Substance‐related disorders

John M Hart General practitioner, Swan Medical Centre, 280 Great Eastern Highway, Midland, WA 6056 swanmedATiinet.net.au To the Editor: I write to share my concerns about the “doctor shoppers” in our community.1 The large medical group in which I practice has long been tormented by the demands of a constant stream of drug addicts, and I feel that we have now lost a very useful tool for dealing with these patients. I refer to the loss of access to the “Doctor Shopping Hotline”. This has resulted in increased aggravation for both staff and doctors. The problem is compounded by our practice being open at weekends and public holidays, when these patients arrive with the familiar story of not being able to get their benzodiazepines and opiates because their own doctors are not available. The Health Insurance Commission recently notified me about a patient who had attended our surgery, and many others, during a 3-month period last year. During this time, he saw more than 30 doctors and was prescribed more than 300 Pharmaceutical Benefits Scheme (PBS) items (6000 benzodiazepines and more than 2000 opiates [Panadeine Forte]). I strongly feel that the hotline should be reinstated — for the benefit of the doctors and the patients, and to help reduce a totally unwarranted drain on the PBS.

John M Hart

Jeff Whalan Managing Director, Health Insurance Commission, PO Box 1001, Tuggeranong, ACT 2901 medicare.enqAThic.gov.au In reply: I note the concerns expressed by Hart in relation to the discontinuation of the Doctor Shopping Hotline, and his call for the reinstatement of such a service. The Doctor Shopping Project, which was funded to the end of June 2002, focused on a limited selection of nervous system medications. It has been replaced by the Prescription Shopping Project, which is much broader in scope, as it encompasses all medicines on the Pharmaceutical Benefits Scheme (PBS). The new project aims to reduce the number of patients obtaining PBS medicines in excess of therapeutic need, and provides the opportunity for more informed prescribing across all categories of PBS medicine. The Health Insurance Commission (HIC) recognises the value of an information service for medical practitioners under the Prescription Shopping Project. An independent researcher has been engaged to explore the reactions and attitudes of medical practitioners and consumers to implementing such an information service. The research also aims to gain insight into medical practitioners’ intentions of using such a service, and their expectations of the scope and delivery of the service. Findings were presented to the HIC in early July 2004. The HIC will now convene a forum of relevant peak bodies to consider the scope and delivery of an information service in light of the findings. The HIC looks forward to working with the profession to establish an information service for medical practitioners under the Prescription Shopping Project.

Jeff Whalan

Julia E Fawcett,* Anthony P Shakeshaft,† Mark F Harris,‡ Alex Wodak,§ Richard P Mattick,¶ Robyn L Richmond** * PhD Candidate, † NHMRC Research Fellow, ¶ Director, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052; ‡,** Professors, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW; § Director, Alcohol and Drug Service, St Vincent's Hospital, Sydney, NSW. A. ShakeshaftATunsw.edu.au To the Editor: Revised Australian Alcohol Guidelines1 were released in 2001. Although general practitioners (GPs) can be influential in initiating and supporting behaviour change to reduce levels of alcohol misuse among their patients,2,3 the extent to which their advice remains relevant and effective depends largely on the extent to which screening tools can be modified to take account of revised versions of such guidelines. The Alcohol Use Disorders Identification Test (AUDIT)4 is a clinical instrument used widely to screen patients for problematic alcohol use. The aims of our study were to examine the ability of AUDIT to classify general practice patients’ alcohol consumption into the categories specified in the revised Australian guidelines, and to identify any additional information needed for such classification. Patients aged at least 16 years attending a general practice surgery in western Sydney were asked by receptionists to complete a health-related survey by means of a hand-held computer while waiting for their consultation. Items covered a number of domains, including demographics, the AUDIT, and two additional questions about consumption of specified quantities of alcohol. The use of computers ensured patients were only asked questions relevant to them. Risk of harm in the long term: Respondents’ average number of standard drinks per week was calculated from the first two AUDIT questions, using a previously devised method.5 Risk of harm in the short term: AUDIT question 3 is not specific enough to distinguish short-term risk of harm, so additional, sex-specific questions on how many occasions in the previous 30 days the patient had consumed “7–10” and “11 or more” (men) or “5–6” and “7 or more” (women) standard drinks were asked. Of the 115 patients who completed the survey, 62% were female; their mean age was 42 years; 10% were unemployed; 34% had had tertiary education; 65% were married or in a de facto relationship; and 80% were born in Australia. Their alcohol consumption patterns are shown in the Box. AUDIT is a reliable and valid instrument, and is widely used as a clinical tool. However, as national guidelines are updated, clinical tools such as AUDIT need to remain consistent with them. Ideally, revisions would build on the benefits of existing tools rather than rendering them obsolete. For example, a major advantage of AUDIT is that it measures a number of drinking dimensions within the one, brief, validated instrument. This multidimensionality could be preserved while promoting AUDIT’s consistency with new guidelines by adding two items, with high face validity, to more accurately assess risk of harm in the short term. Incorp-orating the two additional consumption items we used in this study with AUDIT allows drinkers to be classified according to the guidelines as “low-risk”, “risky” or “high-risk” both in the long term and short term, with minimal additional response time. Alcohol consumption patterns in one general practice in western Sydney, as defined by the recently revised Australian Alcohol Guidelines1 Characteristic Males (%) Females (%) Total (%) Abstinent 18.2 29.6 25.2 Long-term harm Low-risk 68.2 67.6 67.8 Risky 11.4 1.4 5.2 High-risk 2.3 1.4 1.7 Short-term harm Low-risk 61.4 52.1 55.7 Risky 9.1 8.5 8.7 High-risk 11.4 9.9 10.4 Bold text represents categories that cannot be distinguished using AUDIT alone.

Julia E Fawcett · Anthony P Shakeshaft · Mark F Harris · Alex Wodak · Richard P Mattick · Robyn L Richmond

Gordon Broderick Executive Director, Distilled Spirits Industry Council of Australia, 1st Floor, 117 Ferrars Street, South Melbourne, VIC 3205. gordonbATdsica.com.au To the Editor: In their article on risk-taking behaviour among young Australian women, Carr-Gregg and colleagues make a number of statements about alcohol consumption among young women.1 Unfortunately, these statements are not supported by the facts. The authors assert, citing a national study of 14 762 women aged 18–23 years,2 that “seventy percent of young women engage in ‘binge drinking’ (5 or more drinks on one occasion) at some time, with 19% doing so on a weekly basis”. The level and frequency of alcohol consumption that constitutes “binge drinking” is a matter of conjecture. The National Health and Medical Research Council (NHMRC), in guidelines released in 2001,3 state that “binge drinking” is “not a preferred term due to its lack of consistent and specific meaning”. The NHMRC guidelines on short term risk specify 5–6 alcoholic drinks for a female on any one day as being “risky” for health, and 7 drinks or more being “high risk”. For long term risk, 3–4 drinks on an average day, or 15–28 drinks a week, is considered “risky”, with any more constituting “high risk”. Applying these guidelines to the Women’s Health Australia dataset shows that 5.1% of young women engage in drinking that is “risky” or “high risk” in the long term. Of the remaining 94.9%, 14.4% drink 5 or more drinks weekly or more, and 51.9% drink five or more drinks monthly or less. This is a more revealing (and accurate) picture than the blanket statement that “70% of young women are ‘binge drinkers’ ”. Carr-Gregg and colleagues also claim that “22% of females aged 14–19 years drink between 9 and 30 alcoholic drinks a day”. The source for this statement is a survey conducted for the Salvation Army.4 The survey has several limitations, not least the small sample size. The survey sampled 614 respondents, of whom 70 were aged 14–19 years. The assertion that 22% of females in this age category were “binge drinkers” is based on just seven respondents. This number is well below what is required for any reliable statistical estimation. Encouraging responsible drinking among younger people is a major goal of health professionals and the alcohol industry. A constructive policy debate on this issue requires sound, objective evidence about alcohol consumption among younger people. The article by Carr-Gregg et al does not represent progress towards providing that evidence.

