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Introduction: Women who attend alcohol and other drug (AOD) services experience higher rates of unintended pregnancy, and access less contraception, than the general population. This study aims to observe contraceptive initiation and use after contraception services were offered at metropolitan and regional AOD services., Methods: Clinical staff were provided contraception education. One hundred women aged 16-49 were recruited from two services between 2017 and 2021. Women completed a questionnaire on their obstetrics and gynaecological history, pregnancy plans and contraception use. Women were provided education on contraception options and offered referral to a contraception pathway. The primary outcome was initiation of highly reliable contraception; secondary outcomes were the types of contraception initiated, and contraception use and pregnancy at 12 months. We compared the initiation of contraception across the two study sites., Results: At baseline, 91% of women were not planning a pregnancy within 12 months, with 21% of these using highly reliable contraception. Of all women not planning a pregnancy, 28% initiated highly reliable contraception via the pathway (2% metropolitan, 51% regional, p < 0.001), with intrauterine devices being the most frequent method initiated (15%). At 12 months, 44% were using highly reliable contraception and 15% had recorded pregnancies., Discussion and Conclusions: Contraception pathways for women in AOD treatment can improve initiation of highly reliable methods of contraception, although pregnancy rates were still high and there were large differences between the study sites. Care navigation and clinical champions are some potential facilitators to contraception access, and understanding additional barriers to access may be useful., (© 2024 The Author(s). Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: The costs of providing medication-assisted treatment for opioid dependence can determine its scale of provision. To provide estimates of the costs of extended-release buprenorphine (BUP-XR), we performed a bottom-up costing analysis of provider operational treatment costs., Methods: Data were collected in a single-arm open label trial of BUP-XR injections conducted in specialist public drug treatment services and primary care private practices in three Australian states (the CoLAB study). The unit costs of resources used for each activity were combined with quantities used at each participating facility to arrive at the average annual cost per client., Results: One hundred participants across the six health facility sites received monthly subcutaneous BUP-XR injections administered by a health-care practitioner. The average cost of providing 1 year of treatment per participant was $6656 ($6026-$8326). Screening cost (initial assessment and medical history) was $282 while monthly follow-up appointments cost $531 per client. The main cost driver was the monthly treatment costs accounting for 79% of the average annual client cost, with medication costs comprising 95% of this cost., Discussion and Conclusion: With medication costs making up the largest proportion of treatment costs, treatment using BUP-XR has the potential to free up other health system resources, for example, staff time. The costs reported in this study can be used in an economic evaluation to estimate the net benefit or cost-effectiveness of BUP-XR especially when compared to other opioid agonist treatments., (© 2024 The Author(s). Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: Enhancing health system research capacity can support improved quality care. This study assessed the research capacity of public local health district (LHD) and non-government organisation (NGO) alcohol and other drug (AOD) services, at the organisational, team and individual level. Research barriers and motivators were also examined., Methods: Staff from LHD and NGO AOD treatment services in New South Wales completed an online survey using the Research Capacity and Culture (RCC) tool. Overall median research capacity scores are presented for the RCC subscales (organisational, team and individual). Comparisons were conducted by service type (LHD/NGO), geographical location (metropolitan/rural) and affiliation with a research network (yes/no). Qualitative questions explored barriers and motivators to research at individual and team levels., Results: Of 242 participants, 55% were LHD-based and 45% NGO-based. Overall RCC scores indicated moderate research capacity at all levels. Organisational capacity (Med = 6.50, interquartile range [IQR] = 3.50) scored significantly higher than the team (Med = 5.00, IQR = 6.00) and individual level (Med = 5.00, IQR = 4.25). No differences in RCC scores existed between NGOs and LHDs. Metropolitan AOD services scored higher research capacity at the organisational level (Med = 7.00, IQR = 3.00) than rural services (Med = 5.00, IQR = 5.00). LHDs affiliated with a research network scored significantly higher at the organisational, team and individual level than non-affiliated LHD services. Key research barriers were inadequate time and funding. Motivators included skill development and problem-identification requiring change., Discussions and Conclusions: AOD services in New South Wales have moderate research capacity. Identified barriers and motivators can be used to target responses that enhance capacity and improve treatment outcomes., (© 2023 Australasian Professional Society on Alcohol and other Drugs.)

Issues: Routine outcome monitoring (ROM) involves regularly measuring clients' outcomes during treatment, which can then be fed back to clinicians and/or clients. In the mental health field, ROM and feedback have been shown to improve client outcomes; however, no systematic reviews have examined whether improvement is also seen in alcohol and other drug (AOD) treatment outcomes. This review examines whether feedback to clients and/or clinicians of ROM data in AOD treatment improves future client outcomes., Approach: This systematic review of papers identified in Medline, PsycInfo and Scopus examines the effect on client outcomes of feeding back ROM data to clinicians and/or clients in AOD treatment settings. Key client outcomes included substance use, treatment attendance and wellbeing measures., Key Findings: Ten studies were included-five randomised controlled trials and five pre-post within-subjects designs. Six studies were deemed good- or fair-quality. Of these six, three provided feedback to clinicians only, one to clients only, and two to both clients and clinicians. Only one of the six found feedback was associated with significant reductions in substance use and only among off-track clients. Four of the six found feedback improved other outcomes, including treatment retention, global functioning, therapeutic alliance and mood symptoms., Conclusions: There may be some positive effects for clients of providing feedback to clients and/or clinicians; however, the small number of randomised trials and the heterogeneity of methods, outcome measures and findings, mean that firm conclusions cannot be drawn about the efficacy of feedback until larger randomised studies are conducted., (© 2023 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: Standardised data collection processes allow for harmonisation and comparison of data across different studies and services. This project aimed to develop a 'core dataset' to serve as the default collection when designing future studies and evaluations, building upon data routinely collected in clinical alcohol and other drugs (AOD) settings in NSW, Australia., Methods: A working group was established, comprising clinicians, researchers, data managers and consumers from public sector and non-government organisation AOD services in the NSW Drug and Alcohol Clinical Research and Improvement Network. A series of Delphi meetings occurred to reach consensus on the data items to be included in the core dataset for three domains: demographics, treatment activity and substance use variables., Results: There were 20-40 attendees at each meeting. An initial consensus criterion of having received >70% of the vote was established. Given the difficulty in reaching consensus for most items, subsequently, this was changed to eliminate items that received <5 votes, after which the item receiving the most votes would be selected., Discussions and Conclusions: This important process received considerable interest and buy-in across the NSW AOD sector. Ample opportunity for discussion and voting was provided for the three domains of interest, allowing participants to contribute their expertise and experience to inform decisions. As such, we believe the core dataset includes the best options currently available to collect data for these domains in the NSW AOD context, and potentially more broadly. This foundational study may inform other attempts to harmonise data across AOD services., (© 2023 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: Amphetamine type substances (ATS) are commonly used by Australian alcohol and other drug service entrants. We describe demographic characteristics, patterns of ATS and other substance use, health and social conditions among clients entering New South Wales (NSW) public alcohol and other drug services., Methods: Retrospective cohort of 13,864 records across six health districts (2016-2019) for clients seeking substance use treatment. These districts service approximately 44% of the NSW population aged 15 years and over. Multivariate analysis was conducted on a subsample for whom full data were available (N = 9981). Data included NSW Minimum Data Set for drug and alcohol treatment services and Australian Treatment Outcomes Profile items., Results: Over the preceding 4 weeks, 77% (n = 10,610) of clients (N = 13,864) reported no recent ATS use, 15% (n = 2109) reported 