Substance‐related disorders

Health services should collect comprehensive patient information during assessment to facilitate more holistic, tailored, person-centred care

Emma Black · Raimondo Bruno · Kristie Mammen · Llewellyn Mills · Krista J Siefried · Rachel M Deacon · Anthony Shakeshaft · Adrian J Dunlop · Nadine Ezard · Mark Montebello · Steven Childs · David Reid · Jennifer Holmes · Nicholas Lintzeris

Testing for HCV infection should be better integrated into opioid treatment programs

Chris Tremonti · Maree Teesson · Christina Marel · Katherine Mills · Paul S Haber

Brief alcohol interventions in diverse clinical settings can reach groups often not recognised as being at risk of harmful drinking

Jasmin Grigg · Victoria Manning · Darren Lockie · Michelle Giles · Robin J Bell · Peta Stragalinos · Chloe Bernard · Christopher J Greenwood · Isabelle Volpe · Liam Smith · Peter Bragge · Dan I Lubman

Most patients have taken a mixture of agents; the combination of GHB with methamphetamine is particularly frequent

Sam Alfred · Peter Stockham · Emma Partridge · Alastair Ward · Hannah Green · Jake Mallon · Chris Kostakis · Andrew Camilleri · Daniel Haustead

To the Editor: Kamini Vidrawan Ras (Kamini) is an opiate‐containing Ayurvedic preparation with multiple purported functions.1 Kamini comes in the form of handmade tablets or balls, with varying quantities of opium within the tablets ranging from 2mg to 20mg.2 Chemical analysis of Kamini tablets revealed a variety of opioid alkaloids and heavy metals such as lead, mercury and arsenic.2 There are reports of patients suffering significant harms from heavy metal poisoning after ingestion of Ayurvedic medicines.3 Evident risks of the use of Kamini include the development of de novo opioid use disorder, use of the preparation as an additional opioid source by current opioid users, and contribution to potential harms including overdose, particularly when combined with other opioids or drugs. In Australia, Kamini poses a public health concern as an unregulated opiate‐containing medication available in certain Indian grocery stores.4 Australia is trying to curb the harms associated with opioid medications through real‐time prescription monitoring and various other interventions. As opioid medications are being increasingly scrutinised and rationalised, importation of Kamini into Western countries could increase. In 2016, the Therapeutic Goods Administration prohibited the importation of Kamini, but patients are still presenting with opioid use disorder‐associated with this Ayurvedic preparation.1,2,4 The limited evidence regarding treatment and management of opioid dependence related to Kamini shows that the majority of patients can be stabilised with opioid substitution therapy, remain engaged in treatment, and cease Kamini use.1,4 Most patients (22/24) in the two largest case series on Kamini use were of Indian background and a large proportion were of Punjabi origin.1,4 Some sociological studies about Punjabi men and the cultural norms within this community state that it is appropriate to use substances to deal with stress and to increase productivity.5 Traditional views on the role of medications can be precipitating and perpetuating factors for ongoing substance use and could lead to poorer health outcomes. Treatment for patients with Kamini dependence should include culturally appropriate and specific education.

Thileepan Naren · Jon Cook

Streamlined, convenient hepatitis C care promotes engagement with treatment by people at particular risk

Michael B MacIsaac · Bradley Whitton · Adrian Hubble · Shelley Cogger · Matthew Penn · Anthony Weeks · Kasey Elmore · David Pemberton · Jenine Anderson · Rebecca Howard · Una McKeever · Timothy Papaluca · Margaret E Hellard · Mark Stoove · David Wilson · Alisa Pedrana · Joseph Doyle · Nico Clark · Jacinta Holmes · Alexander J Thompson

Prison settings are risk environments for HCV transmission and should therefore be a priority setting for harm reduction and clinical and educational interventions

Rebecca J Winter · Yumi Sheehan · Timothy Papaluca · Graeme A Macdonald · Joy Rowland · Anton Colman · Mark Stoove · Andrew R Lloyd · Alexander J Thompson

Re-introducing public opioid agonist therapy clinics in Victoria could improve accessibility for some people recently released from prison