Gordon Broderick

Cannabis use and dependence: public health and public policy. Wayne Hall and Rosalie Liccardo Pacula. Melbourne: Cambridge University Press, 2003 (xiv + 298 pp). ISBN 0 521 80024 2. “Wayne Hall and Rosalie Pacula have written the first honest book on cannabis addressing the whole range of issues that need to be considered for a sensible policy discussion.” No, the source of this quotation is not the publisher’s advertising department. Rather, these are the words of the author of the book’s preface, Peter Reuter, one of the most perspicacious international scholars in the area of psychoactive drugs policy. Honesty and comprehensiveness are features too often lacking in debates on illicit drugs policy. Hall and Pacula (Australian scholars with outstanding reputations in the drugs field) have taken this head on, aiming “to improve the quality of public policy debate on cannabis by ensuring that all relevant issues are addressed” (p3). The book certainly is comprehensive, striking an excellent balance between reviewing and assessing the evidence about the health, psychological and social consequences of cannabis use and, importantly, the costs and effectiveness of cannabis prohibition. This volume is beautifully designed, making its contents accessible to both the busy professional and the student. This is achieved by the use of many subheadings, chapter summaries and a final topic-by-topic summary chapter. Cannabis use and dependence is a book that I will refer to frequently. It is a wonderful resource, providing in one place a sound presentation and evaluation of the current literature about the impacts of cannabis use and of society’s responses to cannabis and its use, and suggesting pathways towards sounder, more evidence-based public policy on cannabis. It fills a significant gap for students and their instructors, as no other volume provides reliable information and assessment in such a package. People of influence in public health and government, involved in the contested field of evolving policies on cannabis, should also find this an invaluable resource. As Peter Reuter said, it is both honest and comprehensive — quite an achievement! David McDonaldConsultant in Social Research andEvaluation Canberra, ACT

David McDonald

Addictions and healing in Aboriginal country. Gregory Phillips. Canberra: Aboriginal Studies Press, 2003 (xix + 210 pp). ISBN 085575408. This is not the first book documenting the problems of addiction and healing in Aboriginal communities. It is, however, the first written by an Indigenous academic. It is also important because it puts forward a methodology for an Indigenous science that seeks to provide a theoretical and practical basis for Indigenous ways of knowing and working. The study is based on ethnographic research in an Indigenous community in north Queensland. Phillips first discusses his own role and responsibilities as an Indigenous academic working in an Aboriginal community. He articulates an Indigenous-defined methodological theory and culturally appropriate knowledge production, an issue that has received very little discussion in research among Indigenous Australians. Interweaving the voices of the community of “Big River” with a range of historical, anthropological and medical material, the experience of trauma and substance misuse is explored. Arising from these explanations, the author reflects on some of the ways the Big River community talk about addressing addiction problems. One fascinating chapter explores approaches to treating addictions among Native Canadians, where the author, together with a suicide prevention officer from Big River, made a number of visits to different communities and treatment programs. Through these experiences the author provides a provisional approach to the treatment of addictions, one that acknowledges the importance of culture and spirituality, but which also incorporates a number of other approaches, such as harm reduction, Alcoholics Anonymous and residential treatment. One criticism would be that the approaches to an Indigenous science outlined at the beginning are not clear in the following chapters. How would the Indigenous methodologies be replicated elsewhere? Do they rely on identification as an Indigenous person and in what ways can non-Indigenous academics and health professionals engage with this approach? In order for such important ways of knowing to be transferred elsewhere, it is important that such methodologies be clearly formulated. Nevertheless, this is an important book on a difficult subject, and one that successfully conveys the individual and social traumas of substance misuse and the ways communities are addressing them. Richard D ChenhallResearch Fellow Menzies School of Health Research, Darwin, NT

Richard D Chenhall

Smokers who undergo surgery have higher risks and are a greater burden on healthcare resources. Is it acceptable to give them lower priority on surgical waiting lists? A wide range of elective surgical procedures should not be offered to smokers who do not try or do not succeed in quitting. There is no denying that this approach is controversial and overtly discriminatory, but it is also evidence-based. New concerns are not based on well-recognised cardiac and respiratory risks, but on increased risks of wound infection and the adverse complications that ensue. The extent of this evidence is such that it is no longer possible for surgeons and others in the healthcare system to ignore it. What, then, is the evidence? Wound infection rates are higher in smokers than in non-smokers who have had joint replacement surgery,1 breast reconstruction,2 “facelifts”, and a variety of other plastic surgery procedures.3 For example, with breast reconstruction, abdominal-wall site necrosis is seen in 7.9% of current smokers compared with 1% of non-smokers, and mastectomy-flap necrosis in 7.7% of smokers compared with 1.5% of non-smokers.2 Furthermore, after abdominoplasty, secondary surgery for dehiscence was necessary in 24% of smokers and 8.2% of non-smokers.4 In a randomised study examining smoking cessation intervention before joint replacement surgery, wound infection rates were reduced from 27% in continuing smokers to zero in those who quit smoking.1 Reduction rather than cessation in smoking is inadequate.1 Infection rates in parasacral incisions made to remove punch biopsy scars were reduced from 12% to 2% in those who abstained from smoking for 4 weeks, while, in the same study, wound ruptures occurred in 12% of smokers but in no non-smokers.5 The optimum period of smoking cessation is uncertain but it is probably at least 6 weeks. Periods of smoking cessation of less than 3 weeks before colorectal surgery are not associated with a benefit.6 The mechanism for the increased wound infection rate is not clear. Tobacco combustion produces more than 3000 products. Nicotine, the best known of these, is a potent vasoconstrictor and impairs revascularisation of bone.3 Reassuringly, nicotine replacement treatment, used to assist smoking cessation, does not increase infection rates in experimental incisions5 or after joint replacement surgery.1 Of the many other combustion products, carbon monoxide decreases tissue oxygenation and a range of other compounds impair the microcirculation. In surgical wounds, there is relative hypoxia in smokers to an extent that is known to impair wound healing in animals.7 Wound infections are never trivial, but in certain clinical situations they can have particular, deleterious sequelae. Immediate breast reconstruction may be desirable for some patients after mastectomy. An infected prosthesis, or necrosis of a flap or tissue donor site, can delay important adjuvant chemotherapy or radiotherapy. Wound infection after joint replacement surgery is associated with increased risk of infection in the prosthesis,8 delays in hospital discharge, increased time to effective rehabilitation and massively increased cost of hospital care. The extent to which doctors seek, and the wider community provides, permission for discrimination is an issue for serious community debate. An essential part of a surgeon’s role is to be selective in choosing who to operate on, and when, in line with current evidence. Policies and practices that flow from this may be regarded by the healthcare community as discriminating, but by smokers and the wider community as discriminatory. Continuing smokers must accept that some risks are simply unacceptable given the intent of the surgery. To put the smoking-related risk in context in orthopaedic surgery, the adverse effect of failing to quit smoking is similar to that of omitting antibiotic prophylaxis.9 The risk of adverse outcomes from wound infections alone is clear enough evidence to suggest that aesthetic plastic surgery should not be offered to current smokers, and that surgery should be delayed for 6 weeks after cessation. Doing otherwise would be simply foolish. Joint replacement surgery presents a different decision-making framework. Patients are likely to have had time to consider and address cessation of smoking. In relation to an individual, pain and limitation of mobility may be deemed sufficient to justify a procedure, despite an increased risk associated with continuing to smoke. However, public health systems are faced with overwhelming demand and must generate the greatest benefit from limited resources. If smokers, as a group, have a reversible factor that causes a longer hospital stay, incurs greater costs and leads to poorer outcomes, might it be reasonable to allocate them a lower priority? Given that the end of a joint replacement waiting list is likely never to be reached, allocating smokers a lower priority could be tantamount to an indefinite deferral of surgery for a smoker unable to quit. A recent Victorian study found that less than 10% of smokers having day-stay surgery recalled being advised by their surgeon or general practitioner to quit smoking.10 Clearly the medical community needs to do better. The message to the wider community is this: continued smoking in the face of elective surgery increases the risk to the individual and stretches the already stretched healthcare resources and expenditure unnecessarily. The community has to decide whether this waste is justified. Critically, if discriminatory policies are implemented, they must be matched by a commitment to fully and effectively support smokers in quitting, which is an altogether different challenge. This applies particularly to smokers who are already socioeconomically disadvantaged and those with mental illness. Failure to help these individuals risks exacerbating existing health and economic inequalities.