'low frequency' (1-12 days) and 8% (n = 1145) 'high frequency' (13-28 days) use. ATS use was most common among people attending for ATS or opioids as primary drug of concern. A multinomial regression (N = 9981) identified that clients reporting recent arrest (aOR 1.74, 95% CI 1.36, 2.24), higher cannabis use frequency (aOR 1.01, 95% CI 1.00, 1.02), lower opioid use frequency (aOR 0.98, 95% CI 0.97, 0.99) and poorer quality of life (aOR 0.91, 95% CI 0.86, 0.97) were more likely to report 'high frequency' rather than 'low frequency' ATS use., Discussion and Conclusions: People who use ATS experience health and social issues that may require targeted responses. These should be integrated across all services, not only for clients with ATS as principal drug of concern., (© 2022 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: In early 2020, many services modified their delivery of opioid treatment in response to the COVID-19 pandemic, to limit viral spread and maintain treatment continuity. We describe the changes to treatment and preliminary analysis of the association with patients' substance use and well-being., Methods: A pre-post comparison of treatment conditions and patient self-reported outcomes using data extracted from electronic medical records in the 5 months before (December 2019-April 2020) and after (May 2020-September 2020) changes were implemented in three public treatment services in South Eastern Sydney Local Health District., Results: Data are available for 429/460 (93%) patients. Few (21, 5%) dropped out of treatment. In the 'post' period there was significantly more use of depot buprenorphine (12-24%), access to any take-away doses (TAD; 24-69%), access to ≥6 TAD per week (7-31%), pharmacy dosing (24-52%) and telehealth services. There were significant reductions in average opioid and benzodiazepine use, increases in cannabis use, with limited group changes in social conditions, or quality of life, psychological and physical health. At an individual level, 22% of patients reported increases in their use of either alcohol, opioids, benzodiazepines or stimulants of ≥4 days in the past 4 weeks. Regression analysis indicates increases in substance use were associated with higher levels of supervised dosing., Discussion and Conclusions: These preliminary findings suggest that the modified model of care continued to provide safe and effective treatment, during the pandemic. Notably, there was no association between more TAD and significant increases in substance use. Limitations are discussed and further evaluation is needed., (© 2021 Australasian Professional Society on Alcohol and other Drugs.)

Introduction: Alcohol and other drug (AOD) use is common in Australia with significant health and community impacts. General practitioners (GP) often see people with AOD use; however, there is little research to understand how specialist AOD services could assist GPs in the management of patients with AOD issues., Methods: Thirty-five GPs working in general practice in a metropolitan area in Sydney in New South Wales, Australia, participated in one of three focus groups. The groups were recorded, transcribed and thematically analysed., Results: The five themes raised by participants were: GP personal agency and interest in AOD issues; GP education and training gaps; improving pathways between GP and specialist AOD services; easier access to AOD specialist advice; and improving access to collaborative care for patients with complex AOD presentations. Participants requested education on screening, assessing, managing AOD issues, focused on alcohol, stimulants and high-risk prescription medicines. They suggested better referral processes, discharge summaries and care planning for complex presentations. Participants wanted easy access to specialist advice and suggested collaborative care assisted by experienced AOD liaison nurses., Discussion and Conclusions: Australia has several existing programs; online referral pathways and specialist phone advice, that address some of the issues raised. Unfortunately, many participants were not aware of these. GP education must be supported by multiple processes, including durable referral pathways, ready access to local specialist advice, clear communication (including patient attendance and a treatment plan), care planning and written summaries., (© 2022 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: Naloxone is a life-saving medication that reverses opioid overdose; naloxone can be provided on a 'take-home' basis so naloxone can be administered outside of the health-care setting. The Overdose Response and Take Home Naloxone (ORTHN) project established a model of care for take-home naloxone (THN) interventions across alcohol and other drug and harm reduction services in NSW, Australia. This paper evaluates the staff training and credentialing program, and examines staff attitudes and perspectives regarding the provision of THN interventions in these settings., Methods: Staff across seven services were trained through a 'train-the-trainer' credentialing model to deliver ORTHN, including naloxone supply. Staff were surveyed regarding their experience, attitudes and knowledge on THN prior to and after training, and after 6 months. At the 6 months follow up, staff were asked about the interventions they provided, barriers and enablers to uptake, and opinions regarding future rollout., Results: A total of 204 staff were trained and credentialed to provide the ORTHN intervention. Most (60%) were nurses, followed by needle syringe program workers and allied health/counsellors (32%). Linear and logistic regression analyses indicated that the training program was associated with significant improvements in staff knowledge and attitudes towards overdose and THN; however, only attitudinal improvements were maintained over time. There were high rates of staff satisfaction with the ORTHN intervention and training., Discussion/conclusions: The ORTHN program is 'fit for purpose' for broad implementation in these settings. A number of potential barriers (e.g. time, medication and staffing costs) and enablers (e.g. peer engagement, regulatory framework for naloxone supply) in implementing THN interventions were identified., (© 2022 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: Prior research has examined the prevalence and correlates of cannabis use disorder (CUD) in people who use cannabis; however, these are poorly described for people using cannabis for medical reasons., Methods: Data came from a 2018 to 2019 online, anonymous, cross-sectional survey of Australians reporting using either illicit or licit cannabis for medical reasons within the past year. Included were questions on demographics, current and lifetime patterns of cannabis use, clinical conditions for which medical cannabis was used, and individual criteria for CUD and cannabis withdrawal syndrome. Bayesian Horseshoe logistic regression models were used to identify covariates associated with meeting CUD DSM-5 conditions for any-CUD (≥2/11 criteria) and moderate-severe-CUD (≥4/11)., Results: A total of 905 participants were included in the analysis. The majority (98%) used illicit cannabis products. Criteria for any-CUD criteria were met by 290 (32.0%), and 117 (12.9%) met criteria for moderate-severe-CUD. Tolerance (21%) and withdrawal (35%) were the most commonly met criteria. Correlates with the strongest association with CUD were inhaled route of administration [odds ratio (OR) = 2.96, 95% credible interval 1.11, 7.06], frequency of cannabis use (OR = 1.24, 1.11-1.35), proportion of cannabis for medical reasons (OR = 0.83, 0.74, 0.94), frequency of tobacco use (OR = 1.10, 1.03, 1.17), age (OR = 0.75, 0.64, 0.90) and pain as main clinical indication (OR = 0.58, 0.36, 1.00)., Discussion and Conclusions: Prevalence of CUD in medical cannabis users appears comparable to 'recreational' users, with many similar correlates. CUD was associated with using cannabis to treat mental health rather than pain conditions and inhaled over other routes of administration., (© 2022 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: The Australian Treatment Outcomes Profile (ATOP) is a brief instrument that measures self-reported substance use, health, and wellbeing in the previous 28 days for people in alcohol and other drug treatment. Previous studies have established the concurrent validity, inter-rater, and test-retest reliability of the tool. The current study sought to identify recommended cutoff scores for ATOP items for psychological health, physical health and quality of life that identify clients reporting clinically significant problems warranting further assessment and/or intervention, compared to cutoffs used by 'gold-standard' measures for these domains., Methods: Clients attending for treatment for problems with opioid (n = 144) or alcohol use (n = 134) completed the ATOP and comparison standardised questionnaires (Kessler-10, Short Form Survey 12 and the Personal Wellbeing Index) with a researcher. Receiver operating characteristics analysis, along with clinician perspectives, were used to recommend cutoff scores for ATOP items indicative of clinically significant problems., Results: A cutoff score of 5 or less out of 10 was identified as an optimal pragmatic cutoff for ATOP items relating to psychological health, physical health and quality of life items with regards to balancing sensitivity, specificity, and application in a treatment setting., Discussion and Conclusions: The recommended clinical cutoffs will support clinicians and treatment services to identify clients who require further assessment and follow up for their psychological health, physical health and quality of life. The current study provides further evidence for the utility of the ATOP for individual clinical review, service planning and research., (© 2021 Australasian Professional Society on Alcohol and other Drugs.)

