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Aims: This study examined the social, material and temporal effects of extended-release buprenorphine depot treatment (BUP-XR), among a group of participants commencing BUP-XR in Australia, and considered the situated potentials of these new opioid agonist treatment technologies. Methods: Using a longitudinal qualitative design, 36 participants (25 men, 11 women; mean age 44 years) were interviewed, with 32 followed-up, to generate accounts of BUP-XR experiences. Analysis was informed by sociological approaches which attend to the multiple effects of novel health interventions as they are put to use and made to work, with a focus on tracing change over time. Analysis: The shift from daily to monthly dosing altered how opioid agonist treatment was experienced, reconfigured participants’ relationship to treatment, and affected the temporal patterns of participants’ lives. Extending temporal relations released participants from short-term cycles of living and produced different forms of subjectivity, bringing about both transformation and loss. Monthly dosing, and a sense of normalcy characterized by absenting the routines and felt effects of drugs or treatment medications, potentiated a feeling of stability for many participants. For some, disrupting daily routines precipitated disconnection from treatment and social care relations. The transition from daily to monthly dosing required adaptation and new ways of engaging with treatment and care, with medication acting as a bridge to care without necessarily being the focal point. Conclusions: As BUP-XR treatment gains traction internationally, it will be important to attend to the multiple, and sometimes unexpected, effects this intervention makes in the social and material lives of clients. How choice, social connection, and care can be maintained to help secure BUP-XR’s longer-term impact, and how clients can be supported to adjust to what is felt to be a new normal, will be considerations in future treatment delivery.

In this paper we document and analyze emergent participatory processes in drug policy, focusing on the relations between established modes of engagement and emergent participatory formats. We do this through analysis of a case example, attending to policy changes to opioid pharmacotherapy treatment in the context of COVID-19 in Australia. Semistructured interviews ( n = 22) were undertaken between August 2020 and March 2021 with people closely involved in the recent policy changes and discussions surrounding opioid pharmacotherapy treatment in Australia. The analysis of the interview accounts followed work which has forged relational, co-productionist and materialist understandings of participation. Two figures of participation were encountered in the interview accounts: the tables of participation and the huddles of participation. The tables seemingly represented a standardized set of bureaucratic mechanisms for the inclusion of the “voices” of people who use drugs. The huddles emerged as a responsive and less coherent set of ad hoc participatory collectives in the context of rapid policy changes during COVID-19. Instead of viewing emergence as distinct from existing participatory formats, emergence was conceptualized ecologically in this article—that is in relation to established forms of participation. As the institutionally mandated tables served the basis for the emergent huddles of participation in this case study, it demonstrates that even the most foreclosed participatory structures can adapt and be responsive to evolving situations of need, perhaps also in ordinary times and not just in emergency conditions.

Participatory modelling seeks to foster stakeholder engagement to better attune models to their decision-making and policy contexts. Such approaches are increasingly advocated for use in the field of health. We review the instrumental and epistemological claims made in support of participatory modelling approaches. These accentuate participatory models as offering a better evidence-base for health policy decisions. By drawing attention to recent modelling experiments in a sector outside of health, that of water management, we outline a different way of thinking about participation and modelling. Here, the participatory model is configured in relation to matters of 'knowledge controversy', with modelling constituted as an 'evidence-making intervention' in relation to the making of science and expertise. Rather than presenting participatory models as an improved technical solution to addressing given policy problems within an evidence-based intervention approach, models are alternatively potentiated as sites for the redistribution of expertise among actor networks as they seek to engage politically in a matter of concern. This leads us to consider possible new directions for participatory modelling in the field of health.

ObjectiveTo investigate how care is shaped through the material practices and spaces of healthcare environments during the COVID-19 pandemic.DesignCritical interpretive synthesis (CIS) of qualitative research.ParticipantsStudies included qualitative research investigating the experiences of healthcare workers involved in the care of individuals during the COVID-19 pandemic.Results134 articles were identified in the initial sampling frame with 38 studies involving 2507 participants included in the final synthesis. Three themes were identified in the analysis: (1) the hospital transformed, (2) virtual care spaces and (3) objects of care. Through the generation of these themes, a synthesising argument was developed to demonstrate how material spaces and practices of healthcare shape care delivery and to provide insights to support healthcare providers in creating enabling and resilient care environments.ConclusionsThe findings of this study demonstrate how healthcare environments enable and constrain modes of care. Practices of care are shaped through the materiality of spaces and objects, including how these change in the face of pandemic disruption. The implication is that the healthcare environment needs to be viewed as a critical adaptive element in the optimisation of care. The study also develops a versatile and coherent approach to CIS methods that can be taken up in future research.