Matthew J Peters · Lucy C Morgan · Laurence Gluch

Compassion for those with hepatitis C and accurate information about preventing its transmission will also benefit the wider community My GP’s rooms were the last place I would have expected to feel like a leper because I was sick, but that’s my story, and unfortunately it’s a fairly common one among people living with hepatitis C (HCV).1 Discrimination against people who are HCV-positive is not confined to healthcare settings, but this is where it is most often reported,2 partly because it’s the context in which affected people are most likely to disclose their condition. Discrimination also rears its ugly head at home, in social situations, at work, school, in the media and when we attempt to access services, such as insurance. It even clings to people beyond death, with families of people with HCV sometimes being refused viewings of their loved ones’ bodies, even though this is inconsistent with public health regulations. Several Australian government reports and a growing body of social research identify hepatitis C-related discrimination as an epidemic in its own right,3 and show that stigmatisation has detrimental effects on people’s health and quality of life,1 as well as significant social and economic costs.4 When the NSW Anti-Discrimination Board announced its world-first enquiry into hepatitis C-related discrimination in 2001, I decided to make a submission about my experience of being diagnosed with HCV. The Hepatitis C Council of NSW knew my story and that, as a journalist, I would be comfortable dealing with my colleagues, so I was asked if I would talk to the media to raise awareness of the enquiry and the issues it was investigating. Although there are an estimated 225 000 people in Australia with hepatitis C,5 many fear the consequences of disclosure in their daily lives, so very few are prepared to publicly identify themselves as HCV-positive. Since agreeing to talk to the media, I have been invited to tell my story many times. It is always rewarding work, because, as HIV/AIDS-positive speakers throughout the world have demonstrated,6 presenting a personal experience of living with an infection like HCV not only educates audiences about the disease and prevention strategies, but also challenges negative stereotypes that result in discrimination. I was diagnosed in March 2000 by the GP I had consulted for 7 years. She was used to me complaining of extreme tiredness, for which she diagnosed “some sort of virus” and recommended a few days off work. However, in January 2000, I felt as if I had aged 60 years in a couple of months. Vomiting after lunch was becoming routine. I had three weeks off work, but it made little difference to how I felt. I went back to the doctor in March to request a hepatitis C test because I had met a woman who was HCV-positive. She had described the debilitating symptoms that had forced her to give up her career as a medical practitioner, and I identified with them all, so I knew I had to be tested. Back in 1985, before hepatitis C got its name and before there was a test for it, I took heroin for a few months. When I sought help, my drug use was treated in a non-judgemental way by my family, a fabulous GP and a psychiatrist. I received excellent care and emerged with my self-respect intact and my body in good shape. Or so I had thought for 15 years. In 2000, my doctor’s response to my request for an HCV test was “you wouldn’t have that”. My subsequent admission of injecting drug use all those years ago was met with silence, but she ordered the test. When I went back for the results it seemed that she didn’t want to know about me or my illness, despite the fact that I was very sick. She offered almost no information at all about the virus, explaining that she “just doesn’t see it” in her surgery, and handed me a brochure produced in 1991, which said there was little in the way of treatment, that the prognosis was not good, and that the highest risk group was homosexual men. All of this was simply untrue in 2000, but I did not know that then. I felt that my GP’s diagnosis was not that I had a serious liver disease, but an untreatable moral malady. If I had been one of the many people who are diagnosed before they experience any symptoms, I would have left her rooms, not told a soul and tried to forget all about it. I didn’t go home filled with righteous indignation and contempt for my doctor that day. I was consumed with self-loathing — I felt like a piece of human debris, unclean and totally unworthy. But the gods were smiling on me. It was 27 March 2000 — the day the New South Wales Health Department launched the world’s first hepatitis C mass media public awareness campaign. On the news, doctors were talking about treatment and there was some discussion about discrimination. I rang the Hepatitis C Council of NSW helpline the next day and received accurate information, support, and referral to my local liver clinic. I was on the road to recovery, but the shame I felt about my positive status was hard to overcome. After my experience with my GP, I was wary of people finding out about my illness. Sometimes I still am. In the past four years I’ve met lots of people with hepatitis C, and many of them express shame and fear because they have had such negative experiences when they disclosed their HCV status. There were people in my treatment support group who expressed the medieval notion that their illness was direct punishment for their “sins” and that they deserved to suffer and to be treated poorly because they had injected drugs in the past. The NSW Anti-Discrimination Board enquiry into hepatitis C-related discrimination in 2001 found two reasons for discrimination.2 It heard evidence of many cases of stigmatisation as a result of ignorance about the virus and how it is transmitted, but it was the close association between injecting drug use and HCV infection that was found to be the main reason why people with hepatitis C were treated in a discriminatory manner. Its report, C-change, says much more needs to be done to educate the general community, and especially healthcare workers, about what hepatitis C is, how it is contracted and who contracts it. This requires the political will to change things, but is not an insurmountable problem. However, the enquiry found that the perception of people with hepatitis C as being “somehow deviant and automatically engaged in illegal or criminal behaviour” is far more difficult to tackle.2 It is acceptable to vilify very few groups within society these days, but people seem to feel it is quite reasonable to denigrate injecting drug users because their behaviour is illegal and highly stigmatised. In his introduction to the NSW Anti-Discrimination Board report, former president Chris Puplick comments: “Were this nexus to be severed, either by means of legislative change or by changes in perceptions, attitudes and responses, then most of the problems identified in the C-change report would be more easily resolved”.2 There is little hope of this vision being realised in the short term. I believe the Australian Government’s proposed Disability Discrimination Amendment Bill7-9 aims to overturn a Federal Court decision in 2000 that found addiction to a prohibited drug could be regarded as a disability.10 If the bill becomes law, illicit drug users (and their families) could, in some circumstances, face legalised and institutionalised discrimination. Healthcare workers have voiced concerns that such an amendment may result in the increased spread of bloodborne viruses, such as hepatitis C, and limit access to drug treatment programs.7 The illegal status of injecting drug use already results in negative health outcomes for many people with hepatitis C, especially if they are current injecting drug users.11 Quite simply, many do not attempt to seek medical treatment unless they absolutely have to, and, when they do, they sometimes report receiving very shoddy treatment. The Disability Discrimination Amendment Bill and the Federal Government’s rejection of evidence-based recommendations, such as harm minimisation, for combating the HCV epidemic stand in stark contrast to Australia’s highly successful response to HIV/AIDS. This response depended to a large extent on legislative action by Australian governments, in particular the repeal of laws that made homosexuality illegal and discrimination acceptable. A recent study has found that discrimination against people who are already vulnerable because they are ill can be “a profoundly negative experience”.11 This is so not only for the person with hepatitis C, but for the wider community as well, because access to information about preventing transmission is compromised when people are afraid of dealing with healthcare services.11 Around 40% of the relatively small number of people who undergo treatment become free of the virus.12 I consider myself extremely fortunate to count myself as one of them. The side effects of treatment12 were extremely difficult during my 48 weeks of therapy, but it was worth it. I have been free of the virus since 2001, and feel better than I have for many years. It’s wonderful to have a happy ending to share when I talk publicly about living with hepatitis C, but I hope the audience understands that it was not just the medicine that made me better. Love, understanding and compassion are great healers that many with hepatitis C just don’t experience.

Lisa Waller BA

GPs need a means to easily and accurately identify prescription shoppers The Health Insurance Commission (HIC) defines “doctor shoppers” as people who have 30 or more Medicare consultations a year or see more than 15 different general practitioners to obtain more Pharmaceutical Benefits Scheme (PBS) prescriptions than appear to be clinically necessary. In 1995–96, there were 13 240 Australians who met this definition, and in 1999–2000 this figure had fallen to 8780.1 The current system places the legal standing of prescription shoppers above that of the doctors who are trying to deal with them. Recently, the HIC introduced a new definition of “prescription shopper” as a person who has, in a 3-month period, been supplied prescription drugs by six or more different prescribers, or has been prescribed a total of 25 target pharmaceutical benefits or 50 or more pharmaceutical benefits in total. These broadened criteria have resulted in a new figure of 22 000 prescription shoppers.2,3 The agenda of doctor shoppers is to obtain benzodiazepines and opioid analgesic drugs, either for their own use or to swap or sell. The upper quartile of doctor shoppers work hard at their task, and will have seen up to two different GPs a day for every working day of the year.1 Doctor shoppers confront GPs with a confusion of our usual roles and trouble us in many ways. They are not like our usual patients and only want drugs, not help.4 Their dissembling destroys trust and, when unsuccessful in obtaining prescriptions, they can become aggressive and unsettle regular patients and reception staff. They are also quick to spread the word about any new doctor who has been a “soft touch”. Although many doctors have ethical and humanitarian concerns for the wellbeing of these patients, most do not want to get involved. Even reputable and dedicated doctors who espouse a philosophy of harm minimisation can face disciplinary proceedings if they are accused of prescribing excessive amounts of drugs of addiction.5 Strangely, prescription shopping is not illegal, and doctor shoppers are not subject to the same legal constraints as those who prescribe for them. For an experienced GP, making a diagnosis of “doctor shopper” can be easier than diagnosing the trickier presentations of cholecystitis. But for less-experienced doctors, used to giving patients the benefit of the doubt, it can be a problem, and requires educational input. Doctor shoppers are of either sex, and most are between 20 and 40 years old. They often present with fairly transparent stories involving severe pain of some description, stress, insomnia, or a request for benzodiazepines to help them withdraw from opiates or alcohol.4 They often claim to have recently arrived from interstate and present a letter, which may be forged on a stolen letterhead, attesting to their diagnosis and need for opiates and tranquillisers. They are usually much more medically sophisticated than the average patient and are quite explicit about the medication they want.4 They will tell the GP that tramadol is useless for their pain, which only responds to various derivatives of morphine. Similarly, temazepam tablets do not help them to sleep, but capsules do. Subsequent attempts at getting further prescriptions involve a variety of unlikely stories about the loss of previous prescriptions through various forms of theft, washing machine mishaps, and prescription-devouring dogs. In this issue of the Journal, Martyres et al (page 211) analyse the doctor-shopping behaviour of 202 people aged 15–24 years, who died between 1994 and 1999 after using heroin.6 Martyres et al found that the frequency of doctor shopping over a 4-year period increased threefold in the year before death. They see this rapid escalation of doctor shopping as both a cry for help and as an opportunity for GP intervention — even if this is only advice on the options available for help and treatment.6 They are also of the view that the government sees doctor shopping (which costs the PBS more than $30 million a year) as more of an economic than a medical problem. Indeed, the focus of the HIC’s Prescription Shopping Project has a large economic component aimed not only at doctor shoppers, but also at people who hoard drugs or send PBS drugs to relatives in other countries.7 Besides its economic cost, doctor shopping is a public health and ethical problem for the medical profession. Most GPs do not write prescriptions for doctor shoppers — half these prescriptions are written by 7.5% of Australian GPs, most of whom practise in one of 10 residential postcode areas.1 These GPs appear to have an irresponsible, laissez-faire approach to prescribing. The Prescription Shopping Project will provide feedback and educational intervention to excessive prescribers, with the aim of changing their prescribing practices.7 The Prescription Shopping Project also gives the HIC “special authority to contact the patient or to give drug information to their doctor without the patient’s consent”.7 However, if a young heroin user can see up to 613 GPs in a year,1 how will the HIC know which of the 613 GPs is that patient’s doctor? The Prescription Shopping Project legislation empowers the HIC to assist a “prescriber to make decisions about prescribing to the prescription shopper, if that prescription shopper is visiting that prescriber or is a patient of that prescriber”,3 but the immediate need of the busy GP is quick access to information. And the easiest and fastest technology to assist the busy GP is access to a dedicated prescription shoppers’ telephone line. Until August 2002, a doctor could quickly confirm, to a high level of probability, who was a known doctor shopper by using a dedicated telephone line, “The Doctor Shopping Line”. This was the diagnostic equivalent of the ultrasound in confirming the diagnosis of cholecystitis and the number and type of gallstones involved. Indeed, the HIC won a Government Technology Productivity Award for developing the software for generating the required doctor-shopping information within 30 seconds.8 Budgetary constraints, fears about privacy provisions, and a re-examination of the secrecy provisions of the National Health Act 1953 (Cwlth) led to a cancellation of this dedicated telephone line. Its replacement requires patients to sign a voluntary release-of-information form and it takes 7–10 days for the GP to receive the prescription-shopping history. The current system places the legal standing of prescription shoppers above that of the doctors who are trying to deal with them,9 and may have placed these individuals’ fragile lives at greater risk than is necessary.6 If Martyres et al are correct in seeing an escalation in prescription shopping as a cry for help, GPs must have the information on which to act. The success of the federal government’s Prescription Shopping Project also depends on GPs accessing quick and accurate prescription-shopping information. The necessary legislation and technology to reactivate the previously effective dedicated doctor-shopping line is already in place. 3,8 There is no logic in further governmental delay in its reintroduction. Doctors want it and need it, and will not in the least mind if the new politically correct term is “Prescription Shoppers’ Line”.