Buprenorphine is a partial opioid agonist commonly used to treat opioid dependence. The pharmacology of buprenorphine increases the risk of a precipitated opioid withdrawal when commencing patients on buprenorphine treatment, particularly when transferring from long acting opioids (e.g. methadone). There is little documented experience regarding the management of precipitated withdrawal. In our case, a patient developed a significant precipitated opioid withdrawal following buprenorphine administration, and was able to be successfully treated in hospital with further buprenorphine. This demonstrates that rapid increases in buprenorphine dose can be used as an effective treatment for buprenorphine-induced precipitated opioid withdrawal. The use of buprenorphine to manage withdrawal then allows the individual to continue on this highly effective treatment., (© 2021 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: The Australian Treatment Outcomes Profile (ATOP) is a brief clinical tool measuring recent substance use, health and wellbeing among clients attending alcohol and other drug (AOD) treatment services. It has previously been assessed for concurrent validity and inter-rater reliability. In this study we examine whether it is suitable for administration over the telephone., Design and Methods: We recruited a sample of 107 AOD clients across public sector specialist AOD treatment services in New South Wales, Australia between 2016 and 2018. Participants had a mean age of 47 years and 46% were female. Participants completed a face-to-face ATOP and a phone ATOP with a researcher within 5 days. Comparisons between the two administration modes were undertaken using Spearman's rank correlation coefficient for continuous or ordinal variables, and Cohen's Kappa for nominal variables., Results: Among 107 participants, 59% were attending for alcohol treatment and 41% for opioid treatment. Most ATOP items (76%) reached above 0.7 (good) or 0.9 (excellent) agreement between face-to-face and telephone use., Discussion and Conclusions: Our findings suggest that the ATOP is a suitable instrument for telephone monitoring of recent substance use, health and social functioning among AOD clients. Its validation for remote use over the telephone will support staff to monitor clients' risks and outcomes-of particular relevance in response to the COVID-19 pandemic in which services are increasingly relying on telework approaches to client monitoring., (© 2020 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: The Australian Treatment Outcomes Profile (ATOP) was developed as a clinical tool for monitoring the substance use, health and wellbeing of clients in alcohol and other drug treatment. This is the first psychometric validation of the ATOP in a cannabis-dependent treatment population., Design and Methods: A total of 128 individuals with cannabis dependence enrolled in an outpatient randomised controlled trial were administered the ATOP and gold-standard health and wellbeing questionnaires once by clinicians and once by researchers at baseline. Concurrent validity was assessed by testing ATOP Psychological Health, Physical Health and Quality of Life questions against concurrently administered gold-standard questionnaires: the Short Form 36 Health Survey (SF-36), the 21-item Depression, Anxiety and Stress Scale (DASS-21) and the Sheehan Disability Scale (SDS). Interrater reliability was tested by comparing clinician-administered ATOP items at the medical screening interview to the same ATOP items administered by researchers at baseline., Results: ATOP Psychological Health showed moderate to strong correlations with SF-36 Mental Components, SF-36 Mental Health and DASS-21 scores (r = 0.40-0.52) and ATOP Physical Health with SF-36 Physical Components and SF-36 General Health scores (r = 0.36-0.67). The ATOP Quality of Life scale showed moderate agreement with the SDS and six-dimensional health state short form scales (r = 0.38-0.40). ATOP substance use, employment, education and child care items showed good to excellent interrater reliability (Krippendorff's α = 0.62-0.81), and tobacco use, Psychological Health, Physical Health and Quality of Life showed fair to moderate interrater reliability (Krippendorff's α = 0.42-0.53)., Discussion and Conclusions: The ATOP appears to be valid and reliable when tested in a population with cannabis-dependence, justifying its widespread use in clinical settings., (© 2020 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Designs: Take-home naloxone (THN) interventions are an effective response to preventing overdose deaths, however uptake across Australia remains limited. This project designed, implemented and evaluated a model of care targeting opioid users attending alcohol and other drug (AOD) treatment, needle and syringe programs (NSP) and related health services targeting people who inject drugs., Design and Methods: Service providers, consumers and regulators collaboratively designed a THN brief intervention (ORTHN, Overdose Response with Take-Home Naloxone) involving client education and supply of naloxone in pre-filled syringes, delivered by nursing, allied health and NSP workers. ORTHN interventions were implemented in over 15 services across New South Wales, Australia. The evaluation included client knowledge, attitudes, substance use and overdose experiences immediately before and 3 months after ORTHN intervention in a subsample of participants., Results: Six hundred and sixteen interventions were delivered, with 145 participants recruited to the research subsample, of whom 95 completed the three-month follow up. Overdose-related attitudes amongst participants improved following ORTHN, with no evidence of increased substance use or failure to implement other 'first responses' (e.g. calling an ambulance). Nine participants (10%) reversed an overdose using THN in the follow-up period. Participants identified a willingness to access THN from a range of services. While a minority (16%) indicated they were unwilling to pay for THN, the median price that participants were willing to pay was $AUD20 (IQR $10.40)., Discussion and Conclusions: The ORTHN model of care for THN appears an effective way to disseminate THN to people who use opioids attending AOD, NSP and related health-care settings., (© 2019 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Despite large increases in pharmaceutical opioid dependence and related mortality, few studies have focused on the characteristics and treatment experiences of those with pharmaceutical opioid dependence. We describe the formation of a prospective cohort of people receiving treatment for pharmaceutical opioid dependence and describe their baseline characteristics., Design and Methods: People who had entered treatment for pharmaceutical opioid dependence (n = 108) were recruited through drug treatment services in New South Wales, Australia. We describe baseline characteristics of those that commenced pharmaceutical opioids for pain or other reasons and conducted a thematic analysis of responses regarding their treatment experience., Results: Mean age was 41 years (SD 11), half were male (48%). Just over half reported lifetime heroin use (57%). Oxycodone (49%) and codeine (29%) were the most common opioids reported. Most (85%) reported past-year problematic pain, 38% reported chronic pain. Half (52%) reported moderate to severe depression symptoms. Most (66%) commenced opioids for pain, and this group were older, less likely to report a previous overdose and less likely to report use of illicit drugs compared to those commencing for other reasons. Five themes related to treatment expectations: (i) stigma; (ii) the restrictive nature of treatment; (iii) knowledge; (iv) pain; and (v) positive experience with buprenorphine., Discussion and Conclusions: This study describes the complexities in an important emerging treatment population of pharmaceutical opioid-dependent people. Findings highlights that addressing knowledge and perceptions around treatment may be critical to address the rising mortality associated with pharmaceutical opioid dependence., (© 2018 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Opioid overdose prevention programs providing take-home naloxone have been expanding internationally. This paper summarises findings and lessons learnt from the Overdose Prevention and Emergency Naloxone Project which is the first take-home naloxone program in Australia implemented in a health care setting., Methods: The Project intervention provided education and take-home naloxone to opioid-using clients at Kirketon Road Centre and The Langton Centre in Sydney. The evaluation study examined uptake and acceptability of the intervention; participants' knowledge and attitudes regarding overdose and participants' experience in opioid overdose situations six months after the intervention. Participants completed baseline, post-training and follow-up