While there is widespread agreement as to the importance of increasing participation in drug policy design, drug policy literature contains limited reflection on the practices that may support inclusion and collaboration amongst policy actors, particularly when disagreement and difference are an intrinsic part of participation. Drawing on qualitative interviews and ethnographic fieldwork with actors engaged in an Australian illicit drug policy reform campaign, this paper examines how particular modes of personal connection mattered in establishing and maintaining working relationships between a range of differently situated actors. Through engagement with this case study, we argue that modes of personal connection marked by qualities such as being frank; engaged; not forcing consensus; enacting respect; listening in order to understand; and acting in ways that respected the obligations and limits that came with people's roles while also recognising one another as more than those roles, were particularly important qualities that supported connection across difference. Such personal connections seem to have been even more important for the engagement of people representing more marginal positionalities. Arguing that personal connection is already an element of both inclusion and exclusion in drug policy creation, we suggest that policy actors interested in contributing to a more diverse and rigorous policy participation space attend to how people connect, with whom, and with what space for disagreement, while also taking seriously the labour of such connection across difference.

In efforts to control disease, mathematical models and numerical targets play a key role. We take the elimination of a viral infection as a case for exploring mathematical models as ‘evidence‐making interventions’. Using interviews with mathematical modellers and implementation scientists, and focusing on the emergence of models of ‘treatment‐as‐prevention’ in hepatitis C control, we trace how projections detach from their calculative origins as social and policy practices. Drawing on the work of Michel Callon and others, we show that modelled projections of viral elimination circulate as ‘qualculations’, taking flight via their affects, including as anticipation. Modelled numerical targets do not need ‘actual numbers’ or precise measurements to perform their authority as evidence of viral elimination or as situated matters‐of‐concern. Modellers grapple with the ways that their models transform in policy and social practices, apparently beyond reasonable calculus. We highlight how practices of ‘holding‐on’ to projections in relation to imaginaries of ‘evidence‐based’ science entangle with the ‘letting‐go’ of models beyond calculus. We conclude that the ‘virtual precision’ of models affords them fluid evidence‐making potential. We imagine a different mode of modelling science in health, one more attuned to treating projections as qualculative, affective and relational, as excitable matter.

Summary Interprofessional practice has been broadly endorsed as a strategy which supports the delivery of high-quality health services. Few studies have addressed the dynamics inherent to interprofessional mental health practice in an era in which client empowerment is prioritised and valued. Social work perspectives are also underexplored in the studies which have been published on interprofessional health care, despite the increasingly important role of this discipline in community mental health contexts. Through a thematic analysis of 26 semi-structured interviews, this study explored the perspectives of mental health social workers located in two geographically and culturally distinctive sites (Hong Kong and Sydney), and identified a strong theme encompassing their concerns about the facilitation of client empowerment in interprofessional settings. Findings Participant accounts direct attention to the strategies required to co-constitute the shared territories of the different mental health professions. Findings also highlight the frustration with recent mental health reforms which aim to challenge power differentials in interprofessional decision-making. Strategies were proposed for supporting the construction of shared language among different professions, revealing the creativity and insight of practitioners in managing the conflicts arising from interactions between different professional knowledge systems. The comparison of Hong Kong and Sydney accounts highlights the importance of structural, political and cultural influences in supporting not only interprofessional collaboration but also the independence and effectiveness of distinct professional roles. Application This article provides unique insights which aim to strengthen the contribution of social work to interprofessional practice in the promotion of empowerment-oriented interprofessional practice and education.

This article investigates how evidence of the safety and efficacy of COVID-19 vaccines is enacted in news media via a focus on the temporality of vaccine development. We argue that time constitutes a crucial object of and mechanism for knowledge production in such media and investigate how time comes to matter in vaccine evidence-making communication practices. In science communication on vaccine development, the vaccine object (along with the practices through which it is produced) undergoes a material-discursive shift from an imagined “rushed” product to being many years in the making and uninhibited by unnecessarily lengthy processes. In both these enactments of vaccine development, time itself is constituted as evidence of vaccine efficacy and safety. This article traces how time (performed as both calendar time and as a series of relational events) is materialized as an affective and epistemic object of evidence within public science communication by analyzing the material-discursive techniques through which temporality is enacted within news media focused on the timeline of COVID-19 vaccine development. We contend that time (as evidence) is remade through these techniques as an ontopolitical concern within the COVID-19 vaccine assemblage. We furthermore argue that science communication itself is an important actor in the hinterland of public health practices with performative effects and vital evidence-making capacities.

Until recently, the only medical treatment available for the hepatitis C virus (HCV) was interferon-based therapy, a notoriously long and arduous treatment with limited success. However, in December 2015, the Australian Government announced a scheme of ‘universal access’ to new, highly effective direct-acting antiviral therapies (DAAs). This article draws on in-depth interviews with community actors engaged in national and state-based drug user and viral hepatitis advocacy to trace how universal access to curative medicines affords revised notions of citizenship and social inclusion among people who inject drugs and others affected by HCV. To inform our analysis, we draw on and combine critical perspectives from the biological citizenship literature, particularly pharmaceutical citizenship, along with work on the concepts of ‘publics and counterpublics’. We ask: what kinds of emergent HCV communities or publics are being enacted through our participant accounts in response to the new DAA-era of universal access, and what forms of citizenship and inclusion (or non-citizenship and exclusion) do they postulate? Some accounts indeed enacted treatment as an individual, sometimes collective, ‘good’: a citizenship potential. However, a number of accounts enacted situated limits to a straightforward actualisation of this potential, performing a model of public health governance that prioritised viral cure whilst rendering injecting drug use and its attendant social disadvantages an absent presence. Reconceptualising HCV treatment within a counterpublic health sensibility would, by engaging with the everyday health needs and aspirations of people living with HCV in conditions of social disadvantage, create space for new social inclusions and citizenships.