Max Kamien MD, FRACGP, RACP

Objective: To identify prescription drug-seeking behaviour patterns among young people who subsequently died of heroin-related overdose.Design: Linkage of Medicare and Pharmaceutical Benefits Scheme and Coroner’s Court records from Victoria.Subjects: Two hundred and two 15–24-year-olds who died of heroin-related overdose between 6 January 1994 and 6 October 1999.Main outcome measures: Patterns of use of medical services and prescription drugs listed on the Pharmaceutical Benefits Scheme in the years before death, and use of all drugs just before death.Results: Polydrug use was reported in 90% of toxicology reports, and prescription drugs were present in 80% of subjects. Subjects accessed medical services six times more frequently than the general population aged 14–24 years, and more than half of all prescribed drugs were those prone to misuse, such as benzodiazepines and opioid analgesics. A pattern of increasing drug-seeking behaviour in the years before death was identified, with doctor-visitation rates, number of different doctors seen and rates of prescriptions peaking in the year before death.Conclusions: An apparent increase in “doctor shopping” in the years before heroin-related death may reflect the increasing misuse of prescription drugs, but also an increasing need for help. Identification of a pattern of escalating doctor shopping could be an opportunity for intervention, and potentially, reduction in mortality.

Raymond F Martyres MB BS, MMed, FRACGP · Danielle Clode BA(Hons), DPhil(Oxon) · Jane M Burns BA(Hons), PhD

Cyberdrugs will only take off if there is a significant price advantage over that on the black market The Wild West is a prominent metaphor for the new challenges and opportunities the Internet brings. The adventurous welcome the challenge, the cautious fear the hazards. The Internet has opened up a whole new area of information exchange and free trade. The information exchange makes it difficult for totalitarian regimes to easily control their citizens’ access to information, and Internet share trading makes governments more cautious about their fiscal policies. Free traders welcome the level playing field, for they see restricted markets opening up, and efficiencies based on market forces.1 The Internet cuts out the “middle man”. However, there are downsides, as anyone harassed by SPAM mail will know. Multinationals can more easily extend their sphere of influence, the pornography trade flourishes, as does the trade in music and illicit CDs, which boldly flouts copyright laws. Internet trading of pharmaceuticals challenges the tradition that pharmaceutical drugs should only be prescribed by health professionals and dispensed by pharmacists who have seen the person face-to-face. In June 1999, the American Medical Association formally adopted the position that appropriate medical care can only result from face-to-face consultations.2 Likewise, members of the US Food and Drug Administration are expressing a caveat emptor (“let the buyer beware”) about e-pharmaceuticals,3 because of problems with the quality of cyberpharmacies and the qualifications of cyberpharmacists.4 To what extent does society get involved in individuals’ free choice, especially in the context of drug use? Is free trade better than social control? Social safeguards are set both to protect the ignorant and to restrain the wilful, although critics will argue that the medical and pharmacy professions are simply protecting their eroding turf. With drugs of dependence, those involved in misuse would prefer to cut out the “middle man”, and make their own deals. In addition, they are quite prepared to use substances of poor quality and uncertain potency. Should the profession try to stop this? And, if so, how? Social controls of the supply of drugs of dependence vary for different drugs. Thus, society is tightening its control over tobacco advertising and distribution, relaxing controls over alcohol, and clamping down on illicit drugs. Decisions for each drug class are decided somewhat arbitrarily — partly they relate to the severity of the perceived problems arising from use of the drug and partly to the feasibility of control measures. The underlying assumption is that society should exercise some control over drug dealers who seek to exploit those vulnerable to drug addiction, but, in each case — whether tobacco, alcohol or illicit drugs — some uneasy compromises are necessary. These compromises change over time, depending in part on ideological and political forces, as well as on the science of drug-related harm. What is the size of the cyberpharmacy problem in relation to addictive drugs? Is the single case of online purchasing of drugs for misuse described by St George and colleagues in this issue of the Journal (page 118)5 an exception, or the start of a new and dangerous trend? We need more data, but we can make some observations. Licit drugs present a far greater problem than illicit drugs. Most drug-related deaths in our society are a result of diseases caused by tobacco. Tobacco accounts for over 80% of drug-related deaths and 79% of years of life lost. 6 When the cardioprotective effects of alcohol are factored into the equation, the impact of alcohol is on a par with those of the illicit drugs. Yet, alcohol as a licit drug is freely available in our local supermarkets. Are not tobacco and alcohol a higher priority? The illicit use of licit drugs — prescription opioids and benzodiazepines — is more difficult to study. In particular, the impact of sedatives, including benzodiazepines, is difficult to quantify, as their main impact is their contribution to opiate deaths in polydrug overdoses. How big a problem, compared with other sources, is the cybersourcing of licit drugs for illicit use? As general practitioners have become more aware of the need to restrict benzodiazepine prescribing, a black market has developed. There is also a growing market in black-market prescription opiates, like MS Contin (Mundipharma) and Kapenol (GlaxoSmithKline). Thus, there is a ready market for people keen to buy these drugs. Cyberdrugs will only take off if there is a significant price advantage over that on the black market. Data are hard to obtain, but we suspect that, until it becomes harder for users to obtain benzodiazepines from lax prescribers or on the black market, the purchase of cyberdrugs will be regarded as too slow and too expensive. What should we now do? We need more data, and cases like that described by St George et al help to alert health professionals in the field to this new drug source. The suggestions put forward by St George and colleagues have merit, but, without more data, their alarm may be premature. In the past, drug control on the supply side, especially of illicit drugs, has produced disappointing results.7 In the meantime, we believe more effort is needed to control the damage caused by tobacco, alcohol and opiates.

