Specific Population groups

Question 1

The Illicit Drug Reporting system (IDRS)

Answer 1

National Drug and Alcohol Research Centre
Australia’s central monitoring and early warning system which identifies key and emerging trends among injecting drug users
It comprises:
nearly 1,000 interviews with injecting drug users across Australia
interviews with key experts who work in the drug and alcohol sector.
incorporates analysis of other national data related to illicit drug use in Australia.

Question 2

Key findings of the IDRS 2016

Answer 2

Australia’s injecting drug users are getting older

Average age of first injection was age 20

Poly drug use was high - varied markedly across states.

Nearly two thirds of Australia’s injecting drug users inject some form of methamphetamine (lowered frequently)

Morphine was the most commonly used prescription opioid; the majority of that obtained illicitly. Recent oxycodone was high

Methamphetamine and cannabis (daily) were the most commonly used drugs alongside heroin.

Question 3

Key findings of IDRS 2016

Answer 3

80% unemployed

Half of all survey participants are receiving opioid substitution treatment

56% reported high, or very high psychological distress compared (v 10%)

85 per cent had visited their GP in the past year (8x)

Nearly one in five have overdosed in the past year

Question 4

Social factors predicting risky injecting practices

Answer 4

Social factors: predicting risky injecting practices 
depression
suicide attempts
non-consensual sex
unstable housing
low education

Question 5

Injecting drug use is a behaviour strongly associated with other highly marginalised characteristics such as:

Answer 5

Imprisonment
blood borne virus infections
homelessness and
mental illness.

Question 6

Multiple harms include:

Answer 6

Blood borne virus
Overdose
Physical health (including vein care etc)
Mental health
Psychosocial (relationships, law etc)

Question 7

HCV

Answer 7

In developed countries, the majority of new infections attributed to injecting drug use
Australia: 90%
UK: >90%
USA: 54%

Globally, the prevalence of hepatitis C infection among people who inject drugs is estimated to be estimated at 10 million people

Question 8

Australian NSP National Data Survey Report

Answer 8

Australian NSP National Data Survey Report 2008-12 Prevalence of HIV, HCV, and injecting and sexual behaviour among NSP attendees

HCV antibody prevalence declined significantly over the period, from 62% - 53% (2012), evident for men (63% - 52%) and women (61% - 54%).
HCV antibody prevalence was highest among:
35 years and over and
those who first initiated injecting drugs more than ten years
-The prevalence generally increases with longer duration of injecting drug use for both males and females.
60% NSP; 2% general population
Females tested positive more frequently than males, particularly among those injecting < 3 years (48% and 23%, respectively).

Hepatitis B:
prevalence higher for long-term injecting drug users
<0.5% of injecting drug users with an injecting history <5 years
14% of users with a history of 10+ years

Question 9

HIV prevalence IVDU

Answer 9

National prevalence < 5%
1253 new infections in 2012 (10% rise)
28,600 - 34,300 Australians diagnosed with HIV
Many people living with HIV unaware of status

The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2013. The Kirby Institute, The University of New South Wales

Question 10

HIV antibody prevalence

Answer 10

Australian NSP National Data Survey Report 2008-12 Prevalence of HIV, HCV, and injecting and sexual behaviour among NSP attendees

HIV antibody prevalence:
Remained low at 1.5% or less nationally and at 3% or less in all state and territories.
Among men, HIV prevalence declined from 2.1% - 1.2%
Among women HIV prevalence increased from 0.4% - 1.3%

Question 11

Interventions: IVDU

Answer 11

Psychoeducation
Risk taking (injecting, sex, intoxication)
Safer injecting
Vein care
Overdose
Community safety/disposal
Access to NSP
Brief interventions
Replacement programs
Regular testing – prevention and early treatment
General health / well being
Peer interventions

Question 12

“Course, severity and treatment of substance abuse among women verus men”…

Answer 12

Retrospective data analysis: 642 patients (43% women) from university medical program a&d programs (USA)
Data: demographics, family history, patterns of use++, periods of abstinence, current diagnosis
Comparisons were made between women and men

