohol Review 22, 317-321
Carolyn Day, Joanne Ross and Kate Dolan
The hepatitis C virus (HCV) is a common infection among injecting drug users. There are currently few available data on the extent (or prevalence) of HCV-related discrimination. This study examined perceived discrimination among a sample of heroin users and sought to determine whether the discrimination was attributed to their drug user or HCV status. Heroin users were recruited through needle and syringe programmes and methadone clinics in Sydney and were asked about discrimination in the preceding 12 months. Four hundred and one heroin users were recruited, of whom 59% reported being HCV-positive. Discrimination was reported by 22% of the 237 IDU’s who reported being HCV-positive, with 17% reporting that the discrimination occurred in the preceding 12 months. Sixty-seven incidents were reported, of which half were perceived to be due to their drug use status, 15% of these incidents were due to HCV status and 25% due to a combination of both. Twenty-five incidents occurred in a health-care setting, of which 13 resulted in the service being withheld. HCV is a serious public health concern, and if IDU are to be encouraged into drug treatment it is essential that service providers are perceived to be non-discriminatory. In managing IDU patients, health care worker need to be cognisant of the impact that their attitude has on treatment outcome.
www.apsad.org.au/danda_fs.html
Developing a global perspective on drug consumption patterns and trends- the challenge for drug epidemiology
Bulletin on Narcotics, Volume LV Nos. 1 and 2, 1-8
Paul Griffiths and Rebecca McKetin
The purpose of the present paper is to review progress made towards improving drug consumption information at a global level. The paper reviews methodological developments achieved through the collaboration of international experts and organizations in the field of drug use epidemiology at two global meetings. The first was held in January 2000 to develop a consensus on the principles, structures and indicators underpinning drug information systems, and the second in December 2001 to review methods used by regional epidemiological networks and identify opportunities for methodological development, future collaboration and improved working practices. Discussions at these meetings were successful in developing a framework for improved data collection practices at the global level, and showed considerable progress had been made in the coverage and quality of data collected. The use of drug information networks has played a key role in this developmental process by fostering the systematic collection and interpretation of data and providing a forum for the sharing of information and experiences across disciplines and geographic regions. Remaining challenges for data collection at the global level centre on the development of robust low-cost methods of collection that can be adapted to all regions of the world, as well as on the need for ongoing interregional collaboration to foster this process.
Supporting evidence-based policy-making: a case study of the illicit Drug Reporting System in Australia
Bulletin on Narcotics, Volume LV Nos. 1 and 2, 23-30
Libby Topp and Rebecca McKetin
Australia’ Illicit Drug Reporting System (IDRS) was developed in 1996 to provide a cost-effective strategic early warning system for emergent trends in problematic drug use. Through the use of specific case-scenarios, the present article demonstrates the manner in which information obtained from drug information systems such as IDRS can broaden the knowledge base from which evidence-based policy decisions and drug control strategies can be developed. IDRS has achieved this through the wide dissemination of its findings, the establishment of mechanisms for inter-sectoral collaboration and the provision of a context within which to understand drug trends and appreciate their role in policy formation. The present case analysis also illustrates the high level of demand for the in-depth information provided by sentinel surveys of problematic drug users and by qualitative interviews with experts in the field of illicit drugs. This type of information is particularly useful at a policy level when it can be collected on a routine basis using comparable methods, to enable the early detection of trends in problematic drug use. When such information is provided to policy makers in a timely fashion and in a usable format, it can be used t inform the development of policies and strategies. The potential policy utility of data from IDRS will be realized through ongoing dialogue between researchers, officials from the health and law enforcement sectors and policy makers, a process that will be greatly facilitated by the communication channels and inter-sectoral relations established through the system
