Topics
Substance‐related disorders
Hospital-Admitted Injection-Related Infections Among Incarcerated People Who Inject Drugs in Australia: A Retrospective Cohort Study
Objectives To characterise the clinical, microbiological and economic burden of hospital-admitted, injection-related infections among incarcerated people who inject drugs. Study Type Retrospective observational cohort study. Setting Secure unit of the Princess Alexandra Hospital, Brisbane, Australia. Participants Adults incarcerated in Queensland prisons who were admitted to hospital with an injection-related infection between 1 July 2019 and 30 June 2023. Main Outcome Measures Types of injection-related infection, microbiological findings, requirement for surgical or radiological source control, hospital length of stay and inpatient healthcare costs. Results There were 321 hospital admissions for injection-related infection among 265 patients, accounting for 282 unique infections. Most patients were male (241; 90.9%), with a mean age of 33years (standard deviation [SD], 7.4years), and 76 (28.7%) identified as First Nations. The most frequent infections were soft tissue infections (77/282; 27.3%), acute hepatitis C (64/282; 22.7%) and cellulitis (43/282; 15.2%). Surgical or radiological source control was required in 95 infections (34.0%), and infectious diseases consultation occurred in 130 infections (46.1%). Among 39 true-positive blood cultures, Staphylococcus aureus was identified in 17 (43.6%), Burkholderia species in 10 (25.6%) and non-tuberculous Mycobacterium species in 3 (7.7%). Among the 218 non-acute hepatitis C infections, 50 (22.9%) were hepatitis C virus (HCV) RNA positive. Overall, HCV RNA was present in 114 of 282 infections (40.4%). The total inflation-adjusted inpatient cost was $8.39 million, with a median cost per infection of $11,602 (interquartile range, $7426–$34,544). Conclusion Injection-related infections among incarcerated people who inject drugs were associated with substantial morbidity and healthcare costs in this large hospital cohort. A wide clinical spectrum was observed, including atypical pathogens, and clinically overt acute hepatitis C requiring hospital admission. These findings describe a significant burden of preventable disease in custodial settings and support the introduction of established primary prevention and harm-reduction interventions in prisons.
Andrew Palmer, Matthew Carter, Jeremy Yeo, Cecilia Shim, Jason Connor, Jeremy Hayllar, Gerald Holtmann, Naomi Moy, Elliott G. Playford, Naomi Runnegar, Paul J. Clark
The Management of Withdrawal From Alcohol and Other Drugs in Australian Custodial Settings: A Consensus Statement
Introduction For many people entering custody, abrupt changes in alcohol or other drug use is associated with the risk of experiencing a withdrawal syndrome. Management of withdrawal from alcohol and other drugs in a custodial setting is complicated by both a limited evidence base and structural barriers to the delivery of best practice healthcare interventions to people in custody. Main Recommendations A multidisciplinary expert panel representing all Australian states and territories participated in a modified Delphi process. The process generated 22 recommendations to custodial services, health services and government for the management of withdrawal from alcohol and other drugs in custodial settings across five domains: screening for withdrawal risk; assessment of withdrawal; management of withdrawal; specific considerations for the care of First Nations people; and organisational support. Notable recommendations include using universal and timely assessment for withdrawal at reception to custody; using validated clinical tools and evidence-based interventions to assess and manage withdrawal syndromes; and ensuring that the safest location for withdrawal from alcohol or other drugs is provided. Changes in Management as a Result of the Statement This statement presents best practice standards for the management of withdrawal from alcohol and other drugs in Australian custodial settings, as informed by evidence and expert consensus. Implementing the recommendations set out in this statement will improve the quality and consistency of withdrawal care provided to people entering Australian custodial settings and reduce harms associated with incarceration for people who use alcohol and other drugs. This statement has been endorsed by the Royal Australasian College of Physicians, the Australasian Professional Society on Alcohol and Other Drugs, the National Prisons Hepatitis Network, the Pharmaceutical Society of Australia and the Australian Injecting and Illicit Drug Users League. The statement is also approved as an Accepted Clinical Resource by the Royal Australian College of General Practitioners.