Question 13

Women were

Answer 13

Results: Women were…
More likely to be “homemakers” (unemployed)
More likely to have a substance-abusing spouse (if married)
Less likely to have legal problems associated with substance misuse
Less likely to report lifetime use of inhalants or hallucinogens
Less likely to be cannabis-dependent
More likely to have used substances for fewer years (shorter time period)

Question 14

Women reported

Answer 14

Women reported…
Fewer admissions for treatment
Fewer treatment days (when admitted)
Lower overall treatment costs Implications regarding a “male-orientated” treatment system
Consistent with previous research, women have:
A more rapid course (time frame) for developing substance problems
More commonly have a substance-abusing partner
Reduced treatment options/patterns

Question 15

Gender differences: overview

Answer 15

Biological differences—women
Intoxication occurs with less alcohol intake
Metabolise alcohol differently
Develop cirrhosis of the liver more rapidly

Social differences—women
Increased stigma associated with use/misuse
More often caring for children
Cultural differences regarding status in society

Patterns of use—women
Develop problematic use more quickly
More use of prescription medications
More “private” use/misuse

Patterns of use—women
Develop problematic use more quickly
More use of prescription medications
More “private” use/misuse

Question 16

Stigma and substance-using women

Answer 16

More stigma (Swift & Copeland, 1998; Simpson & McNulty, 2008)
Highest among pregnant women
Increased blame for difficulties (Banwell & Bammer, 2006)
Reluctant to seek treatment
Fear negative attitudes of health professionals (e.g., child safety)
Stereotypes and cultural aspects (Hahm et al., 2014)

Question 17

Treatment: Barriers

Answer 17

Lack of awareness of range of treatment options
Stigma
Childcare
Perceived economic and time costs of residential treatment, including costs to family disruption
Lack of support
Concerns about type of treatment, especially confrontational approaches
Having to talk in groups with men present

Question 18

Treatment: Barriers (cont’d)

Answer 18

Fear of children being removed from their care
Male-orientated treatment may not address issues of particular importance to women
Women who are survivors of abuse or in an abusive relationship with a male may feel unsafe in the company of men during treatment
Woman may experience sexual harassment in mixed-gender settings
Women may feel in the minority and less able to speak freely about their issues

Question 19

Stats

Answer 19

Slower decline in smoking rates
Men: higher levels of risky and hazardous drinking
Similarities in levels of illicit drug use
Similarities in IVDU
Differences in frequencies and access
Less services and increased stigma

Question 20

Some CALD populations:

Answer 20

May have higher rates of AOD or be at higher risk

Migrants moving from a culture of no alcohol use to a culture of high alcohol use

Cultural specific substances brought to Australian context

Stressors: PTSD/Trauma, family stressors, unemployment, language barriers and a lack of understanding of available services

Question 21

Best practice approaches to addressing the needs of CALD communities include

Answer 21

Using trained interpreters
Displaying signage and images that reflect culturally diverse clients
Resources and service information in major community languages or in formats which are easier for CALD clients to understand
Providing care that is trauma-informed and client centred - making efforts to understand each client’s cultural background, family, migration and settlement experiences
Providing education and resources at CALD festivals/events
Addressing social determinants such as a lack of connectedness to their community and strained family relationships
Providing a culturally sensitive service which is familiar with the different needs, norms and experiences of different CALD groups
Ensuring appropriate training for frontline staff; diverse workforce

Question 22

ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE

Answer 22

Experience significantly more ill health than other Australians.
Socioeconomic disadvantage experienced places them at greater risk of exposure and vulnerability to health risk factors such as smoking and alcohol misuse.
Suffer a disproportionate amount of harms from alcohol, tobacco and other drug use. Drug-related problems play a major role in disparities in health and life expectancy between Indigenous and non-Indigenous Australians (MCDS 2011).