Issues surrounding the detection of a reduction in drug supply: the heroin shortage in Australia in 2001
Bulletin on Narcotics, Volume LV Nos. 1 and 2, 131-140
Louisa Degenhardt, Libby Topp and Carolyn Day
In the present article, the authors discuss the challenges in characterizing and documenting changes in the availability or supply of drugs. A distinction is made between supply and demand (or consumption), as the assessment of each requires a different set of data. The distinction is illustrated by the recent experience of a heroin shortage in Australia. In late December 2000 or early January 2001, heroin markets in Australia experienced an unexpected and significant reduction in the availability of heroin. That shortage was sustained throughout 2001 in all Australian jurisdictions in which heroin had been freely available for some years at low cost and relative purity
Characteristics of Aboriginal Injecting Drug Users in Sydney, Australia: Prison history, hepatitis C status and drug treatment experiences
Journal of Ethnicity in Substance Abuse 2, 51-58
Carolyn Day, Joanne Ross and Kate Dolan
Australian Aboriginals are over-represented in prisons and tend to be over-represented in studies of injecting drug users (IDU). The aim of this study was to examine differences between Aboriginal and non-Aboriginal IDUs in terms of gender, prison history and hepatitis C status and testing. Secondary analyses were conducted on data from three cross-sectional studies of IDUs. These studies employed similar methodologies, with recruitment being through needle and syringe programs, methadone clinics, snowballing and street intercepts. All studies were coordinated through the National Drug and Alcohol Research Centre. Aboriginal people were over-represented in all studies, were more likely to have been incarcerated and to report heroin as their drug of choice than non-Aboriginal IDUs. Females tended to be over-represented among Aboriginal IDUs, were more likely to have been incarcerated and had a longer period of time since their last hepatitis C test than non-Aboriginal female IDUs. Aboriginal people are over-represented among IDUs in Sydney. Given their greater risk of incarceration, particularly among females, Aboriginal IDUs were at greater risk of hepatitis C exposure than non-Aboriginal IDUs. The prison setting provides an opportunity to promote drug treatment and hepatitis C testing, though more needs to be done to reduce drug use and incarceration
.
Attempted suicide among entrants to three treatment modalities for heroin dependence in the Australian Treatment Outcome Study (ATOS): prevalence and risk factors
Drug and Alcohol Dependence 73, 1-10
Shane Darke, Joanne Ross, Michael Lynskey, and Maree Teesson
Aims: To determine the lifetime and recent histories of attempted suicide among entrants to treatment for heroin dependence in three treatment modalities and a non-treatment comparison group; and to ascertain factors associated with a recent history of attempted suicide.
Design: Cross-sectional structured interview.
Setting: Sydney, Australia.
Participants: Six hundred and fifteen current heroin users: 201 entering methadone/buprenorphine maintenance (MT), 201 entering detoxification (DTX), 133 entering drug free residential rehabilitation (RR) and 80 not in treatment (NT).
Findings: A lifetime history of attempted suicide was reported by 34% of subjects, 13% had attempted suicide in the preceding year and 5% had done so in the preceding month. Females were more likely to have lifetime (44% versus 28%) and 12-month (21% versus 9%) suicide attempt histories. The 12-month prevalence of attempted suicide among treatment groups ranged between 11% (MT, NT) and 17% (RR). Factors associated with recent suicide attempts were: being an RR entrant, female gender, younger age, less education, more extensive polydrug use, benzodiazepine use, recent heroin overdose, Major Depression, current suicidal ideation, Borderline Personality Disorder (BPD) and Post-Traumatic Stress Disorder.
Conclusions: Recent suicidal behaviour is a major clinical problem for heroin users, and for females and RR entrants in particular. An essential adjunct to treatment for heroin dependence is routine screening for depression and suicidal ideation, with the provision of appropriate treatment where needed.