questionnaires regarding overdose prevention and management which were analysed using repeated measures analysis of variance., Results: Eighty-three people participated in the intervention, with 35 (42%) completing follow-up interviews-51% reporting using naloxone with 30 overdoses successfully reversed. There were significant improvements in knowledge and attitudes immediately following training with much retained at follow-up, particularly regarding feeling informed enough (97%) and confident to inject naloxone (100%)., Discussion: Take-home naloxone programs can be successfully implemented in Australian health settings. Barriers to uptake, such as lengthy processes and misperceptions around interest in overdose prevention, should be addressed in future program implementation., (© 2016 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Take-home naloxone (THN) programs have been operating in Australia since 2012 in a variety of settings. We examine whether THN programs were effective in increasing knowledge about opioid overdose and appropriate responses in program participants., Design and Methods: Data were obtained from pre- and post-training questionnaires administered as part of the early evaluations of THN naloxone programs operated in Sydney (n = 67), Melbourne (n = 280), Perth (n = 153) and Canberra (n = 183). Pooled data from comparable items, analysed in the domains specified in previously-developed evaluation scales, were compared using repeated-measures analysis of variance and random effects logistic regression. Results pre- and post-training were compared as well as results across sites., Results: High levels of knowledge about overdose risks and signs and appropriate actions to take were observed at baseline and this generally improved over time. No substantial differences were identified across cities. Knowledge also increased with participant age but the improvements over time were similar in each age group. There were small differences by participant gender with knowledge generally higher among females., Discussion and Conclusions: THN programs are effective in improving knowledge related to overdose response. Major improvements in knowledge were limited to overdose recognition and effect of naloxone suggesting that education may best be focused on overdose signs and the use of naloxone among populations accessed through these programs. A focus on younger people also appears warranted. Further work is needed to understand the impact of training and knowledge on actual behaviours around overdose events., (© 2018 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Take-home naloxone (THN) programs commenced in Australia in 2012 in the Australian Capital Territory and programs now operate in five Australian jurisdictions. The purpose of this paper is to record the progress of THN programs in Australia, to provide a resource for others wanting to start THN projects, and provide a tool for policy makers and others considering expansion of THN programs in this country and elsewhere., Design and Methods: Key stakeholders with principal responsibility for identified THN programs operating in Australia provided descriptions of program development, implementation and characteristics. Short summaries of known THN programs from each jurisdiction are provided along with a table detailing program characteristics and outcomes., Results: Data collected across current Australian THN programs suggest that to date over 2500 Australians at risk of overdose have been trained and provided naloxone. Evaluation data from four programs recorded 146 overdose reversals involving naloxone that was given by THN participants., Discussion and Conclusions: Peer drug user groups currently play a central role in the development, delivery and scale-up of THN in Australia. Health professionals who work with people who use illicit opioids are increasingly taking part as alcohol and other drug-related health agencies have recognised the opportunity for THN provision through interactions with their clients. Australia has made rapid progress in removing regulatory barriers to naloxone since the initiation of the first THN program in 2012. However, logistical and economic barriers remain and further work is needed to expand access to this life-saving medication., (© 2018 Australasian Professional Society on Alcohol and other Drugs.)

Introduction: Use of opioid agonist treatments for prescription opioid (PO) dependence is rapidly increasing. Current guidelines are based on research with heroin users. This study aimed to examine methadone and buprenorphine dose requirements for PO-dependent people., Design and Methods: A retrospective case series of PO-dependent patients entering methadone and buprenorphine treatment. Daily oral morphine equivalent (OME) doses at baseline were calculated using standard dose conversion calculations. Dose conversion tables were used to estimate opioid agonist doses, based on starting dose of PO. Baseline methadone and buprenorphine dose at days 7 and 28 were examined. Linear models were fit to the data., Results: Participants (n = 44) were 67% male, mean age 41 years (SD 10 years); 69% reported a pain condition. The methadone group (n = 21) had a mean PO dose of 704.5 mg OME (SD 783.5 mg) prior to treatment, and mean methadone dose of 45.3 mg (SD 13.1 mg) at day 7 and 61.6 mg (SD 20.8 mg) at day 28. The buprenorphine group (n = 23) had a mean PO dose of 771.7 mg OME (SD 867.7 mg) prior to treatment, with a mean dose of 14.6 mg (SD 8.3 mg) at day 7 and 18.1 (SD 8.9 mg) at day 28. Linear relationships were not found between OME and opioid agonist dose., Conclusions: Opioid agonist dosages varied substantially between individuals, and from predicted dosages based on dose conversion tables. Use of conversion tables to guide selection of opioid agonist dosage may compromise patient safety. [Nielsen S, Bruno R, Degenhardt L, Demirkol A, Lintzeris N. Opioid agonist doses for oxycodone and morphine dependence: Findings from a retrospective case series Drug Alcohol Rev 2017;36:311-316]., (© 2016 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: The Australian Treatment Outcomes Profile (ATOP) is a brief instrument that assesses a range of substance use, health and well-being measures over the past 28 days. Previously, it has been validated in general adult Australian alcohol and other drug (AOD) treatment populations. However, the increasing number of older-aged clients attending AOD treatment warrants the instrument to be validated for this population. The aim of this study was to validate the ATOP for use in older AOD populations, by comparing it with validated 'gold standard' measures used in older populations., Design and Methods: A convenience sample of 99 participants aged ≥50 attending specialist AOD services in Sydney, Australia were administered the ATOP by a researcher, along with alcohol use (AUDIT) and health questionnaires [Physical Health Questionnaire-15, 12-item short-form Health Survey (SF-12) and Geriatric Depression Scale]., Results: The ATOP items had strong agreement with the comparison instruments. The highest correlation was between the 28 days alcohol use and the AUDIT. ATOP psychological health scores highly correlated with the SF-12 mental health subscale and the Geriatric Depression Scale, and ATOP physical health scores significantly correlated with the SF-12 physical health subscale and the Physical Health Questionnaire-15. The ATOP Quality of Life score significantly correlated with all health measures. Discussion and Conclusions The ATOP has good concurrent validity with other validated substance use and health measures in an older population. Comparison with general older populations demonstrated the poorer health of this group of older AOD clients in particular.