Alan J Gijsbers FRACP, FAChAM · Gregory Whelan MD, FRACP, FAFPHM, FAChAM

Overseas-based online pharmacies dispense prescription medications without a prescription, thus creating an alternative source of pharmaceuticals for people using illicit drugs. Health professionals need to be aware of this new drug source, which may change the rates and patterns of illicit drug use in Australia. Because of the nature of the Internet, this issue needs to be dealt with at both an international and a national level. The provision of health-related services through the Internet is fast becoming a reality. Online pharmacies are an extension of this service.1 There have been reservations about privacy as well as the quality of the information available from these health sites, but we have recently become aware of a more disconcerting issue: obtaining potentially addictive prescription medication through the Internet. Online pharmacies, such as those based in Mexico and Asia, will dispense prescription medications without a prescription, including commonly misused pharmaceutical drugs (eg, diazepam, oxycodone, temazepam and anabolic steroids). In 1998, results of the National Drug Strategy Household Survey indicated that 46% of Australians have used an illicit drug at some time. Analgesics were identified as second only to marijuana as the most widely used illicit drugs.2 When compared with the total Australian population, the group with the highest proportion of current users of any illicit drug was young people aged 14–29 years, and in the period 1995–1998 recent illicit drug use by teenagers rose.3 Although illicit drug use is not exclusively a youth issue, young people are competent users of the Internet, with 75% of 18–24 year olds accessing the Internet in 2000, compared with only 9% of those over 65 years.4 Example of drug misuse via the InternetA 20-year-old patient was referred for management of anxiety and polydrug misuse. The patient related that anyone could be a misuser and pusher of drugs without relying on illicit suppliers of such drugs or “doctor shopping”. A click of a mouse could supply whatever drug a patient wanted from online pharmacy services available 24 hours a day. These sites are easy to use and often require little more than a credit card number to gain access to a wide range of prescription drugs, such as diazepam, alprazolam, temazepam, methylphenidate, morphine and codeine. The patient had a 2-year history of using large amounts of zolpidem, temazepam, alprazolam and diazepam with alcohol, as well as regular use of marijuana. These medications were originally obtained by doctor shopping for prescriptions. However, while researching these medications on the Internet, our patient discovered the online pharmacies that dispensed prescription medication without a script. Zolpidem, oxycodone and methylphenidate were all ordered by the patient from online pharmacies based in Mexico and Thailand. He “surfed” the Internet for the site with the cheapest drugs and found one that sold 100 zolpidem, his drug of choice, for US$70.00, with a delivery charge of US$5.50. He was able to order quantities of 100, 200 or 500 tablets. It took 2 weeks for the discreetly packaged drugs to arrive at the patient’s door. The patient volunteered this information during therapy for drug addiction and was quick to see the negative implications. After a period of counselling about the causes of medication misuse, he was motivated to cease further ordering and willing to undergo drug detoxification. Further investigationsWe accessed many of the sites used by the patient to obtain medications. Online pharmacies are subject to the laws of the country in which they are based. Those in Australia require a valid Australian prescription before prescription medication will be dispensed (Peter Waterman, Media Spokesperson, Pharmacy Guild of Australia, personal communication). However, in some countries, such as Mexico, many prescription medications can be purchased over the counter, and they can be sold over the Internet without prescription. Of 33 surveyed pharmacy websites in the United States most (88%) require a prescription before medication will be dispensed,5 and the remaining sites either dispense prescription medication without a prescription, or accept scripts by fax or email. This may mean that one script could be recycled through many of these online pharmacies. Other overseas sites offered to provide consumers with a prescription after an online or phone consultation. Some sites charge a membership fee before medications like morphine and oxycodone can be obtained. There are also sites that provide, for a fee, a directory of online and land-based pharmacies that dispense prescription medications without prescription. Many sites boast of proven methods for getting packages past customs, and some offer to re-ship medication if a seizure notification from customs can be produced. The Therapeutic Goods Administration (TGA) in Australia, the government organisation responsible for controlling and regulating importation and manufacture of medications, prohibits the importation of prescription medications without a permit or prescription. The medications must be for personal use only and cannot be on-sold, but this is difficult to police. Importers can bring up to 3 months’ supply of medications into the country per importation.6 These regulations can only be enforced if the contents of packages are discovered, and it seems that some packages do slip through. We have written to and discussed these issues with the following people: Managing Director of Australia Post; Chief Executive Officer of the Australian Customs Service; Drug Intelligence Network (Australian Federal Police); Crime Stoppers (New South Wales Police); and Local police. We could not determine what actions these authorities were pursuing in regard to this issue. Australia Post does not have the authority to open postal articles because of privacy issues (Sal Perna, Group Manager, Australia Post, personal communication). Customs informed us that their surveillance capacity has been increased over the past 2 years to meet the challenges posed by Internet purchases of medications and other restricted goods. Customs also regularly prosecutes those who attempt to import prohibited goods without permits. At present all international mail and 70% of air cargo arriving in Australia is examined either physically or by x-ray (J H Jeffery, Acting Chief Executive Officer, Australian Customs Service, personal communication). DiscussionThe use of the Internet as an alternative source of supply of prescription medications for people using illicit drugs is unlikely to overtake the street market or doctor shopping for scripts as a means of obtaining illicit drugs; in 1999–2000 the Health Insurance Commission identified over 9000 “doctor shoppers” (defined as people who had attended 15 or more different general practitioners in 1 year).7 However, the extent of the current use of the Internet as a source of drug supply is unclear. Although medications can be ordered from home, without contacting medical practitioners or pharmacists, ordering drugs over the Internet is still expensive and entails a 2-week wait for the medications. However, it may have the potential to encourage people who would not purchase drugs on the street or “doctor shop” to purchase drugs over the Internet. The purchase of medication from offshore pharmacies also raises the issue of the quality of the medication. Drugs manufactured in Mexico are not as closely regulated as they are in Australia or the US, and are not subject to the same quality standards. This increases the potential for increased rates of addiction and accidental overdose. Although the Internet may not be the major source of supply for illicit drug users, restricting access to Schedule 4 and 8 drugs through this channel can do no harm. This is where Customs plays an important role. The decrease in the availability of heroin in Australia caused by the 2001 “heroin drought” led to a marked fall in the number of heroin-related deaths, but did not necessarily lead to a decrease in rates of illicit drug use.8 Many heroin users simply substituted pharmaceutical drugs for heroin. Thus, restricting supply is not the answer to the complex problems posed by drug misuse. Prescription medications are still widely available on the Australian black market and through doctor shopping. However, restricting Internet access to these drugs may help to prevent the creation of new users. Another factor to take into account is that, if drug users are no longer presenting to GPs to acquire scripts, it may be difficult to determine their past drug use histories, as the use of online pharmacies to acquire prescription medication is unrecorded. Because of the nature of the Internet, problems with online pharmacies need to be dealt with at an international and national level. Customs plays a vital role at a national level and has informed us that they and the Australian Government are aware of and are addressing the issue (J H Jeffery, personal communication). We also suggest that the Australian Government could initiate discussions with the countries where these pharmacies are based, perhaps encouraging them to tighten controls. At a local level, doctors and other professionals working with people who misuse drugs, and especially with young people, should be educated about drug availability on the Internet. All those working with these people should be made aware that the avenues for acquiring drugs are changing, and they should continue to provide support through education and harm-minimisation strategies. We realise that it will be impossible to completely stamp out Internet availability of illicit drugs. However, a concerted and concentrated campaign by all involved parties will ensure the vast majority are denied access to such drugs through the Internet.

Bernard N St George MB BS, FRANZCP · Joseph R Emmanuel MRCGP, DRCOG · Kate L Middleton

QuestionCan smokers be assisted in giving up smoking before elective surgery and does this reduce complications? Trial detailsDesign: Randomised controlled trial of preoperative smoking intervention in patients undergoing hip and knee replacement surgery. Setting: Three university-affiliated hospitals in Denmark. Patients: 62 women and 46 men aged 30–85 years, scheduled for surgery in 6–8 weeks. A further 12 patients were recruited to the trial, but were not included in the analysis because their operations had been postponed or cancelled. Median (range) of smoking exposure was 15 (3–30) cigarettes per day. Interventions: Weekly counselling with a project nurse and the option of nicotine replacement therapy. The first meeting included a questionnaire to measure nicotine dependence and a personalised nicotine substitution schedule was devised. The patients were strongly encouraged to stop smoking completely, or to at least reduce their tobacco consumption by at least 50%. At all subsequent meetings, tobacco consumption was recorded and patients were advised on how to manage immediate withdrawal symptoms and how to keep weight gain to a minimum. Main outcome measures: Frequency of postoperative complications. Main results: The overall complication rate was 18% in the intervention group and 52% in controls (P = 0.0003). These included wound-related complications (5% v 31%; P = 0.001), cardiovascular complications (0 v 10%; P = 0.08), and secondary surgery (4% v 15%; P = 0.07). The median length of stay was 11 days (range, 7–55 days) in the intervention group and 13 days (range, 8–65 days) in the control group (P = 0.41). Overall relative risk reduction was 65% and the number needed to treat (NNT) to avoid any complication was 3 (95% CI, 2–6). In addition, the NNT to avoid wound infection was 4 and the NNT to avoid secondary surgery was 9. Conclusion: A smoking intervention program before surgery can help smokers quit and is associated with a reduction in postoperative complications. CommentaryRationale for the trialSmoking increases the risk of complications in patients undergoing surgery, and it is usual practice to recommend stopping smoking for at least 6 weeks beforehand. 1-3 About 25% of all patients who undergo surgery are current smokers. Studies of the adverse effects of smoking in surgical patients have mostly focused on cardiopulmonary risk reduction, but recent studies identify an association with wound infection. 4,5 Trial methodsThe trial was very well conducted and interpreted, but some aspects deserve closer scrutiny. The intervention period was 6–8 weeks before and 10 days after the operation. In Australia, many patients undergoing elective surgery have their operations booked within a few weeks, and so may not have an opportunity to participate in such a program. A shorter intervention program may not be effective, which raises the question of whether surgery ought to be delayed to allow such a program to be instituted. The intervention program included many components: counselling with a project nurse, additional information and support for patients, smoking cessation or reduction, and use of nicotine replacement therapy. Each could have contributed to the reduction in complications. Nicotine substitution products were provided without charge. If smokers were asked to pay, they may be less willing to participate. In this study, 46 patients (of 166) refused to participate. Patients who refused may have been heavier smokers, and could have been more at risk of complications, despite a short-term change in smoking behaviour. This could affect the generalisability of the results. The study population was restricted to orthopaedic patients. It is yet to be determined if this intervention can be effective in patients undergoing procedures associated with a higher risk of pulmonary complications, such as abdominal or thoracic surgery. Patients in the control group received standard care, with little or no information about the risk of tobacco smoking or smoking cessation counselling. Some readers may believe that this does not represent contemporary Australian practice, but most smokers do not quit in any case.4 Twelve patients were excluded from the analysis because of cancellation or postponement of surgery. An additional analysis of the entire intention-to-treat population could be expected to reduce the estimated risk reduction and increase the number needed to treat (NNT). New informationSmoking cessation or at least 50% smoking reduction occurred far more frequently in the smoking intervention group — 36 patients, compared with four in the control group, stopped smoking. This study found an impressive reduction in the rate of postoperative wound complications among patients who underwent the smoking intervention program. Implications for clinical practiceThis trial identified a simple and effective intervention that reduces wound complications after orthopaedic surgery. The study was unable to show an impact on postoperative pulmonary morbidity, but this may have been because orthopaedic procedures are associated with a relatively low risk of pulmonary complications. Other information suggests that extrapolating these findings to patients undergoing other types of surgery might be beneficial. 1-6 The extent of the risk reduction attributable to smoking cessation is consistent with Australian data for smokers having other types of surgery on a day-stay basis.4 This effect is substantial, and highlights a need to identify smoking status before elective surgery to enable an effective intervention to be offered. The known risks of smoking and the benefits of stopping smoking should be made clear to patients. Are doctors doing enough to stop their patients smoking? There are reports of successful smoking intervention programs targeting hospital patients.7 There has been considerable success in reducing coronary heart disease risk factor levels and improving general health status, including reduced anxiety and depression, in patients awaiting coronary artery bypass graft surgery.7 Nicotine replacement and bupropion therapy can be useful adjuncts.8 Community smoking intervention programs are cost-effective, especially when absenteeism, premature disability and death are taken into consideration.9 Additional cost savings could be expected if such programs were used for patients requiring elective surgery, in view of the marked additional costs of increased need for intensive care and treating complications.