Michael Curtis · Paul Dietze · Rebecca J Winter · Kasun Rathnayake · Karen Smith · Mark Stoove

To the Editor: As nicotine prescribers, we welcome much needed advice for doctors on prescribing nicotine. However, we disagree with several recommendations and concerns raised in the article by Ween and colleagues.1 First, in our experience, the recommended starting nicotine concentration of 18mg/mL is inappropriate for most new users. The most popular devices for transitioning to vaping (pod vapes) have small batteries and require higher nicotine salt concentrations to effectively relieve cravings and withdrawal symptoms, typically 20–50mg/mL.2 On the other hand, 18mg/mL would be too strong for a smoker with low nicotine dependence using a more powerful vape pen or mod device. The concentration of nicotine required should be personalised for each user based on the level of nicotine dependence, device type and puffing topography.3 Second, the authors’ concerns about the toxicity of nicotine are overstated in our view. Nicotine is a toxic poison in its highly concentrated form, but the low concentrations used for vaping carry minimal risk of serious harm, although the long term impact of inhaled nicotine on lung tissue is not yet known.4 Third, Ween and colleagues raise concerns about the addictiveness of nicotine. However, most smokers who switch to vaping are already nicotine‐dependent. Dependence on vaping is generally less than for smoking5 because, in many cases, peak nicotine levels from vaping are lower and nicotine delivery is slower. In vitro and animal studies suggest other chemicals in smoke may also increase dependence, but human studies are lacking.6,7 Fourth, a blanket “3‐month prescription maximum” and an “agreed abstinence plan” do not recognise the diversity of the needs of smokers. Switching to vaping and then ceasing smoking can take many months or years for some smokers. Many continue to vape long term to avoid relapse to smoking or for perceived benefits. Therefore, a more flexible and personalised approach is needed. Last, Ween and colleagues are correct that unknown harms from flavours may appear over time and these need to be carefully monitored. However, flavours are an integral part of the appeal of vaping. Flavours encourage the uptake of vaping by smokers and are associated with higher quit rates.8,9 A recommendation to avoid flavours risks inadvertently increasing smoking.

Colin P Mendelsohn · Carolyn Beaumont

The key themes from the 21 years of MSIC experience are that good policy, with clear legislation and careful management of clients within a harm reduction framework, can and does alleviate problems that may be perceived as inherent to the operation of such services

Carolyn A Day · Allison Salmon · Marianne Jauncey · Mark Bartlett · Amanda Roxburgh

Using a multidisciplinary, pragmatic, patient-centred, non-judgemental approach may allow people who inject drugs to achieve improved outcomes for invasive infections and reduce their risk of subsequent admissions

Lucy O Attwood · Megan McKechnie · Olga Vujovic · Peter Higgs · Martyn Lloyd‐Jones · Joseph S Doyle · Andrew J Stewardson

Suicide prevention requires ensuring that social media are responsible and accountable, and that poisoning surveillance systems are adequately supported

Bridin P Murnion · Darren M Roberts

To the Editor: We read with great interest the article by Holmwood1 which provides a new perspective on alcohol screening, brief intervention and referral to treatment (SBIRT) in primary care settings. Holmwood argues that even though addressing unhealthy alcohol consumption in clinical practice has its place, the effectiveness of SBIRT in reducing alcohol intake is supported by little evidence. The author concludes that emphasis should be placed on strategies with the strongest evidence, such as harm reduction policies. We agree with Holmwood that effective strategies to reduce alcohol consumption should be adopted, and SBIRT itself will not solve the problem entirely. As the author pointed out, the 2018 Cochrane review2 shows that the effect of SBIRT on the reduction of alcohol consumption might be limited. Yet, as stated in the review, we emphasise that while the reduction of alcohol consumption due to brief intervention is relatively small, the benefit on the population level and public health is still likely to be positive.2 With an alcohol intake of 11.9 L per capita (aged 15 years or older), the Czech Republic ranked in the third place in the world in 2019.3 In the Czech Republic, health care professionals are obliged by law to provide SBIRT to their patients.4 However, studies among Czech patients show that less than half of them are asked about their alcohol consumption by their doctor, and only 7.9% of patients are advised to lower their alcohol consumption.5 Studies among Czech doctors report that a quarter do not provide brief intervention to any of their patients.5 It would be interesting to know related information from Australia, but with respect to Czech data, we believe there should be an increased emphasis on the education and training of health care professionals in SBIRT and on supporting general practitioners in providing brief interventions (eg, adequate financial reimbursement of their time) to increase the use of SBIRT in clinical practice. That way, SBIRT can be used to its full potential and complement other strategies to address the high alcohol consumption and related harms.