Risk management and empowerment have become key features of social work practice. Despite their increasing salience, relatively little is known about the perspectives of mental health social workers regarding how they navigate competing risk management approaches in modern practice that supports empowerment. The socio-cultural influences on risk management have also received insufficient attention in social work research. Focusing on these issues, this paper explored the perspectives of social workers in two geographically and culturally distinctive settings (i.e., Hong Kong and Sydney). Data were collected through semi-structured interviews with frontline social workers and were analysed using thematic analysis. Similar views were expressed by participants in both settings regarding assessment of clients’ readiness for risk-taking. Differences were identified in their practices of negotiating the perspectives of other key stakeholders and can be attributed to the influences of distinctive cultural and socio-political contexts. These insights may contribute to the development of more systematic, localised and practice-based risk assessment guidelines for mental health practitioners working towards the empowerment of clients.

Background and aims Not all people experiencing opioid dependence benefit from oral opioid agonist treatment. The aim of this study was to examine perceptions of (supervised) injectable opioid agonist treatment (iOAT) (described as ‘an opioid similar to heroin self‐injected at a clinic several times a day’) among people who regularly use opioids and determine how common iOAT eligibility criteria accord with interest in iOAT. Design Cross‐sectional survey Setting Sydney, Melbourne and Hobart, Australia. Participants A total of 344 people (63% male) who use opioids regularly and had ever injected opioids, interviewed December 2017–March 2018. The mean age of participants was 41.5 years [standard deviation (SD) = 8.5]. Measurements Primary outcome measures were interest in iOAT, factors associated with interest and the proportion of participants who would be eligible using common criteria from trials and guidelines. We examined willingness to travel for iOAT, medication preferences and perspectives on whom should receive iOAT. Findings Overall, 53% of participants (n = 182) believed that iOAT would be a good treatment option for them. Participants who believed that iOAT was a good treatment option for them were more likely to be male [adjusted odds ratio (aOR) = 1.76, 95% confidence interval (CI) = 1.10–2.82], have used heroin in the past month (aOR = 6.03, 95% CI = 2.86–12.71), currently regularly inject opioids (aOR = 1.84, 95% CI = 1.16–2.91) and have met ICD‐10 criteria for opioid dependence (aOR = 3.46, 95% CI = 1.65–7.24). Those interested in iOAT had commenced more treatment episodes (aOR =1.06, 95% CI = 1.00–1.12). Among those interested in iOAT (n = 182), 26% (n = 48) met common eligibility criteria for iOAT. Conclusions Interest in injectable opioid agonist treatment does not appear to be universal among people who regularly use opioids. Among study participants who expressed interest in injectable opioid agonist treatment, most did not meet common eligibility criteria.

We explore messy translations of evidence in policy as a site of 'uncomfortable science'. Drawing on the work of John Law, we follow evidence as a 'fluid object' of its situation, also enacted in relation to a hinterland of practices. Working with the qualitative interview accounts of mathematical modellers and other scientists engaged in the UK COVID-19 response, we trace how models perform as evidence. Our point of departure is a moment of controversy in the public announcement of second national lockdown in the UK, and specifically, the projected daily deaths from COVID-19 presented in support of this policy decision. We reflect on this event to trace the messy translations of "scientific consensus" in the face of uncertainty. Efforts among scientists to realise evidence-based expectation and to manage the troubled translations of models in policy, including via "scientific consensus", can extend the dis-ease of uncomfortable science rather than clean it up or close it down. We argue that the project of evidence-based policy is not so much in need of technical management or repair, but that we need to be thinking altogether differently.

BackgroundEvidence-based policy decision-making is a dominant paradigm in health but realizing this ideal has proven challenging.Sources of dataThis paper conceptually maps health policy, policy studies and social science literature critically engaged with evidence and decision-making. No new data were generated or analysed in support of this review.Areas of agreementBarriers to evidence-based policy have been documented, with efforts made to increase the uptake of evidence.Areas of controversyEvident complexities have been regarded as a problem of translation. However, this assumes that policy-making is a process of authoritative choice, and that ‘evidence’ is inherently valuable policy knowledge, which has been critiqued.Growing pointsAlternative accounts urge consideration of how evidence comes to bear on decisions made within complex systems, and what counts as evidence.Areas timely for developing researchAn ‘evidence-making intervention’ approach offers a framework for conceptualizing how evidence and interventions are made relationally in practices, thus working with the politics and contingencies of implementation and policy-making.