www.elsevier.com/locate/drugalcdep
The external validity of results derived from ecstasy users recruited using purposive sampling strategies
Drug and Alcohol Dependence 73, 33-40
Libby Topp, Bridget Barker and Louisa Degenhardt
This study sought to compare the patterns and correlates of `recent' and `regular' ecstasy use estimated on the basis of two datasets generated in 2001 in New South Wales, Australia, from a probability and a non-probability sample. The first was the National Drug Strategy Household Survey (NDSHS), a multistage probability sample of the general population; and the second was the Illicit Drug Reporting System (IDRS) Party Drugs Module, for which regular ecstasy users were recruited using purposive sampling strategies. NDSHS recent ecstasy users (any use in the preceding 12 months) were compared on a range of demographic and drug use variables to NDSHS regular ecstasy users (at least monthly use in the preceding 12 months) and purposively sampled regular ecstasy users (at least monthly use in the preceding 6 months). The demographic characteristics of the three samples were consistent. Among all three, the mean age was approximately 25 years, and a majority (60%) of subjects were male, relatively well-educated, and currently employed or studying. Patterns of ecstasy use were similar among the three samples, although compared to recent users, regular users were likely to report more frequent use of ecstasy. All samples were characterised by extensive polydrug use, although the two samples of regular ecstasy users reported higher rates of other illicit drug use than the sample of recent users. The similarities between the demographic and drug use characteristics of the samples are striking, and suggest that, at least in NSW, purposive sampling that seeks to draw from a wide cross-section of users and to sample a relatively large number of individuals, can give rise to samples of ecstasy users that may be considered sufficiently representative to reasonably warrant the drawing of inferences relating to the entire population. These findings may partially offset concerns that purposive samples of ecstasy users are likely to remain a primary source of ecstasy-related information.
www.elsevier.com/locate/drugalcdepAdapting the Illicit Drug Reporting System (IDRS) to examine the feasibility of monitoring trends in the markets for `party drugs’
Drug and Alcohol Dependence 73, 189-197
Libby Topp, Courtney Breen, Sharlene Kaye and Shane Darke
Since 1996, the Illicit Drug Reporting System (IDRS), Australia's strategic early warning system for illicit drug trends, has monitored annual trends in the markets for the four main illicit drug classes, cannabis, methamphetamine, cocaine and heroin. In 2000, a 2-year trial was implemented to examine the feasibility of using similar methodology to monitor trends in the markets for `party drugs'. A triangulation of three data sources was sought: (1) quantitative interviews with a `sentinel' population of drug users; (2) qualitative interviews with key informants (KIs), or those who have contact with drug users through their work; (3) extant indicator data sources such as the purity of illicit drugs seized by law enforcement agencies. The results suggested that the feasibility of collecting detailed, reliable and valid data about party drug markets is a direct function of the size of those markets. The trial demonstrated that the system would allow the successful monitoring of markets for party drugs that are relatively widely used, such as ecstasy, but would be less sensitive in monitoring markets for party drugs that are used by small proportions of the total population, such as gamma-hydroxy-butyrate (GHB) and ketamine. Methodological issues encountered during the conduct of this trial are discussed, including defining the appropriate sentinel population of drug users, identifying relevant key informants, and the relative absence of extant indicator data sources that could inform our understanding of party drug markets.
www.elsevier.com/locate/drugalcdep
Drug driving among injecting drug users in Sydney, Australia: prevalence, risk factors and risk perceptions
Addiction 99, 177-185
Shane Darke, Erin Kelly and Joanne Ross
Aims: To examine the prevalence of drug driving, the prevalence of drug-related motor vehicle accidents, risk perceptions of drug driving, and factors associated with drug driving among injecting drug users (IDU)
Design: Cross-sectional survey
Setting: Sydney, Australia
Participants: 300 current IDU
Findings: 95% had driven a vehicle, 74% in the previous 12 months (“current drivers”). Eighty seven percent of lifetime drivers reported having drug driven, and 88% of current drivers had drug driven in the previous 12 months. There were no significant sex differences in lifetime or recent drug driving. The most common drugs used before driving in the preceding year were: cannabis, heroin, amphetamines and cocaine. A third of lifetime drivers reported having had a drug driving accident, with males more likely to have done so, and 9% of current drivers reported a drug driving accident in the previous year. The most common drugs that had been used before the most recent drug driving accident were heroin, cannabis and alcohol. Alcohol was perceived to be the most dangerous substance for driving performance and cannabis the least dangerous. Recent drug drivers perceived drug driving to be less dangerous than non-drug drivers. Recent drug drivers had driven more frequently over the preceding 12 months, had significantly higher levels of dependence, higher frequency of drug use, more extensive polydrug use, and were more likely to have used and/or injected a drug in a car in the previous 12 months.