Jana Malinovská · Jan Brož

These revised guidelines have three key recommendations which provide evidence-based advice on how to reduce the health risks from alcohol consumption

Katherine M Conigrave · Robert L Ali · Rebecca Armstrong · Tanya N Chikritzhs · Peter d’Abbs · Mark F Harris · Nicole Hewlett · Michael Livingston · Dan I Lubman · Anne McKenzie · Colleen O’Leary · Alison Ritter · Scott Wilson · Melanie Grimmond · Emily Banks

A 34-year-old man presented seeking treatment for opioid use disorder in Melbourne

Shalini Arunogiri · Rowan Dowling · Vicky Phan · Michelle Sharkey · Temika Mu · Dan I Lubman

The major concern regarding barbiturate-related harm has shifted from accidental overdoses to their use in suicide

Shane Darke · Agata Chrzanowska · Gabrielle Campbell · Emma Zahra · Julia Lappin

Scaling up the treatment of alcohol problems will lead to considerable health benefit across the nation

Paul S Haber · Benjamin C Riordan · Kirsten C Morley

To the Editor: The extension of alcohol brands to non‐alcohol products has been part of the marketing strategy of some alcohol companies on several occasions.1 Recent examples highlight that this marketing tactic warrants further research and policy attention in Australia. Following the release of a limited‐edition Bundaberg Rum‐branded Ice Break (iced coffee) in Queensland in 2019, the product was rolled out nationally in supermarkets and petrol stations in October 2020. This follows similar examples of alcohol‐branded chocolates, zero‐alcohol beverages, and fragrances. The alcohol advertising code of practice in Australia, administered by the industry‐managed Alcohol Beverages Advertising Code (ABAC) Scheme, applies to alcohol brand extensions; however, determinations suggest that the code does not restrict alcohol companies from applying their brands to a variety of non‐alcohol products. In 2019 and 2020, the ABAC Panel reviewed nine complaints about brand extensions, including the rum‐branded iced coffee (Box).2 A common theme raised by complainants was concern about children and young people’s exposure. In almost all cases, the ABAC Panel determined that the alcohol‐branded products or associated marketing would not have strong or evident appeal to minors. Most of the complaints were dismissed. Extending well known alcohol brands to non‐alcohol products provides companies with the opportunity to expose new audiences to their brands, including children and adolescents. While some extensions may not have overt appeal to children, the display of alcohol‐branded products in supermarkets and other retail outlets means children will be exposed to the marketing and may develop connections with the brands.3 The use of brand extensions has also been a strategy of the tobacco industry.1Based on the available determinations, the ABAC Scheme permits alcohol brands to be used on a wide variety of products that are not typically related to alcohol. The inadequate controls on brand extensions are consistent with reviews that have concluded that the ABAC Scheme does little to protect young people from exposure to alcohol marketing.4,5 Efforts to encourage governments to hold the alcohol industry to a higher standard in their marketing would be aided by further attention, including research attention, to the use of brand extensions by alcohol companies. Box – Alcohol Beverages Advertising Code (ABAC) Scheme determinations about alcohol brand extensions published in 2019 and 20202 Product Summary of complaint Outcome and summary of ABAC Panel comments VB‐branded Volleys (ABAC determination No. 185/20) Alcohol promotion via a shoe brand will expose children to the marketing and glorify alcohol use. Upheld in part. The VB‐branded shoes are not merchandise primarily used by young people so the product itself does not breach the ABAC Code. However, one of the associated online promotions featuring a person skateboarding while wearing the VB‐branded shoes would have strong appeal to young people. VB‐branded fragrance sold by the national chemist chain Chemist Warehouse (ABAC determination No. 124/20) The VB‐branded fragrance was marketed as an appropriate gift for Father’s Day, appealing to children and young people. The promotion seen outside a chemist included an image of a child hugging a man next to the words “#1 for Father’s Day”. Children and young people visiting the chemist would be exposed to the VB brand. Dismissed. The VB branding on the fragrance and the poster seen outside the chemist would not strongly appeal to young people, and there are no rules restricting the placement of alcohol ads in shopping centres. Heineken 0.0 television ad (ABAC determination No. 99/20) The ad promoted the product as alcohol‐free when it may not be completely alcohol‐free, and children may drink the product believing it is not alcoholic. Dismissed. The ad shows adults in an adult situation, and would not have particular attractiveness to minors beyond the appeal it has for adults. Bundaberg Rum‐branded Paul’s egg nog (ABAC determination No. 118/19) Egg nog is a flavoured