Informed by work on futurity in science and technology studies, we trace how global disease elimination targets perform a world without disease through their translations in visual advocacy campaigns. Treating disease elimination targets and their visualisations as performative, we take the case of hepatitis C elimination to interrogate how futuring practices in public health govern the present and make effects. We focus specifically on how World Health Organization targets in the Global Health Sector Strategy on Viral Hepatitis entangle with visual resources produced by the World Hepatitis Alliance NOhep advocacy campaign. Targets and their visual representations in campaigns perform a disease elimination future which is set apart from the present, and yet urges action in-the-now. It enacts global health citizens but separates them from localised experiences of living with, and being cured of, disease. This disease elimination future relies heavily on instrumental rationalities and logics of the present, including the privileging of biomedical technoscientific knowledge, implementation science and global health governance, to the exclusion of other matters of concern, flattening out complexity to perform its certain achievability. These enactments raise political questions about how disease elimination futures might be made in a different mode.

Aims To examine perceptions of extended‐release (XR) buprenorphine injections among people who regularly use opioids in Australia. Design Cross‐sectional survey prior to implementation. XR‐buprenorphine was registered in Australia in November 2018. Setting Sydney, Melbourne and Hobart. Participants A total of 402 people who regularly use opioids interviewed December 2017 to March 2018. Measurements Primary outcome concerned the proportion of participants who believed XR‐buprenorphine would be a good treatment option for them, preferred weekly versus monthly injections and perceived advantages/disadvantages of XR‐buprenorphine. Independent variables concerned the demographic characteristics and features of current opioid agonist treatment (OAT; medication‐type, dose, prescriber/dosing setting, unsupervised doses, out‐of‐pocket expenses and travel distance). Findings Sixty‐eight per cent [95% confidence interval (CI) = 63–73%] believed XR‐buprenorphine was a good treatment option for them. They were more likely to report being younger [26–35 versus > 55 years; odds ratio (OR) = 3.16, 95% CI = 1.12–8.89; P = 0.029], being female (OR = 1.67, 95% CI = 1.04–2.69; P = 0.034)

INTRODUCTION AND AIMS Governments across the globe invest considerable amounts in funding alcohol and other drug (AOD) treatment. Little attention however has been paid to the ways AOD service providers are chosen and how they are paid. This study sought to examine the perceptions of Australian AOD treatment purchasers and providers regarding different purchasing and payment mechanisms. DESIGN AND METHODS Qualitative interviews with AOD treatment providers and purchasers (N = 197) were undertaken across the eight Australian states/territories and the Commonwealth. Data were collated against six main AOD treatment purchasing and payment mechanisms (as identified in the literature), then an inductive, comparative analysis to assign codes was conducted, followed by interpretive analysis to explore emergent themes. RESULTS Five main themes were identified in relation to AOD treatment payment and purchasing mechanisms: (i) applying private sector principles to purchasing; (ii) innovation, sector stability and addressing client needs; (iii) performance monitoring and measuring outcomes; (iv) the threat to designated funding for AOD treatment; and (v) the costs and benefits of having multiple funding sources. DISCUSSION AND CONCLUSIONS In many countries reforms are taking place in the health sector consistent with New Public Management principles. These principles, when applied to AOD treatment, have included introducing competition, output and outcomes-based funding models, standards and accountability. Purchaser and providers identified both strengths and weaknesses and highlighted the overarching concern that implementation of any (mix) of these mechanisms should always be underpinned by a client-centred and not a finance-centred approach.

Media and politicians both influence public opinion and policy responses to illicit drug issues. This study examines the contribution each may have made in Australia in 2015 to the problem and poli...

Stigma has corrosive effects on all aspects of care and can undermine individual and population health outcomes. Addiction-related stigma has implications for opiate agonist treatment (OAT) and the people who receive, provide and fund it. It is important to understand how stigma is made in OAT and the political purposes that it serves, in order to change the relations of stigma and avoid the reproduction of stigma in the delivery of new treatment formulations, such as extended release buprenorphine (BUP-XR).Semi-structured qualitative interviews were conducted at two time points with participants in a prospective single-arm, multicentre, open-label trial of monthly BUP-XR. Thirty-six participants (25 men, 11 women) were interviewed, and of these 32 participated in a second interview to explore their experience of transition from other treatment to BUP-XR.Participants were highly aware of the of the social and material effects of stigma through the negative stereotypes attached to OAT and those who receive it. Participants narrated examples of how stigma governed as a biopower in the relations and practices of OAT provision at numerous levels: structural (such as in public discourse about OAT and the people who receive it, in media, in perceptions about the decisions of investment in medical technologies); organisational (policies about legitimate access to OAT); interpersonal (with health workers) and individual (self-identities). BUP-XR allowed greater freedom and normalcy for clients. The experience of BUP-XR drew attention to the stigmatising potential of time, place and things associated with other OAT requiring daily (or frequent) dosing, accentuating how stigma comes to be materialised as a relational effect of everyday practices.Receiving BUP-XR allowed participants to avoid some of the everyday biopolitical powers of other forms of OAT and to reshape self-identities. The altering of relations between time, place and things associated with other forms of OAT allowed participants to feel as though they "pass as normal" . However, the negative public discourse and stigma of OAT is a potential threat to BUP-XR to realise its potential for individual and population benefits.