Grace FitzGerald, Jocelyn Chan, Jon Cook, Mark Stoove, Michael Curtis, Suzanne Nielsen, Rebecca J. Winter, Thileepan Naren
Impact of Prescription Drug Monitoring Program Implementation on Rates and Characteristics of People Seeing Multiple Prescribers in Primary Care: A Controlled Interrupted Time-Series Analysis
Objective To examine changes in rates of primary care patients seeing multiple prescribers and characteristics of patients who ceased seeing multiple prescribers for monitored medicines after voluntary implementation of the Victorian prescription drug monitoring program (PDMP). Study Design Controlled interrupted time series analysis of primary care electronic medical records. Setting A total of 562 general practices across three Victorian healthcare networks (Monash Health, Peninsula Health, Eastern Health). Patients People prescribed at least one PDMP-monitored medicine (e.g., opioids, benzodiazepines) and/or non-monitored psychotropic medicines (e.g., antidepressants, antipsychotics) between 1 January 2017 and 30 June 2023. Intervention Voluntary (1 April 2019) and mandatory (1 April 2020) implementation of the Victorian PDMP. Main Outcome Measures Changes in the monthly rate of people seeing multiple prescribers (defined as four or more prescribers) following PDMP implementation for monitored medicines, with non-monitored medicines used as a control; characteristics of people who ceased seeing multiple prescribers for monitored medicines following PDMP implementation. Results Following voluntary PDMP implementation (1 April 2019), there was a significant reduction in the differential step and trend changes in the rates of seeing multiple prescribers between people prescribed monitored and non-monitored medicines (differential step change: β, −3.55 [95% confidence interval (CI), −5.08 to −2.03]; differential trend change: β, −0.29 [95% CI, −0.46 to −0.12]). Following mandatory PDMP implementation (1 April 2020), there was no significant step change difference. However, there was an increase in the differential trend change in the rate of seeing multiple prescribers between those prescribed monitored and non-monitored medicines (differential trend change: β, 0.21 [95% CI, 0.05–0.37]; p=0.009). Logistic regression revealed that older age (95% CI, 1.39–1.75), male gender (95% CI, 1.09–1.25), metropolitan residence (95% CI, 1.04 and 1.23) and substance use disorder diagnosis (95% CI, 1.07–1.28) were associated with significantly higher odds of seeing multiple prescribers before PDMP implementation. Conclusions Implementation of the PDMP was associated with meaningful reductions in people accessing monitored medicines from four or more prescribers.
Louisa Picco, Monica Jung, Grant Russell, Samanta Lalic, Mahbod A. Fini, Dan I. Lubman, Rachelle Buchbinder, Ting Xia, Suzanne Nielsen
Early Cessation of Acetylcysteine Treatment After Paracetamol Overdose (NACSTOP 2): A Non-Inferiority Randomised Controlled Trial
ObjectivesTo determine whether ceasing acetylcysteine treatment for adults with acute paracetamol overdose after at least 12h of the two-bag acetylcysteine regimen is non-inferior to providing the full 20-h two-bag regimen.Study DesignOpen label, non-inferiority randomised controlled trial.SettingEmergency departments of six Australian metropolitan hospitals (four in Melbourne, two in Sydney), 1 December 2019–31 July 2024.ParticipantsAdults who required acetylcysteine treatment following single or staggered paracetamol ingestions whose serum alanine transaminase (ALT) level was below 40IU/L on presentation, and whose ALT levels were below 40IU/L and serum paracetamol concentrations below 20mg/L after 12 h of acetylcysteine treatment.InterventionControl group (standard care): two-bag intravenous acetylcysteine regimen (200mg/kg over 4h, followed by 100mg/kg over 16h). Intervention group: Acetylcysteine stopped at least 12h after treatment initiation and the 20-h infusion period completed with intravenous compound sodium lactate.Main Outcome MeasuresDifference in ALT level between presentation and 20h after acetylcysteine treatment initiation; non-inferiority was defined as the upper limit of the 95% confidence interval (CI) of the difference between median changes in ALT level for the intervention and control groups being less than 3IU/L.ResultsOf 2830 people who presented with paracetamol overdose, 860 received acetylcysteine treatment; 186 people who met both the presentation and 12-h acetylcysteine treatment blood test inclusion criteria (median age, 17years; interquartile range [IQR], 16–23years; 162 women [87%]) were randomly assigned to the intervention (93 participants) and control groups (93 participants). Median acetylcysteine infusion time in the intervention group was 13h (IQR, 13–13 h). The median change in ALT level between arrival and 20h after starting intravenous acetylcysteine treatment was similar for the intervention (−1IU/L; IQR, −4 to 1IU/L) and control groups (0IU/L; IQR, −2 to 2IU/L); the difference in median change (−1IU/L; 95% CI, −2 to 1IU/L) was consistent with the non-inferiority criterion. No patients developed hepatic injury or hepatotoxicity.ConclusionAn abbreviated acetylcysteine treatment regimen was non-inferior to the standard 20-h two-bag regimen for people with paracetamol overdose who were at low risk of hepatic failure.Trial RegistrationACTRN12619001549112 (prospective)
Anselm Wong, Richard McNulty, Sarah E. Hodgson, Naren Gunja, Andis Graudins
The risk of death after hospitalisation following intentional self‐poisoning: a retrospective observational study (PAVLOVA‐2)
Aftercare for people who have poisoned themselves should include both mental health assessments and reviews of physical health conditions
Firouzeh Noghrehchi · Nicholas A Buckley · Rose Cairns
Opioids and the challenges of managing chronic non‐cancer pain in rural Australia: a qualitative study
We found a marked disparity between evidence-based guidelines for chronic pain management and the reality of rural medical practice
Jessica A Thomas · Jill Benson · Philip Davidson · Paul R Ward
Squeezing the opioid balloon: the need to assess both intended and unintended consequences of policies that target opioid supply but not demand
We need national linkages of data on the use of opioids from multiple markets and relevant health outcomes
Benjamin Daniels · Jonathan Brett
Prescription opioid supply‐restricting policies and hospital use by people prescribed opioid medications, Victoria, 2018–22: a controlled interrupted time series analysis
Opioid-related harm can be reduced without increasing long term non-opioid substance- or mental health-related harm
Suzanne Nielsen · Louisa Picco · Bosco Rowland · Nadine E Andrew · Taya A Collyer · Samanta Lalic · Rachelle Buchbinder · Christopher Pearce · J Simon Bell · Dan I Lubman · Ting Xia
Severe hypoglycaemia secondary to chronic opioid‐induced hypothalamic–pituitary–adrenal axis suppression: an under‐recognised phenomenon
A 49-year-old woman with type 2 diabetes mellitus was hospitalised with critical hypoglycaemia
Michael Do · Annabelle G Hayes · Malgorzata M Brzozowska
Exploring the role of urine drug screening in opioid agonist therapy
Instructive guidelines for urine drug screening during opioid agonist therapy might minimise unnecessary tension in the therapeutic relationship between prescribers and patients
Grace FitzGerald · Sione Crawford · Adrian J Dunlop · Jon Cook · Dean Membrey · Paul MacCartney · Thileepan Naren
The relative toxicity of medicines detected after poisoning suicide deaths in Australia, 2013–19: a data linkage case series study
More toxic medicines should be supplied in limited quantities and their dispensing to individuals monitored
Jessy Lim · Nicholas A Buckley · Kate Chitty · Andrea L Schaffer · Jennifer Schumann · Zein Ali · Rose Cairns
The costs and benefits of a prison needle and syringe program in Australia, 2025–30: a modelling study
Each dollar spent on a needle and syringe program in Australian prisons could save $2.60 in treatment costs
Farah Houdroge · Samantha Colledge‐Frisby · Nadine Kronfli · Rebecca J Winter · Joanne Carson · Mark Stoove · Nick Scott
Responding to reports of nitazene toxicity in Australia
To reduce opioid-related harms, we must support evidence-informed and timely detection and monitoring of nitazenes and emerging drugs; and harm reduction and clinical interventions
Brendan Clifford · Amy Peacock · Krista J Siefried · John Gobeil · Jennifer L Smith · Nadine Ezard
Methylphenidate and (lis)dexamfetamine toxicity‐related deaths of adults, Australia, 2000–24: analysis of NCIS data
People for whom greater caution is warranted including those with histories of substance misuse or mental health problems
Shane Darke · Amy Peacock · Johan A Duflou · Michael Farrell · Julia Lappin
Improving palliative care for people who use alcohol and other drugs
A discussion of the complexities that arise when people who use alcohol and other drugs require palliative care