milk, which is a soft drink that appeals to young people. The placement of Bundaberg Rum’s brand on the egg nog could be seen by young people. Dismissed. While flavoured milk such as chocolate milk might appeal to young people, egg nog is not considered a drink which would particularly appeal to young people. The packaging is mature and traditional and does not have features that would appeal to young people. Bundaberg Rum‐branded Ice Break drink (ABAC determination No. 82/19) The iced coffee promoted Bundaberg Rum and encouraged young people’s exposure to alcohol products and brands. Dismissed. Iced coffee as a product does not strongly or evidently appeal to young people. The product label is mature and does not contain images likely to appeal to young people. Heineken 0.0 bus stop ad (ABAC determination No. 67/19) It was not clear from the ad that the product was alcohol‐free, and it suggested that people can drink Heineken beer before driving, conflicting with anti‐drink‐driving education. Upheld. The overall impression created by the ad was positioning a Heineken product, which would be assumed to be a type of alcoholic beer, with the consumption of the product by a driver of a motor vehicle. Jack Daniels‐branded barbeque sauce and barbeque tools sold at the department store Big W (ABAC determination No. 59/19) Children would be exposed to the alcohol‐branded products being promoted in connection with Father’s Day. Dismissed. The branded barbeque products do not feature any eye‐catching designs or themes that would appeal to children or young people. Carlton Zero radio ad (ABAC determination No. 44/19) The ad referred to a “beer you can drink anywhere” and provided examples of places where it is inappropriate or irresponsible to consume alcohol, and the ad was broadcast at 12 pm on a Sunday, when children and young people are likely to be listening to the radio. Dismissed. A reasonable person would not take the ad as promoting the use of alcohol in unsafe circumstances. The timing of the broadcast was consistent with the requirements of the ABAC placement rules. Carlton Zero television ad (ABAC determination No. 35/19) Carlton Zero was marketed as a light lunch drink and could easily be misinterpreted as a soft drink. Dismissed. The ABAC definition of “strong and evident appeal to minors” refers to “confusion with a soft drink” as part of an example of how the standard might be breached. The ad taken as a whole did not create a message which could be said to be appealing to minors.

Hannah Pierce · Julia Stafford

To the Editor: Published evidence recognises that the recreational misuse of nitrous oxide (N2O) can be associated with vitamin B12 deficiency and subacute combined degeneration of the spinal cord.1 Misuse of N2O is increasing,2 with canisters (known as “nangs” or “whippits”) readily available for legal purchase in convenience stores and online ostensibly for the purpose of whipping cream. In recent years, an increase in the number of emergency presentations and acute hospital admissions related to N2O misuse has been recorded in Australia.3,4 We have also seen an increase in the number of patients requiring specialist multidisciplinary rehabilitation for severe impairments, including proprioceptive deficits, ataxia, disabling lower limb weakness and persistent gait abnormalities. Over recent years, a growing number of patients have been admitted to our inpatient metropolitan Sydney rehabilitation unit with serious disabilities related to N2O misuse. In line with published reports, our experience confirmed that patients are often university students (typically aged < 30 years).3,4 As acute medical specialties recognise the significance of these presentations,3,4 we highlight that the resulting disabilities can remain for months or years at functional, vocational and emotional levels, and many will be lifelong. This will impose a significant disability burden that will require ongoing management by specialist rehabilitation and disability services and will have an impact on the wider health care utilisation and cost. As long as N2O remains legal and accessible and is perceived by many as seemingly innocuous, users will remain largely unaware of the severity and risk presented by its long term use. Compared with messaging surrounding other “hard drugs”, most of the literature and the public health messaging in Australia do not appear to emphasise the potential for catastrophic, permanent injury associated with the misuse of N2O. Given the emerging disability burden resulting from recreational N2O misuse, we recommend enhancing existing public awareness campaigns.5 We suggest that educational resources place greater emphasis on the potential for serious, long term impairments and that education campaigns be targeted to most susceptible people via tertiary and/or secondary education establishments. Widespread restrictions on N2O purchase should also be considered. Such measures may help prevent permanent and devastating disabilities resulting from the misuse of this easily accessible substance.