Summary of recommendations and levels of evidence Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity–frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient’s needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the “teach-back” technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A). Summary of key recommendations and levels of evidence Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A).

One concern in the field of drugs policy is how to make research more futures-oriented. Tracing trends and events with the potential to alter drug futures are seen as ways of becoming more prepared. This challenge is made complex in fast evolving drug markets which entangle with shifting social and material relations at global scale. In this analysis, we argue that drugs policy research orientates to detection and discovery based on the recent past. This narrows future-oriented analyses to the predictable and probable, imagined as extensions of the immediate and local present. We call for a more speculative approach; one which extends beyond the proximal, and one which orientates to possibilities rather than probabilities. Drawing on ideas on speculation from science and technology and futures studies, we argue that speculative research holds potential for more radical alterations in drugs policy. We encourage research approaches which not only valorise knowing in relation to what might happen but which conduct experiments on what could be. Accordingly, we trace how speculative research makes a difference by altering the present through making deliberative interventions on alternative policy options, including policy scenarios which make a radical break with the present. We look specifically at the 'Big Event' and 'Mega Trend' as devices of speculative intervention in futures-oriented drugs policy research. We illustrate how the device of Mega Trend helps to trace as well as to speculate on some of the entangling elements affecting drug futures, including in relation to climate, environment, development, population, drug production, digitalisation, biotechnology, policy and discourse.

Background Remission from alcohol problems in the absence of treatment is common, yet there are wide ranging estimates of the extent to which this occurs, depending on method. A systematic review of the literature on untreated remission from alcohol problems was conducted to analyse the ways different definitions and study designs impact on estimates of untreated remission from alcohol problems, and to explore the implications for treatment planning. Methods 2103 texts were identified through systematic searches of databases (Medline, PsycINFO, EMBASE) and other searches. Peer-reviewed journal articles published since 1975 which provided numeric estimates of untreated remission from alcohol problems were included. A narrative synthesis was undertaken. Results 124 estimates of untreated remission from alcohol problems were extracted from 27 studies. Three different sampling methods were identified: taking an ‘alcohol problems sample’ (method 1) which estimated the proportion of people with alcohol problems who remit without treatment; taking an ‘untreated sample’ (method 2) which estimated the proportion of untreated people who enter remission; and taking a ‘remitted sample’ (method 3) which estimated the proportion of people in remission who have not received treatment. In addition to this sampling diversity, the definitions of an alcohol problem, definitions of remission, and definitions of treatment varied between studies. The combination of the methods and definitional issues impacted on estimates of untreated remission from alcohol problems. Conclusions Estimates derived from the ‘alcohol problems sample’ (method 1) and ‘untreated sample’ (method 2) are the most appropriate for treatment planners. How a treatment planner defines what treatment is, what remission is, and how an alcohol problem is defined all matter for these estimates.

HIV pre-exposure prophylaxis (PrEP) has been embraced in Australia, making PrEP available with public funding to people at risk of HIV. Here, we consider the associated 'problems' of reduced condom use and sexually transmissible infections (STIs), as seen by HIV professionals. Twenty-one interviews were conducted during May-August 2017. All agreed that PrEP was a valuable addition to HIV prevention, but their views about reduced condom use and STIs were variable. Using poststructural policy analysis, three main stances were identified: (1) Concerned/alarmed. PrEP was seen as causing reduced condom use, STIs and antibiotic resistance, posing threats to the general population; (2) Neutral/normalising. Stakeholders emphasised that condom use was declining and STIs increasing independently of PrEP, and that PrEP was simply a new tool to be accommodated; (3) Optimistic/critical. PrEP was seen as diminishing fear of HIV and engaging users in more frequent testing and treatment that could lead to declining STI rates. What linked all three stances was the selective performance of evidence, deploying a mixture of personal experience, clinical observations, behavioural data and epidemiology. Anticipating possible futures through evidence-making suggested practical, political and moral consequences for what PrEP could become. We encourage others to consider these consequences with care.

The United Nations states that prisoners should enjoy the same standards of health care that are available in the community. Despite this, persons in prison experience barriers to care and face unique health challenges. Given the ways in which prisons shape health outcomes for incarcerated persons, it is important to interrogate how the provision of health care is governed in custodial settings. In this article, we examine one important aspect of governance: legislation governing the provision of health care in prisons. We view this issue through a critical lens, building on a body of poststructural scholarship which has illuminated how laws and policies are not merely tools of governance but also key sites for the production of meanings around social “problems,” including the “problem of health.” Taking Canada’s Corrections and Conditional Release Act as a case example and applying Carol Bacchi’s “What’s the Problem Represented to Be” analytical framework, we examine how the specific representation of “health” in this legislation works to produce effects for persons in federal prison. Three key themes are formed through this analysis. First, what constitutes “essential services” in the context of federal prisons is more limited compared with the broader community. Second, the dichotomy between the rights of persons in prison versus the protection of society that is produced in development of these laws has significant bearing on the treatment of those in prison. Third, this representation has negative effects on the health of persons in prison. In order to meet United Nations standards, greater attention must be paid to the ways in which laws and other governing practices reproduce inequities in health care provision in prisons.