[Lintzeris N, Monds L A, Rivas G, Leung S, Withall A, Draper B. The Australian Treatment Outcomes Profile instrument as a clinical tool for older alcohol and other drug clients: A validation study. Drug Alcohol Rev 2016;35:673-677]., (© 2016 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: The number of older clients attending drug and alcohol (D&A) services is increasing, although there is insufficient knowledge regarding service needs for this group. The aim of this study was to document the patterns of substance use, health status, cognition, social conditions, and health service utilisation of older clients in D&A treatment., Design and Methods: A cross-sectional observational study of 99 clients aged ≥50 years (M = 55, SD = 4.5; 77% male) attending specialist D&A services (N = 30 alcohol treatment, N = 69 opioid treatment) in Sydney, Australia. Participants completed a confidential research interview. Findings were compared to aggregated data from younger opioid substitution treatment (OST) clients attending the same services (N = 214)., Results: Alcohol (46%), benzodiazepines (40%) and cannabis (38%) were the most commonly reported substances used in the past 4 weeks; 23% reported no recent substance use, and 17% reported using three or more drugs. Participants reported high levels of physical and mental health problems, social isolation, low levels of employment, and a third reported difficulties with daily living activities. Forty percent had been injured in a fall in the past 12 months. The mean Addenbrooke's Cognitive Examination-R score was 82.4 ± 9.6, with 40% performing at a level consistent with severe cognitive impairment. A significantly higher proportion of older participants used alcohol and benzodiazepines than younger clients, and older participants had significantly poorer psychological health, physical health and quality of life., Discussion and Conclusions: D&A services will require strategies to address the complex physical, mental, cognitive and social problems of older clients., (© 2015 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Codeine dependence is an emerging public health concern, yet no studies have specifically examined the treatment of codeine dependence. Given the lower potency of codeine it cannot be assumed that buprenorphine dose requirements for heroin dependence will generalise to codeine. This is the first study to examine buprenorphine treatment for codeine dependence., Design and Methods: Retrospective case series of 19 codeine-dependent treatment entrants who received sublingual buprenorphine maintenance treatment through six specialist inpatient and outpatient treatment centres. Baseline codeine doses and buprenorphine dose at days 7 and 28 were collected, in addition to details on general demographics, pain and mental health, substance use and outcomes after 28 days of buprenorphine treatment., Results: A significant linear relationship was found between initial codeine dose and dose of buprenorphine given at days 7 and 28 for the codeine dose range of 50-960 mg day -1 (mean: 564 mg; 95% confidence interval 431-696 mg). Median buprenorphine dose was 12.0 mg (interquartile range 9.5 mg, range 4-32 mg) at day 7 and 16.0 mg (interquartile range 13.5 mg, range 4-32 mg) at day 28. Buprenorphine doses received were markedly higher than estimated codeine doses based on standard dose conversion tables., Discussion and Conclusions: With increasing presentations relating to codeine dependence, these findings provide important guidance to clinicians. Buprenorphine doses were consistently higher than doses estimated based on the dose of codeine consumed, and were comparable with doses used in the treatment of dependence with heroin and more potent prescription opioids. [Nielsen S, Bruno R, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. Treating codeine dependence with buprenorphine: Dose requirements and induction outcomes from a retrospective case series in New South Wales, Australia. Drug Alcohol Rev 2015]., (© 2015 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: We report 2 years of post-marketing surveillance of the diversion and injection of buprenorphine-naloxone (BNX) film following its introduction in 2011., Design and Methods: Interviews were conducted with people who inject drugs regularly (PWID) (2004-2013), opioid substitution therapy clients (2013, n = 492) and key experts (n = 44). Key outcomes were unsanctioned removal of supervised doses, diversion, injection and street price. Prevalence of past 6-month injection among PWID was adjusted for background availability of opioid substitution therapy medications using sales data., Results: Among out-of-treatment PWID, the levels of regular (weekly+) BNX film injection were comparable to methadone and BNX tablets, and lower than mono-buprenorphine, adjusting for background availability. Fewer BNX film clients [3%; 95% (CI) 1-5] regularly injected their medication than mono-buprenorphine clients (25%; 95% CI 11-39), but at levels equivalent to those among methadone (3%; 95% CI 1-6) and BNX tablet clients (2%; 95% CI 0-6). Key experts perceived BNX film needed less supervised dosing time as it dissolved rapidly and was harder to remove from the mouth than sublingual tablets; however, removal of supervised doses was higher among BNX film clients (15%; 95% CI: 10-20) than methadone clients (3%; 95% CI 1-6), and not significantly different from BNX tablet (11%; 95% CI 2-21) and mono-buprenorphine clients (31%; 95% CI 16-46)., Discussion and Conclusions: Two years post-introduction, levels of BNX film diversion and injection remained comparable with those for methadone and BNX tablets, and lower than mono-buprenorphine. We found no evidence that BNX film has lower non-adherence and diversion than the tablet formulation. [Larance B, Mattick R, Ali R, Lintzeris N, Jenkinson R, White N, Kihas I, Cassidy R, Degenhardt L. Diversion and injection of buprenorphine-naloxone film two years post-introduction in Australia. Drug Alcohol Rev 2015]., (© 2015 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Experiences of buprenorphine-naloxone (BNX) sublingual film injection are not well documented or understood. We examined how people who inject BNX film seek and share information about this practice, document the methods used to prepare BNX film for injection, and report participants' experiences of this practice., Design and Methods: Interviews were (n = 16) conducted with people who indicated that they had injected BNX film since its introduction onto the Australian market. Semistructured interviews were recorded and transcribed. NVivo10 program (QSR International) was used to analyse the data using qualitative description methodology., Results: Participants largely reported similar BNX film preparation techniques, although the texture of BNX film during preparation to inject was reported to be unusual (gluggy), and there were many varied accounts associated with the amount of water used. Physical harms reported as associated with injecting BNX film were described (including local and systemic issues); participants reported injecting the film to enhance its immediate effects, yet generally reported that sublingual administration provided longer-lasting effects., Discussion and Conclusions: Understanding knowledge acquisition about injecting new formulations of opioid substitution therapy is crucial in developing more effective harm-reduction strategies. Dissemination by peer networks to those who are currently or planning to inject BNX film regarding the 'gelatine like' texture when mixing, using only cold water and double filtering is important to ensure safer injecting practices. Findings from this study highlight the importance of peer networks for the dissemination of harm-reduction information. Introduction of new formulations internationally requires more qualitative studies to inform safer practices., (© 2015 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: The harms associated with non-medical use of pharmaceutical opioid analgesics are well established; however, less is known about the characteristics and drug-use patterns of the growing and hidden populations of people using pharmaceutical opioids illicitly, including the frequency of pharmaceutical opioid injection. This paper aimed to undertake a detailed examination of jurisdictional differences in patterns of opioid use among a cohort of people who regularly tamper with pharmaceutical opioids in Australia., Design and Methods: Data were drawn from the National Opioid Medications Abuse Deterrence study. The cohort was recruited from New South Wales (NSW; n = 303), South Australia (SA; n = 150) and Tasmania (TAS; n = 153) to participate in face-to-face structured interviews collecting data on use of pharmaceutical opioids, benzodiazepines, other sedative drugs and illicit substances, as well as the harms associated with substance use., Results: TAS participants reported greater use and injection of certain pharmaceutical opioids (particularly morphine and methadone tablets), and limited heroin use, with lower rates of engagement in opioid substitution treatment, compared with NSW participants. NSW participants were more socially disadvantaged and more likely to report risky injecting behaviours and injecting-related injuries and diseases compared with SA and TAS participants. SA participants reported greater rates of pain conditions, greater use of pain-based services, as well as broader use of pharmaceutical opioids in regards to forms and route of administration, compared with NSW participants., Discussion and Conclusions: Distinct jurisdictional profiles were evident for people who tamper with pharmaceutical opioids, potentially reflecting jurisdictional differences in prescribing regulatory mechanisms and addiction treatment models., (© 2015 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Buprenorphine-naloxone (BNX) film for opioid dependence treatment was introduced in Australia in 2011. A key difference in State policy approaches saw transfer from BNX tablets to BNX film mandated in South