Grace FitzGerald · Jon Cook · Peter Higgs · Charles Henderson · Sione Crawford · Thileepan Naren
National consensus statement on opioid agonist treatment in custodial settings
Introduction: Opioid use and dependence are prevalent among incarcerated people, contributing to elevated rates of overdose and other harms in this population. Opioid agonist treatment (OAT) has been shown to be an effective intervention to mitigate these risks. However, challenges to health care implementation in the custodial sector result in suboptimal and variable access to OAT in prisons nationally. Main recommendations: Among a national multidisciplinary expert panel, we conducted a modified Delphi study that yielded 19 recommendations to government, relevant health authorities and custodial health services. These recommendations cover five core domains: induction or continuation of OAT, OAT options and administration, transition of care to the community, special populations, and organisational support. Key recommendations include prompt recognition and treatment of opioid withdrawal, active linkage to community‐based OAT providers upon release, and ensuring appropriate organisational support through local protocols, adequate funding, and monitoring of key program indicators. Changes in management as a result of this statement: This consensus statement addresses a significant gap in national policy on OAT in Australian prisons. The recommendations, finalised in July 2024, set forth best practice standards grounded in evidence and expert consensus. We expect that implementing these recommendations will enhance the quality, consistency and continuity of OAT both within prison and upon release. Optimising OAT provision is crucial for improving health outcomes and addressing the risk of overdose, which is the leading cause of death among people released from prison.
Jocelyn Chan · Jon Cook · Michael Curtis · Adrian J Dunlop · Ele Morrison · Suzanne Nielsen · Rebecca J Winter · Thileepan Naren
Cannabis poisonings in Australia following the legalisation of medicinal cannabis, 2014–24: analysis of NSW Poisons Information Centre data
Edible cannabis forms may be less harmful than smoking cannabis, but the acute poisoning risk they pose must be considered
Rose Cairns · Sara Allaf · Nicholas A Buckley
Current approaches to the identification and management of gambling disorder: a narrative review to inform clinical practice in Australia and New Zealand
Discussion of recent developments in the identification and management of gambling disorder and the remaining gaps in literature and research
Simone N Rodda · Stephanie S Merkouris · Nicki A Dowling
Is the current commercial model of medicinal cannabis in the best interest of patients?
Richard CJ Bradlow · Ferghal Armstrong
The Health4Life e‐health intervention for modifying lifestyle risk behaviours of adolescents: secondary outcomes of a cluster randomised controlled trial
School-based e-health multiple health behaviour change interventions need effective engagement strategies to maximise their effectiveness
Siobhan O'Dean · Matthew Sunderland · Nicola Newton · Lauren Gardner · Maree Teesson · Cath Chapman · Louise Thornton · Tim Slade · Leanne Hides · Nyanda McBride · Frances J Kay‐Lambkin · Steve J Allsop · David Lubans · Belinda Parmenter · Katherine Mills · Bonnie Spring · Bridie Osman · Rhiannon Ellem · Scarlett Smout · Karrah McCann · Emily Hunter · Amra Catakovic · Katrina Champion
Interventions for reducing the prescribing of pharmaceutical opioids in Australia: are they effectively reducing opioid harm?
Capturing the intended and unintended outcomes of interventions is important for fully assessing their impact
Suzanne Nielsen · Ting Xia
The uptake of long‐acting depot buprenorphine for treating opioid dependence in Australia, 2019–2022: longitudinal sales data analysis
There was a marked shift from daily opioid agonist treatments to long-acting depot buprenorphine during 2019–2022
Nicholas Lintzeris · Victoria Hayes · Adrian J Dunlop
A brief intervention for improving alcohol literacy and reducing harmful alcohol use by women attending a breast screening service: a randomised controlled trial
Jasmin Grigg · Victoria Manning · Dan I Lubman
Management of opiate dependence related to dihydrocodeine–sorbitol misuse
Regular use of dihydrocodeine, which can be purchased over the counter without a prescription, can lead to opioid use disorder
Richard CJ Bradlow · Baden Hicks · Temika Mu · Daniel Pham · Michelle Sharkey · Noel Plumley · Dan I Lubman · Shalini Arunogiri