Question 23

Live Strong: Closing the Gap on Chronic Disease

Answer 23

Gap in life expectancy is now about 10 to 12 years earlier than non-Indigenous Australians
Due to chronic diseases such as diabetes, lung, heart and kidney disease.
Lifestyle factors such as smoking, lack of exercise, and obesity.
At an earlier age than other Australians
Higher rates of illness and hospitalisation; earlier death
Much of this chronic illness, and the associated complications, can be prevented.

Question 24

Issues and harms: Aboriginals

Answer 24

Experience multiple risk factors more frequently / factors that increase the risk of poor outcomes over every aspect of life (e.g., Daly & Smith, 2002)
a changing population structure 
cultural change
family dysfunction/breakdown
removal of children from their families
poverty
lack of educational opportunities & unemployment
alcohol and other drug misuse
social injustice and racism

Question 25

Smoking Aboriginals

Answer 25

more likely to die of smoking-related illnesses, such as diseases of the respiratory system and cancers, than other Australians (AIHW 2008).
2.5 times more likely to smoke daily than non-Indigenous people
Daily smoking rate declined from 35% in 2010 to 32% in 2013 (not statistically significant)

Question 26

Alcohol aboriginals

Answer 26

more likely to abstain from drinking alcohol than non-Indigenous Australians (28% compared with 22% respectively).
Among those who did drink, a higher proportion of Indigenous Australians drank at risky levels
There were fewer Indigenous Australians drinking alcohol at levels that put them at risk of harm from a single drinking occasion at least once a month in 2013 (from 45% to 38%)

Question 27

Illicit drugs Aboriginals

Answer 27

Other than ecstasy and cocaine, Indigenous Australians use illicit drugs at a higher rate than the general population.

1. 6 times more likely to use any illicit drug in the last 12 months
2. 9 times more likely to use cannabis;
3. 6 times more likely to use meth/amphetamines;
4. 5 times more likely to misuse pharmaceuticals than non-Indigenous people.

Question 28

Historical perspective

Answer 28

Acknowledge history in Aboriginal substance use
Dispossession and human-rights violations
Increased susceptibility to substance use
Helped form & maintain drug problems
Evidence of controlled alcohol use prior to colonisation
Lack of awareness increased vulnerability
Some believe alcohol was used as a method of control Indigenous people encouraged to be like ‘white’ people – including binging/drinking

Question 29

History

Answer 29

1837: legislation to ban alcohol (among ATSI people)
Exceptions e.g., mixed decent, “good hygiene”
Alcohol used for payment and for trade
May have shape drinking patterns
I.e., to avoid incarceration people would drink quickly
Illegal to drink in hotels  drink in public places
Resulted in increased public drunkenness & arrests
Perpetuated stereotype & restricted access to treatment
1960’s-1970’s: period of “assimilation”
1957-1975: reform prohibition laws, including rights to drink
Drinking seen by Indigenous community as a sign of equality & status

Question 30

Anthropological perspective

Answer 30

Culturally determined responses to change in history
Peer influence is particularly important
‘group-sharing’
Belonging
Non-confronting culture
‘Hunter-gatherer’ explanation
Food shortage means food gathered rarely & shared among the community
Extends to alcohol use
Bought when money available & consumed quickly
Shared amongst community

Question 31

Physiological disease perspective

Answer 31

Racial interpretation
genetic predisposition to alcohol dependence
disease model
Most treatment programs for ATSI have goal of abstinence
Disease model popular within ATSI community

Question 32

Psycho-social perspective

Answer 32

Learned behaviours reinforce drinking, and social norms and cultural practices undermine resistance.

5 elements for outbreak of substance misuse: Pearson (2002)
Availability
Money
Spare time
Examples of others in immediate environment
Permissive social ideology

Question 33

Interventions/Policy

Answer 33

National Drug Strategy 2004 - 2009:

1. Enhanced capacity of individuals, families and communities to address current and future issues in the use of alcohol, tobacco and other drugs, and promote their own health and wellbeing.
   E.g., Community leaders and Elders taking responsibility and a leading role, in partnership with government, in design and delivery of alcohol, tobacco and other drug programs.
2. Whole-of-government effort in collaboration with non-government organisations to implement, evaluate and improve comprehensive approaches to reduce drug-related harm.
   E.g., Achieving better coordination among the three tiers of government and each local community in
3. Substantially improved access to the appropriate range of health and wellbeing services that play a role in addressing alcohol, tobacco and other drugs issues.
   E.g., Providing and improving access for Aboriginal and Torres Strait Islander peoples to police diversion, pre-sentencing programs and legal aid.
4. A range of holistic approaches from prevention through to treatment and continuing care that is locally available and accessible.
   E.g., Medical services becoming more inclusive with consideration of holistic service provision and not denying people services due to their use of alcohol, tobacco and other drugs.
5. Workforce initiatives to enhance capacity of community-controlled and mainstream organisations to provide quality services.
   E.g., Employing Torres Strait and Northern Peninsula area people within health and related organisations to reflect their representation in the local population and special health requirements.
6. Increased ownership and sustainable partnerships of research, monitoring, evaluation and dissemination of information.
   E.g., Increasing the availability of information about what does and does not work in relation to approaches to address the impact of the use of alcohol, tobacco and other drugs, and psychoactive substances on Torres Strait Islander peoples.

Question 34

Best practice approaches to addressing the needs of Aboriginal and Torres Strait Islander people include:

Answer 34

Culturally responsive and appropriate mainstream programs
Aboriginal and Torres Strait Islander community-controlled services leading the planning, implementation and delivery of programs
Services delivered by specialist Aboriginal and Torres Strait Islander drug and alcohol services with an understanding of their physical, spiritual, cultural, emotional and social needs
Screening and brief intervention in primary care, Aboriginal Medical Services and other relevant health services
Services delivered in urban, regional and remote locations and in settings such as prisons, hospitals and mental health facilities
Involvement of families and communities where appropriate
Addressing the social determinants of alcohol, tobacco and other drugs use, including homelessness, education, unemployment, grief/loss/trauma and violence
Interagency collaboration and data sharing.

Question 35

Tx issues to consider

Answer 35

Few Aboriginal people choose to access treatment programs for the general population
Limited access to culturally sensitive treatment is a major theme in the research
The most successful strategies are often those designed & run by the community
Need for more rigorous evaluation of what works.

Question 36

People in contact with the criminal justice system

Answer 36

High underlying rates of AOD use
50% of all prison entrants reported using cannabis prior to entering prison; 37% reported using methamphetamines.
Between 50-90% of people who inject drugs have spent time in prison and 34% continue to inject while incarcerated.
For those injecting drugs in prison, 90% report sharing needles/injecting equipment.
Blood borne virus rates among the prison population, who report injecting drug use in 2010 were for hepatitis C (51%); hepatitis B (1%); HIV (<1%).
80% of prison discharges reported that they smoked tobacco.

Question 37

Best practice approaches to addressing the needs of people in contact with the criminal justice system:

Answer 37

Implement smoke-free policies in correctional facilities.
Access to education, health promotion, treatment and support services while in prison and during their transition back into the community
Provision of a range of treatments, including detoxification and withdrawal management, pharmacotherapy, drug free units or therapeutic communities
Testing, education and treatment for blood borne viruses
Restorative justice conferencing
Strengthen harm reduction efforts in prison settings, eg opioid substitution therapy; support inmates to adopt safe behaviours; assist inmates connect with health and social services post-release
Aftercare and support post release
Drug detection units and searching of offenders, staff, visitors, vehicles.

Question 38

Harm reduction recommendations:

Answer 38

Provide equal quality A&D Tx to that available to general population
Provide education re: substances
Introduce methadone treatment, NSPs
Use alternative sentencing/diversionary programs
Provide prison staff with better training
Provide voluntary testing of Hep B & C

Question 39

LESIBIAN, GAY, BISEXUAL, TRANSGENDER, INTERSEX (LGBTI)

Answer 39

Methodological and research issues

AOD prevalence
Australian and international research has found that rates of AOD use by LGBT people is two to four times higher than AOD rates by heterosexual people (Fergusson et al 2005, QAHC 2010).