Australia (SA) with New South Wales (NSW) and Victoria (VIC) having less stringent policies. This study examined (i) how initiations and transfers were implemented, (ii) the profile and predictors of adverse effects as self-reported by BNX film clients, and (iii) dosing issues., Design and Methods: Survey of 334 buprenorphine (BPN), BNX tablet and BNX film clients and semi-structured interviews with 39 key experts (KEs) in 2012. Comparisons are made between clients interviewed in SA versus NSW and VIC combined., Results: Among the 180 current BNX film clients, 23% started treatment on BNX film, 18% requested a transfer to BNX film and 59% (n = 106) reported their clinic/prescriber recommended transfer to BNX film. Among clients who were offered but refused a transfer to BNX film (n = 66), the most common reason was 'I am happy with my current treatment and do not see a reason to change' (53%). Some opioid substitution therapy clients and KE viewed transfers as 'forced' (i.e. no choice of buprenorphine formulation). Multivariable regression showed residing in SA (vs. NSW/VIC) and a shorter length of current treatment episode were associated with more BNX film-attributed adverse effects but clinic/prescriber-recommended transfer was not., Discussion and Conclusions: The introduction of BNX film in Australia varied across States. A perception of restricted choice in medication may have undermined initial acceptance in SA., (© 2015 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Few studies have described those seeking treatment for codeine dependence. This study aimed to compare patients presenting for treatment where either codeine or a strong pharmaceutical opioid (oxycodone or morphine) was the principal drug of concern to understand if codeine users may have unique treatment needs., Design and Methods: Retrospective case review of 135 patients from three geographical areas in New South Wales, Australia. Cases where the principal drug of concern was codeine (n = 53) or a strong pharmaceutical opioid (oxycodone or morphine, n = 82) were compared. Differences in demographic characteristics, pain history, mental health, substance use history and, subsequently, the treatment that was received were examined., Results: People whose principal drug of concern was codeine were more likely to be female (66% vs. 37%, P < 0.001), employed (43% vs. 22%, P < 0.01) and use only one pharmaceutical opioid (91% vs. 49%, P < 0.001). There was no difference in age between the codeine group (mean 38.6 years) and the strong opioid group (39.3 years). Opioid substitution therapy was the most common treatment received by both groups although codeine patients were more likely to be treated with buprenorphine than methadone (odds ratio = 7.7, 95% confidence interval 2.2-27.2, P < 0.001) and more likely to attempt withdrawal (odds ratio = 2.6, 95% confidence interval 1.2-5.3, P = 0.010)., Discussion and Conclusions: There are important differences between codeine-dependent patients and strong prescription opioid-dependent patients. Further work should explore the outcomes of withdrawal versus maintenance treatment for codeine users., (© 2014 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: There has been an increase in prescription of opioids for chronic non-cancer pain, and concern exists over possible diversion of prescription opioids to the illicit marketplace. Recent media coverage suggests that elderly patients sell their prescribed opioids for additional income. This study investigated the extent to which an Australian community sample of chronic pain patients prescribed opioids reported supplying their prescribed opioids to others., Design and Methods: Participants living with chronic non-cancer pain and prescribed opioids for their pain (n=952) were recruited across Australia via advertisements at pharmacies. A telephone interview included questions about their pain condition and opioid medication., Results: Participants had been living with pain for a mean of 14.2 years; most common conditions included chronic back/neck problems and arthritis/rheumatism. Around half (43%) were currently prescribed one opioid, and 55% had been prescribed 2-5 opioids; the most common was oxycodone. Forty-two participants (4%) reported ever supplying prescribed opioids to another person; one participant reported receiving payment. Participants who supplied opioids to others were younger (odds ratio 0.97, 95% confidence interval 0.95-0.99) and engaged in a greater number of aberrant behaviours relating to their opioid medication (odds ratio 1.77, 95% confidence interval 1.45-2.17), including tampering with doses, taking opioids by alternative routes, seeing doctors to obtain extra opioids and refilling prescriptions early., Discussion and Conclusion: Few people with chronic non-cancer pain divert their opioids to others. Media reports of elderly patients selling their opioids to supplement their income may be reflective of exceptional cases. Future studies may investigate the extent to which other patient groups divert prescription opioids to the illicit marketplace., (© 2013 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: The measurement of clinical outcomes is an important, but lacking, component of drug and alcohol treatment in Australia. This study aimed to psychometrically validate the Treatment Outcomes Profile under Australian conditions, examining implementation and feasibility issues in three public opioid treatment program clinics in NSW., Design and Methods: The Treatment Outcomes Profile was modified to reflect Australian conditions and re-named the Australian Treatment Outcomes Profile (ATOP). The ATOP was introduced into the participating clinics and administered by clinic staff at 3-month intervals as part of routine clinical practice. Participants completed a research interview, consisting of the ATOP and a suite of 'gold standard' instruments assessing substance use and related health and welfare domains, in the 72 h following completion of a routine clinical ATOP. The researcher- and clinician-administered ATOPs were compared to assess interrater reliability, and the researcher-administered ATOP and 'gold standard' instruments were compared to assess concurrent validity. Implementation and feasibility issues were assessed using questionnaires and focus groups with clinician and clients., Results: The ATOP demonstrated acceptable concurrent validity and interrater reliability. It was well received by clients and clinicians, particularly for its ease of use, applicability and brevity., Conclusions: The ATOP is a psychometrically valid instrument for the measurement of treatment outcomes in Australian opioid treatment populations and can feasibly be implemented as part of routine clinical practice in specialist opioid treatment program clinics. The role of the ATOP to measure outcomes in other drug and alcohol treatment modalities requires exploration., (© 2013 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: The study investigates patients' pre-treatment expectations of, and post-treatment satisfaction with, supervised injectable opiate treatment delivered within UK's first such clinics within the Randomised Injectable Opiate Treatment Trial (RIOTT) (ISRCTN0133807)., Design and Methods: Data were collected from 127 chronic heroin addicts recruited to RIOTT and randomised to receive supervised injectable (heroin or methadone) treatment or optimised oral maintenance treatment at supervised injectable maintenance clinics in London, Darlington and Brighton., Results: Of 127 RIOTT patients, 113 (89%) provided responses to structured enquiry about treatment expectations, and 94 (74%) subsequent responses about treatment satisfaction (at six months). Patients were hoping that injectable heroin treatment would: reduce substance misuse (81%); help achieve normality, routine and structure (16%); and increase education and work prospects (15%). At six months, an area of treatment satisfaction most commonly reported by all three trial groups was reduced substance misuse (supervised injectable heroin 59%, supervised injectable methadone 56%, optimised oral methadone 54%). Most found supervision acceptable, but some desired modifications were also identified., Discussion and Conclusions: Patients previously considered non-responsive to treatment appear to have similar treatment expectations and aspirations as other drug users in treatment. Supervised injectable opioid treatment patients consistently reported treatment satisfaction but also that more could be done to optimise aspects of current arrangement. This raised the challenging issue of the extent to which opinions of patients need to be taken into consideration in shaping future treatment provision. Future research may need to examine the extent of expectations 'fit' and the relationship between treatment sought and received., (© 2013 Australasian Professional Society on Alcohol and other Drugs.)