Crystal methamphetamine (“ice”) has been a fixture in Australian newspapers since the early 2000s. This study explores discourses at work in constructing the ice “problem” in recent Australian media, possible implications for how people who use ice are discursively positioned, and the resulting significance for drug policy. Twenty-seven articles were selected for discourse analysis, sampled from a larger study of Australian ice-related news items. By critically engaging with sociological concepts of “moral panic” and the “risk society,” we demonstrate how three media discourses produce the subject of the “young person” as both victimized by ice and a catastrophic threat in and of themselves: (1) “ice traps and transforms youth,” (2) “ice does not discriminate,” and (3) “ice perverts sanctuary.” These discourses illustrate the tensions between the meanings of ice use and understandings of safety and risk, speaking to current anxieties in Western, neoliberal societies. Ice use is further constructed as a form of abjection, threatening traditional social boundaries and institutions. However, the agency and determinism simultaneously granted to ice the substance troubles the notion we are witnessing yet another “drug scare” that polices social behavior. Instead, we observe how these discourses mirror those in the biomedical literature, which construct ice as a uniform, agentic, and uniquely dangerous drug. With use attributed to entrapment and/or naturalized as addiction, the drug is constituted as engineering its own, always harmful, consumption. This limits conceptions of any “safer,” “rational,” or “pleasurable” forms of ice use and further justifies state intervention on its users. Overall, these discourses rationalize prohibitionist interventions around ice and singularize drug consumption as a behavior requiring institutional management.

The idea of identifying and monitoring urinary excretion of illicit drugs and their metabolites in wastewater has been seen by governments and international organisations as 'promising'. It is claimed that such approaches will enable governments to effectively direct resources to priority areas, monitor the progress of demand and supply reduction strategies, as well as identify emerging trends. Drawing on poststructural approaches to policy analysis and insights from science and technology studies, we consider how the technology of wastewater analysis may be seen as a kind of proposal with productive capacity and constitutive effects. Through this analysis, we seek to raise ontopolitical questions about the production of data by interrogating the claims to 'accuracy' promoted in wastewater analysis, and illuminating the assumptions underpinning such pursuits. By taking an approach which sees method as performative rather than as descriptive of a pre-existing reality, we consider how wastewater analysis enacts realities into being in the drugs field. Taking Australia's National Wastewater Drug Monitoring Program as a case example, we argue that wastewater analysis constitutes drug use as measurable, countable and comparable and, in doing so, enacts a homogenous drug using population in a bounded geographical space, with implications for drug policy. Furthermore, the claim to 'accuracy' constitutes people who use drugs as lacking in knowledge and unaware, and relates to a range of practices which work to continually re-produce people who use drugs as criminal, untrustworthy and in need of surveillance. Through this analysis, we seek to generate critical discussion about practices of 'evidence-making', the privileging of 'scientific data' in drug policy processes (especially as it relates to population prevalence of drug use), and the hitherto unexamined effects of wastewater analysis for drug policy.

In this paper, we trace how mathematical models are made 'evidence enough' and 'useful for policy'. Working with the interview accounts of mathematical modellers and other scientists engaged in the UK Covid-19 response, we focus on two weeks in March 2020 prior to the announcement of an unprecedented national lockdown. A key thread in our analysis is how pandemics are made 'big'. We follow the work of one particular device, that of modelled 'doubling-time'. By following how modelled doubling-time entangles in its assemblage of evidence-making, we draw attention to multiple actors, including beyond models and metrics, which affect how evidence is performed in relation to the scale of epidemic and its policy response. We draw attention to: policy; Government scientific advice infrastructure; time; uncertainty; and leaps of faith. The 'bigness' of the pandemic, and its evidencing, is situated in social and affective practices, in which uncertainty and dis-ease are inseparable from calculus. This materialises modelling in policy as an 'uncomfortable science'. We argue that situational fit in-the-moment is at least as important as empirical fit when attending to what models perform in policy.

More often than not, global health targets are not met. In many ways, we might say that global health is governed through failure. Writing in a moment of global disruption and dis-ease in the context of the COVID-19 pandemic, and as the anticipated future of 2020 imagined in the UNAIDS 90-90-90 target becomes the past, we consider how missed targets govern disease elimination. Drawing on critical scholarship on numbering practices in the field of science and technology studies, we explore how global health targets continue to do their governing even as they appear to fall short. We argue that targets, as enumerated entities, do their work through progression and not completion, and enact disease elimination as a vague predicate. Success or failure has a latitude which makes ongoing governance and imagined futures possible. We find that the enumerated entity of the 90-90-90 target affords the possibility of a virtual elimination – even as it falls short. Missed targets do not ‘fail’ in performing anticipated progress. We tentatively propose that thinking differently about the timescapes of disease elimination and global health might be one way of extending the affordances of targets and their governing potential.