Paul S Myles MD, FRARCSI, FANZCA

On 9 March 2003, during the New South Wales state election campaign, Premier Bob Carr announced that a re-elected Labor government would convene a state summit on alcohol. The 1999 NSW Drug Summit and the 2002 Obesity Summit were obvious models. The 1999 Drug Summit, also conceived during a state election campaign, was generally considered to have been successful. It developed a realistic policy framework and substantially increased funding to improve prevention, community and treatment services to reduce problems resulting from illicit drug use in NSW. However, the problems arising from alcohol greatly exceed those of illicit drugs, and, as our favourite drug provides both considerable benefits as well as sizeable costs, these problems are more complex for communities to grapple with. The Alcohol Summit was held in the NSW Parliament from 26 to 29 August 2003, and involved key government departments (including Health, Police, Gaming and Racing, and the Cabinet Office), as well as health professionals, such as Emeritus Professor Ian Webster, the doyen of the alcohol and drug field in Australia, and industry and community representatives. The Summit comprised plenary sessions with national and international invited speakers who are international authorities on the prevention of alcohol-related problems (eg, Professor Tim Stockwell, Director of the National Drug Research Institute, Perth; and Professor Sally Casswell, Chair of the World Health Organization Committee on the Prevention of Alcohol-Related Problems); 10 working groups addressing specific issues; and site visits to drug and alcohol services to enable parliamentarians to inspect treatment facilities at first hand. All members of the NSW Legislative Assembly and Council were invited to attend the Summit along with 131 delegates from diverse backgrounds. Two one-day satellite meetings preceding the Summit addressed alcohol problems in young people and Aboriginal people, respectively. BackgroundThe Summit began with expert reviews on several topics, including the history of alcohol in Australia, the epidemiology of alcohol problems and the evidence base for effective prevention of alcohol problems. About half the alcohol-related morbidity and mortality in Australia results from acute intoxication, and includes injury, road trauma and suicide. The remaining half results from chronic excessive consumption, and includes cirrhosis, stroke and other medical complications. A large proportion (39%) of the alcohol consumed in Australia is drunk at levels that confer moderate-to-high risk of chronic harm, while 51% of the alcohol consumed poses short-term risks to the drinker.1 Mr Ken Moroney, NSW Commissioner of Police, stated that people intoxicated with alcohol and perpetrating domestic and other violence account for up to 75% of the workload of the NSW police. Furthermore, alcohol-related problems are very unevenly distributed. For example, the NSW town of Walgett, with a total population of 2000, has 10 liquor licences and one in three of the adult male population has had at least one conviction for alcohol-related violence. The debateMany initiatives were reviewed, especially primary prevention methods to limit intoxication, such as increasing the price (by raising taxes) of cask wine and other beverages particularly associated with severe intoxication. Secondary prevention initiatives proposed included improving enforcement of existing laws concerning responsible service of alcohol. Enforcement of these laws was acknowledged by senior NSW police to be less than adequate, and penalties were generally considered to be insufficient. Installation of breathalysers in bars could enable patrons to test their breath alcohol level before driving home. Tertiary prevention measures were also considered, such as expanding measures focused on problem drinkers. These included ignition interlocks to reduce recidivist drink-driving by requiring participants to pass a breathalyser test before starting their car engine. Numerous delegates expressed concern about the ready availability of alcohol to under-age youth. The alcohol beverage industry rejected the evidence that under-age drinking is an increasing problem. Anecdotal reports suggested that provision of alcohol by adults to under-aged young people is widespread and quite widely accepted. To address this problem, education of adults and young people was proposed, along with a range of measures to increase enforcement of the law and to increase penalties for offenders (Summit communiqué resolutions 1.10, 8.8–8.23 and 10.1).2 Delegates heard that alcohol taxation is one of the prevention measures best supported by evidence of effectiveness.3 However, taxation of alcohol in Australia is riddled with inconsistencies and anomalies. A more public-health-oriented approach involves taxing alcoholic beverages according to alcohol content rather than beverage class or cost. One of the key recommendations of the Summit was to hold a national public inquiry into alcohol taxation (Summit communiqué resolution 2.9). Earmarking some additional tax revenue for prevention and treatment programs is supported by evidence of effectiveness, but was not supported by the Summit. At times, the debate became quite confrontational. Representatives of the alcohol beverage industry denied developing products designed to appeal to under-age drinkers and advertising inappropriately (including appealing to under-age drinkers). The alcohol beverage industry advocated retaining self-regulation of alcohol advertising, despite the evidence presented to the Summit that the current system does not prevent grossly inappropriate advertising. The industry argued vigorously that it already promotes responsible drinking. Curfews for young people were debated but not adopted. The industry expressed a strong interest in developing voluntary partnerships with health and community groups, but argued that funding should be drawn from existing alcohol taxes. Total federal, state and territory government revenue from alcohol exceeds $5 billion annually, not including income from the goods and services tax. Most of this revenue is generated by the federal government, and very little is directed towards preventing or alleviating the adverse effects of alcohol. The outcomeIn the final sessions, resolutions from the 10 working groups were collated into an interim report for debate. Most resolutions were not controversial: all the proposals of several working groups were adopted without significant change. There was strong support for improving the capacity and quality of treatment for people with alcohol-related problems, and for general practitioners to receive support in this endeavour. A fundamental issue for most delegates was the extent to which the alcohol industry should accept responsibility for the manner in which alcohol is consumed. For example, how can a server more reliably recognise intoxication and refuse further service? The final communiqué comprised 44 pages of recommendations, with 315 recommendations to reduce the burden of alcohol-related harms supported by a majority of delegates (Box).2 The outstanding achievement of the Alcohol Summit so far has been returning alcohol control policy to the public health agenda. The resulting policy changes have the capacity to achieve considerable future benefits for the community. However, it is critical that the NSW government maintains its focus on this field and injects new resources to ensure that the Alcohol Summit leads to tangible outcomes. Selected recommendations of the NSW Alcohol Summit* 1. A retailer alerts system should be developed to highlight breaches of the Voluntary Advertising Code. 2. There should be a national public inquiry into alcohol taxation to consider the health, economic, social and community costs and benefits of current and proposed alcohol excise and taxation measures. 3. The liquor industry should be required to set aside a proportion of its advertising budget for harm-minimisation programs. 4. The acceptability of inappropriate alcohol use at sporting events, by both participants and spectators, should be challenged. 5. The distribution of alcohol treatment services in NSW should be reviewed and adjusted to ensure equity of access. 6. The NSW police should investigate the feasibility of random breath testing on waterways. 7. Drink drivers convicted of more serious offences should be required to undertake an alcohol-related brief intervention program before licence reinstatement. 8. The NSW Vice Chancellors’ Committee should be asked to consider the development of additional postgraduate programs for professional and clinical staff in drug and alcohol treatment. 9. Intoxication should be defined in relevant legislation so that responsible service-of-alcohol requirements can be applied by both servers and the police. 10. Existing schemes to divert offenders from the criminal justice system towards treatment should be considered for extension to cover those with alcohol misuse problems, and adequate treatment places should be available to absorb court referrals. *Resolutions have been edited. The full text is available from the Summit website.2

Paul S Haber MD, FRACP · Katherine M Conigrave FAChAM, FAFPHM, PhD · Alex D Wodak FRACP, FAFPHM, FAChAM