Introduction: Few general practitioners (GP) prescribe opioid substitution therapy. Our aim was to analyse their previously identified motivating factors by describing their frequency and demographic associations., Methods: An anonymous, cross-sectional questionnaire-based survey on opioid prescribing in pain and dependency was distributed across five New South Wales Divisions of GPs. Questions elicited opinions on 11 barriers and five facilitators previously described in qualitative literature. Data were analysed against demographic variables, including opioid substitution therapy prescriber (OSTP) status and postgraduate training status. 'Profiles' of non-OSTPs were then constructed using latent class analysis., Results: Of the 1735 surveys posted, there were 404 responses (23.3%), with 16% respondents being OSTPs. Frequently reported barriers included: 'negative experiences with the opioid dependent' (72%), 'heavy workload' (60%) and 'lack of specialist support' (58%), with most barriers less frequent among OSTPs. Facilitating factors included: 'more accessible specialist support' (75%), 'more accessible training' (67%) and 'better evidence of safety and efficacy' (64%), with the latter two significantly less frequently among OSTPs. Latent class analysis of the non-OSTPs revealed three distinct clusters. The smallest ('class 3') had the least barriers and resembled OSTPs demographically., Discussion and Conclusions: The pattern of motivating factors towards the psychological, social and behavioural challenges of the management of dependency has a predominantly negative bias. However, this lessens with postgraduate training and OSTP experience. Structural and logistical options are identified to promote OSTP recruitment and retention. GPs resembling class 3 may be more amenable to becoming OSTPs and may be worth targeting for recruitment., (© 2013 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: The limited literature on pain in opioid-treatment samples indicates that it is highly prevalent. Understanding the implications of pain on treatment outcomes is important, particularly in light of ageing opioid-treatment cohorts. This study explores correlates of pain, including aberrant behaviours related to prescribed opioids. Our hypothesis is that pain may increase aberrant opioid-related behaviours, including illicit substance use, among opioid-dependent people., Design and Methods: We examined pain in methadone or buprenorphine patients (n = 141) from three treatment services. Measures included basic demographics, Brief Pain Inventory, general mental health, physical health and quality of life measures, pain history and treatments, and an aberrant opioid-related behaviour scale. Univariate and multivariate analyses were used to examine correlates of pain., Results: Forty percent reported current pain, measured with the first question of the Brief Pain Inventory. Correlates of pain were depression ratings [adjusted odds ratio (OR) 2.24, 95% confidence interval (CI) 1.04, 4.83], anxiety ratings (adjusted OR 4.29, 95% CI 1.88, 9.80) and self-reported health ratings (adjusted OR 0.35, 95% CI 0.16, 0.76). Contrary to our hypothesis, pain was not associated with greater use of illicit opioids, nor any aberrant opioid-related behaviours. Pain was comparable among methadone and buprenorphine patients., Discussion and Conclusions: The lack of association with pain and aberrant behaviours suggest that it should not be assumed that those in opioid treatment misuse medications in response to pain. The high prevalence of depression/anxiety symptoms indicates a need for further work with larger samples to explore pain and co-morbidity among opioid-dependent people., (© 2013 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Case-management is a client-centred intervention to improve the coordination and continuity of delivery of services for people with complex needs. This service has been incorporated into opioid treatment programs in various ways. This study was undertaken to compare two case-management models, termed individual case-management (ICM) and team-based case-management (TBCM). This study aims to describe the new TBCM and client attitudes to, and acceptance of, this model compared with ICM., Design and Methods: Clients from two opioid treatment programs, one implementing ICM and one implementing the TBCM, were recruited to undertake a self-complete survey examining satisfaction with case-management during dosing hours over 7 months. Surveys took approximately 10 min to complete., Results: One hundred and sixty-three clients were surveyed (62 ICM, 101 TBCM). Clients were demographically similar, but differed in terms of treatment and drug use characteristics. Significantly higher ratings of case-management were reported from TBCM compared with ICM clients for help with opiate use (P < 0.001), other drug use (P < 0.001), mental health (P < 0.001), accommodation (P = 0.023), relationships/parenting (P = 0.003) and physical health (P = 0.002) and clinic services in terms of fairness and consistency, safety, respect, staff quality and confidentiality (P < 0.001). Compared with ICM clients, TBCM clients were more likely to report ease of access to case-management (P < 0.001), wait significantly less time to see a case-manager (38% vs. 7% seen same day) and 93% and 47% of clients, respectively, reported satisfaction with treatment (P < 0.001)., Discussion and Conclusions: These initial data indicate client acceptance and satisfaction with the TBCM model. Further evaluation of the model, including cost-effectiveness, is warranted., (© 2011 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: To examine Australian opioid substitution treatment (OST) prescribers' perceptions of (i) diversion and/or injection of methadone, buprenorphine, buprenorphine-naloxone by patients; and (ii) effectiveness of current treatment policies in minimising the associated risks., Design and Methods: 1278 authorised OST prescribers, identified by each jurisdiction's health department records, were sent a postal survey in 2007. Reminder letters and additional copies of the survey were sent to non-responders at weeks four and eight following the initial mail-out. Respondents went into a draw to win one of ten $100 book vouchers., Results: Although the response rate was 26% (N = 291), participating prescribers served half (49%) of all OST patients in Australia. Prescribers perceived more buprenorphine patients removed supervised doses (7%) and diverted unsupervised doses (20%), compared with methadone patients (1% and 4% respectively) and buprenorphine-naloxone patients (3% and 2% respectively). Prescribers reported significantly more buprenorphine and buprenorphine-naloxone patients injected doses (5% respectively), compared with methadone patients (2%). Non-adherence was identified through patient self-report (51%), and the reports of pharmacists (49%) and other staff (34%). More prescribers were confident in assessing the risk of injection (54%) than diversion (37%). Many prescribers responded 'don't know' to quantitative survey items. Qualitative responses highlighted uncertainties in assessing diversion/injection and whether current responses constituted 'best practice'., Discussion and Conclusions: Australian prescribers perceive most patients adhere with OST, although they may underestimate the levels of diversion. Prescribers' beliefs about patients' behaviours are important and influence decisions to prescribe, medication choice and suitability for unsupervised dosing. The uncertainties in assessing and responding to diversion/injection may be a factor deterring prescribers' participation in OST., (© 2011 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: High-dose methadone has been associated with rate-corrected QT (QTc) prolongation and 'torsade de pointes'. The Medicines and Healthcare products Regulatory Agency (MHRA) advise electrocardiograms (ECGs) for patients on methadone with heart/liver disease, electrolyte abnormalities, concomitant QT prolonging medications/CYP3A4 inhibitors or prescribed methadone >100 mg daily. The percentage of patients fulfilling MHRA criteria for ECG monitoring and prevalence of QT prolongation in patients who had an ECG was assessed., Design and Methods: A cross-sectional study of opioid-dependent patients prescribed opioid maintenance that completed a screening questionnaire prior to referral for an ECG. MHRA criteria were assessed in the referred group. The automated QTc score was analysed with methadone dose, substance use and QT risk factors., Results: Of 155 patients screened; 57.4% (n = 89) fulfilled MHRA criteria for ECG monitoring (75.5% (n = 117) if cocaine included as QT prolonging drug). Eighty-three (53.5%) had ECGs; 19.3% (n = 16) prescribed QT prolonging medication, 22.9% (n = 19) prescribed >100 mg methadone and 47% (n = 39) used cocaine. Mean QTc interval was 429.0 ms (SD 26.4, 351-489). Eighteen per cent exceeded QTc gender-specific thresholds (≥450 ms men and≥470 ms women). Linear regression found total daily methadone dose (β = 0.318, P = 0.003) and stimulant use (β = -0.213, P = 0.043) predictive of QTc length., Discussion: Over half to three-quarters of methadone maintenance patients fulfilled MHRA criteria for ECG monitoring, which has costly implications. QTc prolongation prevalence was 18.1% with no 'clinically significant' QTc prolongation >500 ms or torsade de pointes known to be present. Methadone dose and stimulant use were associated with longer QTc intervals. Further research on the clinical management of QTc prolongation with methadone is required., (© 2010 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: The use of opioid substitution therapy (OST) is a widely used and effective treatment for opioid dependence, yet many Australian general practitioners (GPs) authorised to administer OST, prescribe to very few or no patients. This is a particular issue within Victoria that places greater reliance on a small number of active OST prescribing GPs, compared with other jurisdictions. Given the unmet demand for treatment, the provision of accurate figures on the OST prescribing practices of Victorian GPs is necessary for workforce planning. This study aimed to ascertain information on the prescribing patterns of Victorian GPs in their first 5 years after training, and elicit any trends that may explain their reluctance to prescribe OST., Design and Methods: The prescribing patterns over a 5 year period of 168 Victorian GPs who became first authorised to prescribe OST during the years 2001-2004 were examined by accessing the Victorian Department of Human Services OST individual patient treatment permit data., Results: Forty-six per cent of these GPs never held a patient permit, and at any one time, approximately two-thirds did not hold a permit. The majority of active prescribers were treating fewer than 10 patients and only 12.5% ever prescribed to more than 50 patients., Discussion and Conclusions: The study suggests the Victorian GP workforce is inadequate to address the demand for OST. Many more GPs will need to be recruited, and encouraged to prescribe for more patients. Further research is required to identify barriers to GP OST prescribing., (© 2010 Australasian Professional Society on Alcohol and other Drugs.)