INTRODUCTION While treatment is an effective way to resolve alcohol problems, many people resolve their alcohol problems in the absence of treatment. Just how many do so is not known and may vary based on the definition of treatment. Various estimates of untreated alcohol problem resolution were calculated in this study, and the differences between people who resolve their alcohol problems with or without treatment were explored in relation to sociodemographic variables, levels of alcohol consumption in the past 12 months and lifetime alcohol problem severity. METHODS A cross-sectional online survey was administered to 719 people who had resolved an alcohol problem in Australia. Convenience sampling was used through a recruitment strategy targeted towards the general population via Facebook. RESULTS Almost half (49.8%) of all people who resolved their alcohol problem did so in the absence of alcohol treatment, whether specialist alcohol treatment, mutual-aid services or digital support services. When accessing mental health treatment is included under the scope of 'treatment', this estimate dropped to 12.8%. The estimated odds of having accessed treatment increased with age and lifetime alcohol problem severity. Other sociodemographic variables, or levels of alcohol consumption in the past 12 months, were not significantly associated with treatment status. DISCUSSION AND CONCLUSIONS It might be beneficial to expand the scope of 'treatment' to include mental health services and focus on the development of cost-effective and less intrusive standalone activities, which can expedite and support alcohol problem resolution for those who choose not to access specialist treatment.

Background:In public health emergencies, evidence, intervention, decisions and translation proceed simultaneously, in greatly compressed timeframes, with knowledge and advice constantly in flux. Idealised approaches to evidence-based policy and practice are ill equipped to deal with the uncertainties arising in evolving situations of need. Key points for discussion:There is much to learn from rapid assessment and outbreak science approaches. These emphasise methodological pluralism, adaptive knowledge generation, intervention pragmatism, and an understanding of health and intervention as situated in their practices of implementation. The unprecedented challenges of novel viral outbreaks like COVID-19 do not simply require us to speed up existing evidence-based approaches, but necessitate new ways of thinking about how a more emergent and adaptive evidence-making might be done. The COVID-19 pandemic requires us to appraise critically what constitutes ‘evidence-enough’ for iterative rapid decisions in-the-now. There are important lessons for how evidence and intervention co-emerge in social practices, and for how evidence-making and intervening proceeds through dialogue incorporating multiple forms of evidence and expertise. Conclusions and implications:Rather than treating adaptive evidence-making and decision making as a break from the routine, we argue that this should be a defining feature of an ‘evidence-making intervention’ approach to health.

Background The importance of engaging people who use drugs in drug policy development is increasingly acknowledged including in recent UN documents. Little scholarly attention has been paid to ‘drug user representation’ in the global drug policy setting of the UN such as the Commission on Narcotic Drugs (CND). This paper examines ‘drug user representation’ in key UN drug policy processes over three decades. Method A mapping process was undertaken using a corpus of publicly available documents from the UNGASS on Drugs and associated CND processes to identify relevant policy processes from 1987 to 2019 (n = 15) which were then assess for presence/absence of ‘drug user representation’. Those processes with positive evidence of ‘drug user representation’ (n = 9) were critically interrogated across three co-constitutive domains of the subjects, objects and forms of ‘drug user representation’. Results Our analysis shows that despite calls for greater involvement, dominant UN drug policy discourses and other practices delimit both the political subjectivities available to people who use/have used drugs and their capacity to bring their voices to bear in this context. The analysis also highlights that human rights-based discourses, employed by ‘drug user representatives’, have emerged as an important practice of resistance against the problematic and delimiting power effects of existing UN discourses, governing practices and modes of engagement. Conclusions In addition to the practices of resistance being undertaken by ‘drug user representatives’, we suggest there is a need to improve how ‘drug user representation’ is being made possible and done in the sites of UN drug policy deliberation and, that these sites should be opened for questioning. This we argue will not only have a positive impact on political legitimacy for ‘drug user representation’, but on the health and human rights of people who use/have used drugs.

Background and aims Recovery from alcohol problems in the absence of treatment or mutual-aid is very common, but under-researched. This study explores the lives of people who had resolved their alcohol problems without treatment, seeking to situate experiences of recovery in social contexts and broader life narratives. Design The in-depth qualitative interviews were aided by a life-history methodology that invited participants to account retrospectively for their lives. A narrative analysis was undertaken. Setting Two major cities (Sydney and Melbourne) in Australia. Participants People who had resolved an alcohol problem in the absence of treatment (n = 12) were recruited from the general community using convenience sampling. Measurements Eligible participants had received 'minimal treatment' for an alcohol use disorder: fewer than three sessions in an outpatient treatment programme or nine sessions with mutual-aid groups (e.g. Alcoholics Anonymous), or having accessed mental health treatment for problems other than drinking at least 2 years prior or 1 year after having resolved an alcohol problem. Participants were considered to have had an alcohol use disorder if they reported two or more symptoms (DSM-V) within a 1-year period prior to the past year, using questions endorsed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). People were considered to have resolved their alcohol use disorder by responding to the recruitment message calling for people who "used to have an alcohol problem but no longer do". The Alcohol Use Disorders Identification Test (AUDIT-C) was used to understand participant's drinking behaviours in the past 12 months. Findings Four different narratives were identified in the analysis. In the emancipation narrative, identity development and major changes across the life-curve were associated with separating oneself from an oppressive circumstance. In discovery narratives, art culture and other consciousness-expanding experiences were sources of identity development, but sometimes a barrier to alcohol recovery. In mastery narratives, life events were understood as failures or successes, and recovery was positioned as an individual journey accomplished through increased problem awareness. Finally, in coping narratives, changes were understood as a series of continuous struggles, and recovery was made sense of through diagnostic discourses. Conclusions People who resolve an alcohol use disorder in the absence of treatment or mutual-aid appear to explain their recovery in terms of at least four different life narratives: emancipation, discovery, mastery or coping. Social contexts and cultures outside the treatment setting, and the various identities and narratives they provide, shape change processes.