John R M Caplehorn Senior Lecturer, Clinical Epidemiology, School of Public Health, University of Sydney, Sydney, NSW 2006. johncAThealth.usyd.edu.au To the Editor: The trial of buprenorphine-assisted heroin detoxification in primary care and a specialist clinic by Gibson et al1 was intended to compare the effectiveness and cost-effectiveness of buprenorphine-assisted withdrawal in a specialist clinic with treatment by general practitioners. However, of the average $191 for primary care staff costs, $69 was incurred at the clinic. As at least a third of interactions between patients and staff actually took place in the clinic, the primary care arm of the trial was really a combination of specialist clinic and primary care. Another design problem was the study’s lack of statistical power. A study would need 550 participants to have an 80% chance of identifying (at the 0.05 level of statistical significance) a difference of 50% in self-reported abstinence during the 8-day detoxification (ie, improving the percentage reporting abstinence from 22% to 33%). The trial by Gibson and colleagues had only 115 participants. As expected, the trial produced statistically non-significant results. Yet, the authors highlight the finding that 23% of primary care patients reported being abstinent during the 8-day detoxification, compared with 22% of the clinic patients, (95% CI risk difference, –14.1% to 16.5%; P = 0.9 [χ2]). Moreover, the clinic group performed better on an objective and more reliable measure of abstinence: 20% of clinic patients versus 14% of primary care patients gave morphine-free 8th day urine specimens, (95% CI risk difference, –7.7% to 19.8%; P = 0.4 [χ2]). As the confidence intervals for these risk differences include zero, the confidence interval for any estimate of incremental cost-effectiveness includes infinity. It is quite misleading for Gibson and colleagues to claim that “it costs $20 to achieve a 1% improvement in outcome in primary care”, as this ignores both the conflict and the variability in their clinical outcomes.1 Moreover, the statement ignores the variability in the estimated costs of treatment (eg, mean cost per clinic patient, $332; SD, $70). Surprisingly, Gibson and colleagues did not collect any information on continuing abstinence at the 13-week follow-up. Rather, they collected information on patients’ current treatment. While patients in whom detoxification therapy fails should be offered other treatment, post-withdrawal engagement in maintenance treatment is not a meaningful measure of the effectiveness of detoxification. If anything, it is a measure of failure. The trial needed sufficient statistical power to identify clinically meaningful differences in abstinence at the end of the 8-day detoxification and at 13 weeks. Staff working in the specialist clinic should not have been extensively involved in the delivery of primary care. Gibson and colleagues should have summarised their findings using appropriate estimates of clinical effect and cost-effectiveness with 95% confidence intervals.2

John R M Caplehorn

Amy E Gibson Senior Research Officer, The National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052. amy.gibsonATunsw.edu.au In reply: The primary focus of our study1 was retention in treatment, and not differences in abstinence. Caplehorn has previously argued compellingly that an orientation to abstinence can have an adverse impact on treatment outcomes in opioid dependence.2 We were using buprenorphine to redefine detoxification, not as a treatment producing lasting abstinence but as a way of promoting engagement in ongoing treatment. The power of our study was calculated on the basis of the proportion of subjects entering post-detoxification treatment, not on their self-reported abstinence levels. During the detoxification stage in the primary care setting, we used a shared-care dosing arrangement. This was primarily because of the need to give an initial research assessment to all participants before they were randomly allocated to treatment arms — something that would only occur in the context of a research study, and noted in the discussion. Further details of the health economic analysis are soon to be published.3 Ours was a study of the setting for buprenorphine treatment. Its critical finding was that patients were equally as likely to be engaged in maintenance treatment with practitioners in primary care as in specialist clinics.

Amy E Gibson

Treating substance misuse might not significantly reduce the number of offenders According to recent estimates, crime costs the community $32 billion annually. Of this, $1960 million is directly attributable to drugs, and, if indirect costs were included, the proportion attributable to drugs would be higher.1 Clearly, interventions that target potential risk factors for crime, such as drugs and mental health problems, will have significant payoffs for individuals and the wider community. However, the relationship between drugs and crime is complex. Policy development in this regard needs to take into account the multifaceted nature of the problem. In this issue of the Journal (page 408), Heffernan et al present the first Australian publication that seeks to clinically assess the level of substance-use disorders and psychological distress among police arrestees.2 This article makes a constructive contribution to the evidence base. The study highlights that the overwhelming majority of arrestees suffer from clinical substance-use disorders and psychological distress, and that they are a population who may be in need of treatment. Replication of these findings is important to furthering our understanding of the need for treatment among this group. In Australia, evidence is emerging (building on overseas research) that criminal behaviours among arrestee and prison populations vary widely, from minor disorderly conduct through to homicide, with different factors contributing to these behaviours. Illegal drug use is just one of many risk factors, but there is no doubt that it is significant in the behaviour of a subset of offenders. Recent analyses of police detainees and the incarcerated adult male population estimate that this is the case for between 34% and 52% of offenders.3,4 This clearly suggests that effective treatment interventions could significantly reduce crime rates. Criminological studies that track when people start, persist with and desist from drug use and offending demonstrate that most offenders become involved in minor crime before experimenting with and using illegal drugs.5,6 For example, the onset of crime preceded regular heroin use in 69% of one sample of offenders.5 Illegal drug use seems to compound a pre-existing problem, and so produces higher levels of offending.7 Thus, treating substance misuse among offenders, although an essential public health measure, might not necessarily result in significant reductions in the number of offenders. This is because crime and drug use may be caused more by factors external to the individual, such as early-childhood experiences and development, access to labour markets, access to local drug markets and their supply routes, the social and cultural environment, lifestyle choices, and other determinants that are not easily amenable to treatment.8 The links between drug use and crime and the policy implications that flow from this will be affected by the nature of the local drug market. The Australian Institute of Criminology’s Drug Use Monitoring in Australia project has conclusively shown that police detainees’ drug use patterns vary across the country. Higher rates of amphetamine use have been detected in Queensland, Western Australia and South Australian sites; while higher rates of heroin use have been detected in New South Wales sites.9 Furthermore, breakdowns by offence type indicate that users of amphetamines are arrested for a range of offences, not just violence, and similarly heroin users are arrested for a range of offences, not just property. The links between drugs and offending types appear more variable than is often thought. Changing human behaviour is difficult. Some people take drugs because they like the effects, some because they are risk takers, and some to self-medicate for past and current painful situations and events; others take them because they are addicted and simply cannot stop. Not everybody who is defined as dependent will want or seek treatment. In this complex environment, public policy responses, such as drug courts and court diversion systems, need to be cognizant of what drives behaviours and develop appropriate responsive systems (of which levels of dependency will be only one factor). Recent evaluations of the south-east Queensland and NSW drug courts10,11 have shown that, even with a 12-month, structured, supervised program, some people continue to be criminally active and use illegal drugs. Estimates from the early stages of the Queensland study suggest about a third of graduates reoffended within the follow-up period after graduating from the court. Similarly, police diversion schemes need careful targeting, as good longitudinal research shows that, after a “first” contact with the criminal justice system, many young offenders (upwards of 60%) do not come back into contact with the juvenile system again.12-15 Because of the intersection between illegal drug use and crime, the criminal justice systems in Australia have developed a range of policy innovations to divert offenders into treatment and other programs. These include early police diversion programs, court-based initiatives to divert offenders into treatment, and formal drug courts for serious offenders. There have also been attempts to provide treatment programs within prisons. However, opportunities for diversion could be strengthened in other areas. The first area is at the “end” of the criminal justice system, by providing postrelease support programs for prisoners leaving custody. Given that some 58% of prisoners have been imprisoned previously and 22% of police detainees have been imprisoned in the past 12 months, interventions to break the cycle of reoffending would have a significant beneficial effect on both the individual and the wider community — drug treatment is clearly one of those interventions. The second opportunity to improve diversion to treatment is in the gap between police diversion and the drug court: targeting people who are arrested and processed but whose offence is not sufficiently serious to meet the criteria for a formal drug court program. The study by Heffernan et al includes a significant number of these people, providing support for “arrest drug referral” schemes, as undertaken in the United Kingdom.16 However, there could be very large numbers of people suitable for such schemes. Policymakers first need to know how many of those people would avail themselves of treatment. In addition, treatment options must exist — at present, there is a range of effective treatments for heroin, but options for other illegal drugs are extremely limited. Reducing crime requires a multipronged approach that goes beyond criminal justice and treatment responses, to include a whole-of-government approach. Building the evidence base with valuable contributions such as that by Heffernan et al is vital to ensuring our interventions are successful.

Toni Makkai PhD

Objectives: To determine the 12-month prevalence of substance-use disorders and psychological morbidity in an Australian arrestee population.Design: Cross-sectional descriptive study.Participants and setting: 288 police arrestees at the Brisbane City Police Watch House in February and March 2001.Outcome measures: Prevalence of drug and alcohol disorders; psychological “caseness” according to the 28-item General Health Questionnaire; demographics and index offences.Results: 86% of the arrestees had at least one substance-use disorder; most had multiple disorders. More than 80% were substance dependent. The predominant substances used were amphetamines, marijuana, opioids and alcohol. 82% of the men and 94% of the women were suffering significant psychological distress.Conclusions: Development of services for detoxification and treatment of this population is a pressing need. The findings provide crucial information for the planning and implementation of drug courts and court diversion systems.

Edward B Heffernan BSc(Hons), FRANZCP · John B Saunders FRACP, FAFPHM, FRCP · Gerard Byrne PhD, FRANZCP · Joe Finn BN

Objectives: To investigate the effectiveness of telephone counselling as an adjunct to nicotine replacement therapy (NRT) by transdermal patch in smoking cessation.Design: Randomised controlled trial.Participants and setting: 854 smokers from New South Wales, aged 18 years and older, who had smoked at least 10 cigarettes per day for the past year and responded to newspaper advertisements between October 2001 and January 2002; the trial was conducted between October 2001 and August 2002.Interventions: Random allocation to either NRT alone or NRT plus telephone counselling (5 sessions spaced according to a relapse-sensitive call schedule).Main outcome measures: Self-reported abstinence assessed by telephone questionnaires at 1, 2, 3 and 6 months: 28-day continuous abstinence at 3 and 6 months, and 90-day continuous abstinence at 6 months.Results: 28-day continuous abstinence rates among participants receiving telephone counselling were significantly greater than among those not receiving telephone counselling at both 3 and 6 months (31.6% v 25.1%; P = 0.04 at 3 months; and 30.1% v 22.4%; P = 0.01 at 6 months). Similarly, 90-day continuous abstinence rates at 6 months were significantly greater for participants receiving counselling (26.7% v 18.6%; P = 0.004).Conclusion: Telephone counselling as an adjunct to NRT increases abstinence rates beyond the use of NRT alone.