Some studies have shown comparable rates or use, however increased poly-drug use and higher use of amphetamines, cannabis, amyl, and other “party” drugs

Question 40

Lea et al (2013) IVDU by gay/bisexual men Sydney

Answer 40

Lea et al (2013) IVDU by gay/bisexual men Sydney

5. 6 % of men reported injecting drugs in the previous 6 months
6. 4 % reported methamphetamine injection and 0.4 % heroin

Men who injected were:
less likely to be employed full-time
more likely to be HCV+, HIV+
more likely to have used party drugs for sex, and
have engaged in esoteric sexual practices

Question 41

Mental health

lgb

Answer 41

41% of LGB people had a mental disorder in the previous 12 months (20% of heterosexual people) (National Survey of Mental Health and Wellbeing: Summary of Results 2007).
This is higher than for any age group, any income level, any area of residence, any education level, and any employment status.
LGB people attempt suicide at rates between 3.5 – 14 x those of their heterosexual peers.

Among transgender people the prevalence of attempted suicide is 16% to 47%
(Suicide Prevention Australia 2009)

Question 42

What is the connection with AOD?

Answer 42

Minority Stress
‘Coming out’ increases the likelihood of prejudicial treatment
Stigma LGBT identity
Homophobia (internalised and externalised)
Using to cope with negative feelings
Peer modelling of AOD - Use is commonly linked to social and/or sexual contexts—other places to socialise are limited
Many LGBTI people avoid mainstream services due to concerns about

Question 43

Relationships between substance use and sexual risk-taking—implications for HIV transmission (Mullens et al., 2009, 2010, 2011)

Answer 43

Relationships between substance use and sexual risk-taking—implications for HIV transmission (Mullens et al., 2009, 2010, 2011)

Prevalence of HIV among gay men
AOD used by gay men to fulfil specific functions
AOD use can facilitate sexual encounters and unsafe sex via a variety of mechanisms (state dependent learning, tension reduction, sensation seeking, expectancies, etc)
AOD use can facilitate HIV transmission

Question 44

Perceptions of AOD use between LGBTI and heterosexual communities

Answer 44

Over half of the sample (59.5%) believed there were no differences in AOD use between the LGBT and heterosexual community.
Significant differences were found for gender with 50% of gender diverse and 46% of males correctly perceiving that there was more AOD use in the LGBT community compared to 24% of females.
71.1% of females perceive levels of use to be the same in the LGBT and general community.

Question 45

Homophobia and AOD use

Answer 45

96.9% of young people reported having had experienced a form of homophobia.
Although the impact of homophobia varies individual to individual, in this study almost 60% of young people associated their AOD use with coping with homophobia.
Young people who associated AOD use with homophobia were significantly more likely to smoke tobacco, consume alcohol (and at hazardous levels), and use illicit substances (in particular cannabis and stimulants).

Question 46

Best practice approaches are not well defined

Answer 46

However, the literature does indicate the following approaches may be effective:
Involve GLBTI community/ local GLBTI-friendly health clinics in health education and prevention programs
Review how consumer data can be collected by providers to collect baseline data on health needs and services usage by GLBTI consumers
Address homophobia and bullying in school education as well as provide comprehensive education around sexuality
Workforce development and training in appropriate supports for GLBTI people
Provide support groups specifically for GLBTI people
Provide relevant educational materials at GLBTI social events
Build capacity within GLBTI communities.

Question 47

Interventions

Answer 47

The importance of creating opportunities for supporting disclosure & improving inclusive practises.
Decrease the ‘invisibility’ of LGBT clients accessing health services & provide a space that is safe & responsive.
Tailored to specific needs and issues

Harm reduction strategies:
Improve social issues: stigma/discrimination
Provide safe places for LGBT—apart from contexts for AOD use
Promote appropriate and accessible Tx options for mental health and A&D issues
Continue community based health promotion campaigns

Question 48

Summary

Answer 48

AOD can serve differing roles, and have differing harms and impacts according to population groups

Importance of being aware of these differences to ensure different population groups better engage in and respond to treatment