Aims: This paper (i) reviews the language used to describe and manage those patient practices that fall outside standard medical models of opioid treatment (for pain and opioid dependence), and (ii) proposes a consistent terminology that can be applied across multiple healthcare settings., Method: Peer-reviewed and grey literature documenting empirical studies of (non-)adherence with opioid treatment, proposed definitions or other potentially important aspects of terminology were included in this review., Results: There are international inconsistencies in the terminology used to describe the unintended consequences of opioid treatment, and the terms used often lack specificity. The terms 'hazardous use', 'extramedical use', 'opioid dependence', 'diversion', 'non-adherence' and 'aberrant behaviours' are defined. We advocate for consistent application of these terms in the context of opioid treatment, and propose that care is taken to describe individual practices and intentions., Conclusions: The increasing global attention on the use and diversion of pharmaceutical opioids warrants a discussion of current terms and definitions. Exaggerated concerns regarding 'addiction potential' may result in restrictions in the supply of opioids and the under-treatment of legitimate medical conditions. Researchers, clinicians, policy-makers and patients need to ensure greater care is given to terminology, including detailed descriptions of patient practices, the context in which they occur and severity of associated harm., (© 2011 Australasian Professional Society on Alcohol and other Drugs.)

Introduction and Aims: Non-prescribed use of pharmaceutical opioid analgesics (POA) has been escalating internationally. In Australia, few studies have examined if POA users have similar characteristics and treatment needs to heroin users. The aim of this study was to compare those presenting for treatment where heroin versus POA were the primary drugs of concern., Design and Methods: A convenience sample of 192 treatment entrants were recruited from alcohol and drug treatment services in four Australian jurisdictions. A structured interview collected data on demographic characteristics, substance use, self-perceived mental and physical health, crime and harms resulting from drug use. Multivariate analyses were performed to identify characteristics which may differentiate those seeking treatment for heroin compared with POA., Results: Most treatment entrants sampled reported a history of injection drug use and use of both heroin and POA. However, those with primary POA problems were less likely to report an overdose history (adjusted odds ratio 0.90, 95% confidence interval 0.81-0.99) and more likely to initiate opioid use for pain (adjusted odds ratio 2.52, 95% confidence interval 1.04-6.12) than those with primary heroin problems. Latent Class Analysis found that, while most of the POA group were similar to heroin users in demographics, health and injecting drug use, there was a small, distinct group of primary POA problem users that did not typically inject and who commonly initiated opioid use for pain and also experienced elevated physical and mental health disability., Discussion and Conclusions: While some differences existed, this study of Australian treatment seekers found many similar characteristics between those with primary problems with heroin and POA. Few non-injecting POA were recruited in this sample. This finding contrasts with reports of a growing population of opioid-dependent people with characteristics that are distinct from traditional opioid-dependent populations, which may reflect the orientation of current treatment systems in Australia towards injection drug users., (© 2011 Australasian Professional Society on Alcohol and other Drugs.)

Issues: There is a shortage of high-quality intervention-based evidence in the drug and alcohol misuse field. That is, evidence based on replicated effects using rigorous methodology, to establish a causal knowledge base around ethical, cost-effective methods relevant to clinical practice. The knowledge base in this field is limited participant recruitment challenges; difficulty generalizing results from single-centre studies; lack of research culture; issues in managing research teams; incentives for descriptive research; and limited expertise in research design and working in multidisciplinary teams., Approach: An Australian national multicentre collaboration is proposed to overcome these barriers, and reduce the burden of drug and alcohol misuse by increasing the number of high-quality clinical trials in this field. It would involve: selecting a representative sample of centres nation-wide with expertise in specific drug and alcohol issues; creating an expert multidisciplinary team to facilitate clinical trials; simultaneous recruitment and implementation of clinical trials across centres; establishing a virtual infrastructure; forming an independent data-integrity and methodology review panel; and attracting and allocating funding for clinical trials., Implications: The ability to allocate funding, the involvement of multidisciplinary experts in drug and alcohol research, and the establishment of infrastructure and procedures are likely to result in the national multicentre group's capacity to prescribe the type of research conducted under its auspices., Conclusion: The proposed initiative is likely to increase the volume of high-quality clinical trials in the Australian drug and alcohol field, a key step towards reducing the burden of drug and alcohol misuse.

This study aimed to establish a buprenorphine regime suitable for the short-term management of out-patient heroin withdrawal using an open-label, single-group case series. Eighteen dependent injecting heroin users underwent an 8-day withdrawal episode with supervised dosing of sublingual Subutex tablets. Buprenorphine doses were titrated daily over a 5-day period. Fifteen subjects (83%) completed the 5-day regime, and 14 (78%) completed the 8-day withdrawal episode. The mean doses ((SD) were 6.1 (1.2) mg on day 1; 9.6 (1.7) mg on day 2; 10.1 (1.9) mg on day 3; 8.9 (2.0) mg on day 4; 4.1 (1.5) mg on day 5; and a total regime dose of 38.9 (5.8) mg. Withdrawal severity was mild, with minimal rebound upon the cessation of dosing. Five subjects reported no heroin use, and five subjects reported using on only one occasion during the 8 days. An out-patient buprenorphine regime is recommended.

Amphetamines are among the most widely used of illicit drugs in Australia, and evidence documenting the occurrence of amphetamine-related harms, particularly among chronic regular users, is increasing, A review of contemporary Australian treatment approaches suggests that conventional modalities are unlikely to address the needs of a large proportion of dependent amphetamine users. This has prompted clinicians in Australia and the United Kingdom to commence treatment programmes incorporating substitution therapy. Despite the positive impressions of clinicians involved in these programmes, further research is required to establish the role and efficacy of such treatment approaches. Issues to be addressed in the establishment of a controlled study are examined.