Simon Mosalski · Anne Tanner · Christine T Shiner

A comprehensive and coordinated approach to overdose prevention by national and state governments and professional groups is needed

Adrian J Dunlop · Buddhima Lokuge · Nicholas Lintzeris

Opioid agonist therapy should be normalised as a routine part of opioid dependence treatment

Pallavi Prathivadi · Elizabeth A Sturgiss

To the Editor: We identified a geographic and temporal cluster of four patients with drug poisoning occurring within one week in February 2020 from two addresses less than 1 km apart. All patients presented with typical features of opiate poisoning but had no history of opiate use. There was one death, with the three other cases having significant morbidity, which required escalating bolus doses of naloxone. Rapid sample analysis by the New South Wales Pathology Forensic and Analytical Science Service (FASS) using liquid chromatography quadrupole time‐of‐flight mass spectrometry (LC‐Q‐TOF‐MS) found acetyl fentanyl — a synthetic fentanyl non‐pharmaceutical designer drug — in all cases within 3 days. The identification and subsequent response were coordinated by the Prescription, Recreational and Illicit Substance Evaluation (PRISE) program, a collaboration between the NSW Ministry of Health, the NSW Poisons Information Centre and FASS. The analytical confirmation and public health response, involving data collection, risk assessment with a health expert committee and customised clinical and public health response, occurred within 15 days of notification to PRISE. Two further cases were identified by the NSW Ministry of Health in other hospitals in the 2 months prior and 2 months subsequent to our cases. In October 2020, a further cluster of five cases occurred in regional NSW. Ethics approval was granted by the Sydney Local Health District Research Ethics and Governance Office, HREC 2020/ETH01380. The presence of fentanyl analogues as an adulterant in recreational drugs has become common globally but only one case of poisoning by acetyl fentanyl has been reported in the literature in Australia.1,2 This poses a significant risk to unassuming users, particularly users whose primary recreational use is stimulants, as they are likely to be opioid naïve and have worse clinical outcomes. Cases of toxicity from fentanyl and its analogues are often under‐reported because of issues with detection. Synthetic opioids do not test positive on urine drug screen immunoassays; mass spectrometry is required to confirm the diagnosis.3 Acetyl fentanyl is a non‐pharmaceutical designer analogue of fentanyl first described in 2013 after an outbreak with reported mortality in Rhode Island.4 Pharmacokinetic data for acetyl fentanyl are limited, but the drug is 15 times more potent than heroin and has an ED50 (median effective dose) and LD50 (median lethal dose) ten times narrower than morphine.5 The purpose of PRISE is to detect atypical substances in the community, focusing on presentations that are unexpected, severe and/or clusters, and coordinate an appropriate response. Rapid detection and toxicosurveillance allowed for prompt dissemination of information to clinicians and the public. Information directed to user groups is a particularly important harm minimisation strategy. Rapid detection and early dissemination of information may have limited further outbreaks. Clinicians should be informed that atypical presentations in recreational drug use may be due to substitution or contamination by other substances. Notification of cases to Poisons Information Centres can provide treatment advice and facilitate rapid identification and response by providing an access pathway, such as the NSW Ministry of Health PRISE Program.

Varan Perananthan · Chris Tremonti · Emily Nash · Thanjira Jiranantakan · Andrew H Dawson