Mathematical models are key actors in policy and public responses to the COVID-19 pandemic. The projections from COVID-19 models travel beyond science into policy decisions and social life. Treating models as 'boundary objects', and focusing on media and public communications, we 'follow the numbers' to trace the social life of key projections from prominent mathematical models of COVID-19. Public deliberations and controversies about models and their projections are illuminating. These help trace how projections are 'made multiple' in their enactments as 'public troubles'. We need an approach to evidence-making for policy which is emergent and adaptive, and which treats science as an entangled effect of public concern made in social practices. We offer a rapid sociological response on the social life of science in the emerging COVID-19 pandemic to speculate on how evidence-making might be done differently going forwards.

Viral outbreaks and public health emergencies obligate an urgent need for evidence to inform rapid responses. In the case of SARS-Cov-2, a novel virus linked to the fast-moving COVID-19 pandemic, mathematical models projecting disease outbreaks and the potential effects of interventions are playing a critical role. Modelled projections are not only evidence-making policy decisions, but are afforded power-of-acting in public understandings and in social life. We propose here that COVID-19 is coming to be known in maths and models. We trace this process not only in policy but in media stories of maths, mathematicians and models. We accentuate the social life of maths and models, which feed citizen science and social actions in relation to COVID-19. There are general lessons from the emergent evidence-making of COVID-19 for how we do science for public health.

Increasing attention has been paid to matters of ontology, and its accompanying politics, in the drug policy field. In this commentary, we consider what an ‘ontological politics’ might mean for how we think about what drug policy is and what it might become, as well as for how we think about (and do) research in drug policy. Thinking ontopolitically questions the tacitly accepted status of ‘drug problems’, calls into question the realist presumptions which underpin much drug policy analysis, and provokes thinking about what counts as ‘evidence’ and the ‘evidence-based policy’ paradigm itself. We call attention to the inventive possibilities of method when grappling with the challenges thrown forth by the ontological turn, with a renewed focus on practice and relations. An ontological politics disrupts consensual claims and draws critical attention to objects that might otherwise appear ‘finished’ or ‘ready-made’, not least the things we call ‘drugs’ and ‘drug policy’. Working with ‘drug policy multiples’ invites new thinking and dialogue to provoke an ethico-political mode of intervention in the field of drug policy and drugs research.

The field of public health is replete with mathematical models and numerical targets. In the case of disease eliminations, modelled projections and targets play a key role in evidencing elimination futures and in shaping actions in relation to these. Drawing on ideas within science and technology studies, we take hepatitis C elimination as a case for reflecting on how to think with mathematical models and numerical targets as 'performative actors' in evidence-making. We focus specifically on the emergence of 'treatment-as-prevention' as a means to trace the social and material effects that models and targets make, including beyond science. We also focus on how enumerations are made locally in their methods and events of production. We trace the work that models and targets do in relation to three analytical themes: governing; affecting; and enacting. This allows us to situate models and targets as technologies of governance in the constitution of health, which affect and are affected by their material relations, including in relation to matters-of-concern which extend beyond calculus. By emphasising models and targets as enactments, we draw attention to how these devices give life to new enumerated entities, which detach from their calculative origins and take flight in new ways. We make this analysis for two reasons: first, as a call to bring the social and enumeration sciences closer together to speculate on how we might think with models and targets differently and more carefully; and second, to encourage an approach to science which treats evidencing-making interventions, such as models and targets, as performative and political.

Utilizing Bacchi’s poststructuralist approach, “What’s the problem represented to be?,” we critically examine how the “problem” of drug use in prison is represented within a key initiative—the Identified Drug User program (IDUP)—of prison drug policy in one Australian jurisdiction. We use two data sources for our analysis: interview transcripts of recently incarcerated young men (aged 19–24) with histories of injecting drug use and selected prison drug policy and program documents. We examine how the “problem” of drug use in prison is problematized within the IDUP and question commonly accepted ways of thinking that underpin the program. We explore the discursive and subjectification effects of problem representations which produce young men as “rational” and “choosing” and, at the same time, as “untrustworthy” and “deserving of punishment.” We highlight how these effects have consequences for young men’s connections to family while incarcerated which can work against the very issues the IDUP is trying to address. We make two claims in particular: that the IDUP produces harmful effects for young men and their families and that the harmful effects produced are, paradoxically, those the IDUP aims to avoid. Our analysis offers insights into how drug use in prison could be thought about differently, including suggestions that might reduce at least some of its adverse effects.