Conclusions: Drug driving, and drug-related accidents are large scale public health problems among IDU. These behaviours pose serious risks to IDU themselves, and to the broader community.
www.blackwell-science.com/add
Web-based interventions for substance use disorders: a qualitative review
Journal of Substance Abuse Treatment 26, 109-116.
Jan Copeland and Greg Martin
Background: Substance use disorders are one of the most common mental health problems in the Western world with a significant contribution to the global burden of disease and a high level of unmet treatment need.
Aims: To assess the use and effectiveness of web-based interventions for substance use disorders.
Method: A qualitative review of the published literature across databases Medline, EMBASE, PsychINFO, GrayLIT Network, and Web of Science using relevant key terms. A search of the worldwide web was also conducted using search engines such as Google.
Results: There were a number of computerised and internet based interventions for mental health disorders including substance use disorders located, however, they are largely descriptive with no large randomised controlled trials of internet delivered interventions for substance use disorders reported.
Conclusions: While the literature on internet based substance use interventions is sparse and flawed, the potential impact of effective intervention is considerable. On the basis of the limited research available it is reasonable to suggest that a demand for such interventions exists and there is a likelihood that they would be as effective as those delivered by therapists for the majority of less severely dependent clients. Further clinical outcome research, particularly in the area of brief interventions for alcohol use disorders and extension to other drugs such as cannabis and club drugs, is certainly justified.
The definition of opioid-related deaths in Australia: implications for surveillance and policy
Drug and Alcohol Review 24, 401-409
Marianne Jauncey, Lee Taylor and Louisa Degenhardt
The reported number of deaths caused by opioid use depends on the definition of an opioid-related death. In this study, we used Australian Bureau of Statistics (ABS) mortality data to illustrate how choice of classification codes used to record cause of death can impact on the statistics reported for national surveillance of opioid deaths. Using International Classification of Diseases version 10 (ICD-10) codes from ABS mortality data 1997–2002, we examined all deaths where opioids were reported as a contributing or underlying cause. For the 6-year period there was a total of 5839 deaths where opioids were reported. Three possible surveillance definitions of accidental opioid-related deaths were examined, and compared to the total number of deaths where opioids were reported for each year. Age restrictions, often placed on surveillance definitions, were also examined. As expected, the number of deaths was higher with the more inclusive definitions. Trends in deaths were found to be similar regardless of the definition used; however, a comparison between Australian states revealed up to a twofold difference in the absolute numbers of accidental opioid-related deaths, depending on the definition. Any interpretation of reported numbers of opioid deaths should specify any restrictions placed on the data, and describe the implications of definitions used.
www.apsad.org.au/danda_fs.html
The structure of alcohol dependence in the community
Drug and Alcohol Dependence 81, 21-26
Heather Proudfoot, Andrew J. Baillie and Maree Teesson
Background:Although dependence on alcohol appears to be a reliable unitary construct, abuse has not found a similar level of support as a separate construct. This paper describes a confirmatory factor analysis of the DSM-IV alcohol abuse and dependence criteria in a general population sample.
Methods: Data from alcohol drinkers (
n = 7746) were obtained from a cross-sectional study of a large, representative sample of the Australian general population. One- and two-factor solutions for the DSM-IV criteria for abuse and dependence (assessed by CIDI-Auto) were compared using confirmatory factor analysis.
Results: Approximately 74% of Australians had used alcohol 12 or more times in the past year and 19% met at least one DSM-IV alcohol abuse or dependence criterion. Overall 6% met criteria for an alcohol use disorder (1.9% abuse, 4.1% dependence). More men than women met criteria for an alcohol use disorder and the prevalence of alcohol use disorders decreased with increasing age. Both one- and two-factor solutions from the confirmatory factor analyses provided an adequate fit to the data for the overall sample. The correlation between the abuse and dependence factors in the two-factor model was extremely high (0.95).
Conclusion: Alcohol abuse and dependence criteria were most parsimoniously described by a single continuous construct incorporating all eleven abuse and dependence criteria.
www.elsevier.com/locate/drugalcdep
The characteristics of heroin users entering treatment: findings from the Australian treatment outcome study (ATOS)
Drug and Alcohol Review 24, 411-418
Joanne Ross, Maree Teesson, Shane Darke, Michael Lynskey, Robert Ali, Alison Ritter and Richard Cooke
The current study aimed to describe the characteristics (demographics, drug use, mental and physical health) of entrants to treatment for heroin dependence in three treatment modalities; and to compare these characteristics with heroin users not in or seeking treatment. Participants were 825 current heroin users recruited from Sydney, Adelaide and Melbourne: 277 entering methadone/buprenorphine maintenance treatment (MT), 288 entering detoxification (DTX), 180 entering drug-free residential rehabilitation (RR) and 80 not in treatment (NT). Treatment entrants were generally long-term heroin users with previous treatment experience. The majority of the sample (55%) were criminally active in the month preceding interview. Injection-related health problems (74%) and a history of heroin overdose (58%) were commonly reported. There were high degrees of psychiatric co-morbidity, with 49% reporting severe psychological distress, 28% having current major depression, 37% having attempted suicide and 42% having a lifetime history of post-traumatic stress disorder. Personality disorders were also prevalent, with 72% meeting criteria for antisocial personality disorder and 47% screening positive for borderline personality disorder. Striking similarities were noted between the non-treatment and treatment groups in length of heroin use career, drug use and treatment histories.
www.apsad.org.au/danda_fs.html
Cycling in and out of treatment; participation in methadone treatment in NSW, 1990–2002
Drug and Alcohol Dependence 81, 55-61<I>
James Bell, Tracy Burrell, Devon Indig and Stuart Gilmour
Background:There are few descriptions of patterns of long-term participation in methadone treatment. There has been progressive expansion of methadone maintenance treatment (MMT) in Australia in the last 15 years, and by international standards Australia has a high participation rate in MMT, and has accumulated extensive data on participation.
Aim: (1) To analyse predictors of retention in treatment (a proxy measure of treatment effectiveness) in three cohorts of people entering public and private methadone treatment, in 1990, 1995, and 2000 in the state of New South Wales (NSW), and to compare retention rates with those reported from recent clinical trials; and (2) to describe the pattern of participation in subsequent treatment and predictors of re-entry.
Method: Sequential first admissions to MMT for the month of February during 1990, 1995, and 2000, were identified from the NSW Health database. Initial treatment setting (public or private) was identified. Pattern of subsequent participation in treatment of all subjects was also extracted. Descriptive statistics were generated, and predictors of retention in treatment and re-entry to treatment were analysed.
Results: The sample comprised 342 subjects commencing in private and 135 in public settings. Retention did not differ between settings. At 6 months, 51% in the current study were retained, compared to 48% in pooled clinical trials from Australia. There was a significant cohort effect; at 3 months retention was significantly better in the 1990 cohort, but by 12 months, differences between the year-cohorts were not statistically significant. Most people who left treatment dropped out; two-thirds subsequently re-entered MMT, often having multiple episodes. Participation in non-continuous treatment was around 45% for the 5 years after first entering treatment. Using multiple logistic regression, the significant predictors of re-entry to treatment were age, and duration of first treatment episode; specifically, older people and those with >12 months continuous treatment were significantly less likely to re-enter.
Conclusion: Retention in treatment in practice, across a range of settings, appears comparable to treatment delivered in clinical trials. Participants cycle in and out of treatment, and this recycling appears to have increased as the program has expanded and access to treatment has increased.
www.elsevier.com/locate/drugalcdep
Non-fatal heroin overdose, treatment exposure and client characteristics: Findings from the Australian treatment outcome study (ATOS)
Drug and Alcohol Review 24, 425-432
Shane Darke, Anna Williamson, Joanne Ross, and Maree Teesson
The relationship between treatment exposure, drug use, psychosocial variables and non-fatal heroin overdose was examined among a cohort of 495 heroin users, re-interviewed at 12 months. The 12-month overdose rate declined from 24% to 12%, and the proportion administered naloxone declined from 15% to 7%. There were significant reductions in overdose among those who entered maintenance therapies (22% to 4%) and residential rehabilitation (33% vs. 19%) at baseline, but not among those who entered detoxification or were not entering treatment. The total number of treatment days received over the follow-up period was associated independently with a reduced risk of overdose. Each extra treatment day was associated with a 1% reduction in risk of overdose over the follow-up period. By contrast, more treatment episodes were associated with an increased risk of overdose (OR 1.62). Other independent predictors of overdose over follow-up were more extensive polydrug use (OR 1.40), and having overdosed in the year preceding the study (OR 7.87).
www.apsad.org.au/danda_fs.html
Characteristics of treatment provided for amphetamine use in New South Wales, Australia
Drug and Alcohol Review 24, 433-436
Rebecca McKetin, Erin Kelly & Devon Indig
The purpose of this study was to examine the types of treatment services provided for amphetamine use, the characteristics of amphetamine treatment clients and the geographic areas most affected by amphetamine treatment provision within New South Wales (NSW), Australia. Data on completed amphetamine treatment episodes were extracted from the NSW Minimum Data Set for Alcohol and Other Drug Treatment Services for the year 2002/03 (
n = 4337). The geographic area of treatment presentations was based on the location of the treatment service, and was categorized as metropolitan, regional or rural. Treatment disproportionately affected regional and rural NSW, and treatment 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. In conclusion, the development of appropriate interventions for amphetamine use needs to consider that the majority of treatment recipients will be based in a regional or rural setting, and treating amphetamine users will often involve treatment of concurrent cannabis and alcohol problems. The nature and appropriateness of treatment services provided for amphetamine use needs to be reviewed in detail, and further research is needed into the nature of problematic amphetamine use and factors affecting treatment demand in regional and rural NSW.
www.apsad.org.au/danda_fs.html
Risk and benefit perceptions of party drug use
Addictive Behaviors 31, 137-142
Bethany White, Louisa Degenhardt, Courtney Breen, Raimondo Bruno, Jaclyn Newman, and Phoebe Proudfoot
A cross-sectional survey of 372 regular ecstasy users was conducted to examine the benefits and risks perceived to be associated with the use of party drugs. A wide range of benefits and risks were reported across six drug types with some considered drug-specific. Commonly perceived risks included physical and psychological harms that were consistent with current harm reduction messages. Harm reduction campaigns may need to acknowledge benefits of drug use to ensure health promotion messages are considered credible and acceptable to users.
Impulsivity and borderline personality as risk factors for suicide attempts among opioid-dependent individuals
Psychiatry Research 169, 16-21
Elizabeth Maloney, Louisa Degenhardt, Shane Darke and Elliot C. Nelson
The study aimed to examine the association of impulsivity and screening positively for borderline personality disorder (BPD+) as risk factors for suicide attempts among opioid-dependent individuals. The study used a case-control design with 775 opioid-dependent cases and 306 non-opioid-dependent controls. Cases were more likely than controls to screen BPD+ and to be classed as highly impulsive. Significant risk for lifetime suicide attempt was associated with screening BPD+ and also with high impulsivity. A number of risk factors were identified for suicide attempts among those with either high impulsivity or among those who screened BPD+: being female, a diagnosis of an anxiety disorder and a diagnosis of illicit drug dependence (other than opioid dependence). Opioid dependence was not a unique risk factor for suicide attempts among either the BPD+ group or the high impulsivity group. Although opioid dependence was not a unique risk factor for suicide attempts among those who screened BPD+, cases presented with multiple risk factors at substantially higher rates than controls. This research also highlights the importance of assessing impulsivity, in both clinical settings and research, particularly among those with a history of suicidal behaviour.