Zane R Macleod BA(Hons), MPsych, MAPS · Veronica C Arnaldi · Ian M Adams BSc(Hons), MSc, MBA · Margaret A Charles BA, PhD, MAPS

Lynne Hillier,* Richard De Visser,† Anne M Kavanagh,‡ Ruth P McNair§ *,† Research Fellows, ‡ Senior Research Fellow, Australian Research Centre in Sex Health and Society, La Trobe University, Level 1, 215 Franklin Street, Melbourne, VIC 3000; § Senior Lecturer, Department of General Practice, Melbourne University, Carlton, VIC. l.hillierATlatrobe.edu.au To the Editor: Studies of non-representative population samples show that recreational drug use is more prevalent among non-heterosexual women than heterosexual women.1 The Australian Longitudinal Study of Women’s Health2 allowed an examination of the links between sexuality and recreational drug use in a representative sample of 9260 women aged 22–27 years in 2000. Respondents reported their history of tobacco, alcohol and illicit drug use. Reported frequency and volume of alcohol consumption were recorded according to National Health and Medical Research Council guidelines.3 Use of illicit drugs in the last year was dichotomised between marijuana and other illicit drugs (see Box). Respondents also indicated whether they had ever injected illicit drugs. Analyses compared exclusively heterosexual women with all other women. Data were weighted to correct for over-sampling in non-metropolitan areas. Odds ratios were adjusted for age, region of residence, and father’s occupation (as a measure of social class). Younger women were significantly more likely to report risky drinking and illicit drug use. Women from urban areas were significantly more likely to be non-heterosexual and to use illicit drugs, but less likely to report risky levels of alcohol consumption. Women whose fathers were professionals or managers were significantly more likely to be non-heterosexual and more likely to use illicit drugs, but less likely to smoke or report risky drinking. Details are available from the authors. Non-heterosexual women were significantly more likely than heterosexual women to have ever smoked, to be current smokers, to report risky levels of alcohol consumption, to have used marijuana and other illicit drugs in the last year, and to have ever injected drugs (Box). Although these relative differences are important, so too are the absolute values — 45.6% of non-heterosexual women were smokers, and 45.6% reported alcohol consumption of concern. In the last year, 58.2% used marijuana and 40.7% used other illicit drugs. One in 10 had ever injected illicit drugs. Although women are generally less likely than men to use drugs, and may not be a high-priority target for drug education, non-heterosexual young women’s rates of illicit drug use are at least as high as those of young men.4 Higher levels of drug use among young non-heterosexual women may be the result of individual experiences of homophobic discrimination, where drugs are used as an — albeit, short lived — panacea.1 Greater drug use may also be the result of normalisation of recreational drug use within lesbian communities.5 There is a need for specific interventions in young non-heterosexual women, and for further research to determine the reasons for their high levels of recreational drug use. Frequencies and adjusted odds ratios for drug use among 9260 heterosexual and non-heterosexual Australian women aged 22–27 years, 2000 Drug use Exclusively heterosexual Bisexual and lesbian Adjusted odds ratio* (95% CI) Smoking status (n = 8284) (n = 755) Never smoked 60.8% 37.0% 1.00 Former smoker 14.2% 17.4% 2.15 (1.65–2.79) Current smoker 25.0% 45.6% 3.18 (2.61–3.89) Alcohol consumption† (n = 8419) (n = 796) No risk 36.7% 23.9% 1.00 Low risk (no bingeing) 31.5% 30.6% 1.33 (1.05–1.69) Low risk (with bingeing) 27.9% 38.6% 2.01 (1.60–2.52) Risky 3.9% 7.0% 2.50 (1.68–3.72) Illicit drugs (n = 8409) (n = 797) Marijuana (in the last year) 21.5% 58.2% 4.68 (3.91–5.61) Other illicit drugs‡ (in the last year) 10.2% 40.7% 5.50 (4.51–6.71) Injected drugs (ever) 1.2% 10.8% 12.26 (8.53–17.63) * Adjusted for age, region of residence, and father’s occupation. † According to National Health and Medical Research Council guidelines.3 ‡ Amphetamines, LSD (d-lysergic acid diethylamide), ecstasy/designer drugs, tranquillisers, natural hallucinogens, cocaine, inhalants, heroin, barbiturates.

Lynne Hillier · Richard De Visser · Anne M Kavanagh · Ruth P McNair

Christopher M Doran,* Julia E Fawcett,† Anthony P Shakeshaft,‡ Marian D Shanahan,§ Richard P Mattick¶ * Health Economist, † Research Officer, ‡ NHMRC Fellow and Senior Investigator, § Health Economist, ¶ Director, National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052. C. DoranATunsw.edu.au To the Editor: An estimated 512 935 Australian adults satisfy criteria for alcohol dependence (3.5% of the population aged 18 years and over).1 Pharmacotherapy for this condition typically comprises a benzodiazepine, such as diazepam, for withdrawal and disulfiram for relapse prevention.2 Acamprosate and naltrexone have also recently become available for treating alcohol dependence in Australia, but little is known about their uptake or cost. One indicator of uptake is the proportion of alcohol-dependent individuals who have a script filled. Based on the number of scripts for these drugs filled in Australia in 2001, and assuming 50% compliance with the recommended treatment periods, we estimated that 4602 people took acamprosate and 8899 naltrexone in that year (Box). This is equivalent to a maximum of about 3% of alcohol-dependent individuals taking either drug (13 501 individuals using either drug/512 935 alcohol-dependent individuals). We also estimated the cost of visits to medical practitioners for scripts for these drugs, assuming that most were written by general practitioners, and the costs of the drugs themselves to the Australian government and to individual patients (Box). Total treatment and medication cost of the two drugs in 2001 was $7 420 741. These estimates are based on assumptions about the relevant population sub-group (age >18 years), rate of compliance with the recommended regimen (50%), source of scripts (GPs), and GP fees (first visit, $25.05; subsequent visits, $11.14). Varying these assumptions makes little difference to the likely uptake of either acamprosate or naltrexone; applying more conservative assumptions suggests that either medication is unlikely to have been used by more than 5% of alcohol-dependent individuals in Australia. Although use of these medications is not necessarily appropriate for all dependent individuals, their low uptake raises serious concerns about why they are being under-utilised: it may be because they are poorly marketed, or it may be that they are of limited effectiveness in Australia outside the context of clinical trials. The latter possibility is exacerbated by the nebulous nature of the comprehensive treatment programs recommended for their use.5 Without methodologically rigorous Australian data, it is difficult to confidently allay such concerns. However, these results indicate a considerable amount of resources are being devoted to acamprosate and naltrexone as treatments for alcohol dependence, with little Australian evidence as to whether this investment represents value for money. Use and cost of new medications for alcohol dependence in Australia in 2001 Acamprosate Naltrexone Number of scripts filled3 27 613 13 349 Estimated number of users* 4602 8899 General practitioner visits Estimated number† 13 807 8899 Estimated cost§ $251 129 $240 794 Medication cost3,5 Cost to government $4 442 204 $2 115 315 Estimated cost to patients¶ $252 407 $118 892 Total cost $4 945 740 $2 475 001 * Number of scripts filled/number of scripts needed for recommended treatment period (12 months for acamprosate and 3 months for naltrexone,4 with each script providing one month’s supply5)/compliance (assumed to be 50%). † Based on 6 visits per year for acamprosate prescription (12 scripts; 1 repeat per script), and 2 visits per year for naltrexone prescription (3 scripts; 1 repeat per script), but assuming 50% compliance with recommended treatment period. § Based on 2001 Medicare rates (85% of MBS code 23 [$25.05] for first visit, and 85% of MBS code 3 [$11.14] for subsequent visits) plus mean patient cost per GP/vocationally registered GP visit for 2001 of $2.62.6 ¶ Taking into account variation in patient Medicare classification (general, concessional or safety net), which varied over the year.3,5

Christopher M Doran · Julia E Fawcett · Anthony P Shakeshaft · Marian D Shanahan · Richard P Mattick

Michael Copeman Paediatrician, Department of Paediatrics, Manly and Mona Vale Hospitals, Darley Road, Manly, NSW 2095. mcopeman@bigpond.net.au To the Editor: Law and Batey1 rely on a flawed study for their conclusion that needle/syringe programs (NSPs) have saved lives and money. The study in question2 compared the incidence of HIV and hepatitis C virus (HCV) infections in cities round the world and concluded that cities with NSPs had achieved reductions in HIV incidence that were not seen in cities without NSPs. However, interestingly, no similar reduction in HCV incidence was reported. Detailed reading of the study shows that a third of the cities (22/67) without NSPs were in Thailand — a country in which, unfortunately, there are many other reasons why HIV incidence is increasing rapidly. Given the large proportion of Thai cities included in the study, it is plausible that the rapid rise in HIV incidence in these cities biased the overall results of the study, leading to an erroneous conclusion that NSPs themselves were associated with a reduction in HIV incidence in cities worldwide. Further reading of the study shows that HCV incidence was not measured in any studies in Thailand. So, the reported lack of effect of NSPs on HCV incidence depends on comparisons between cities with and without NSPs from other parts of the world, perhaps less affected by some of the problems in Thailand. In conclusion, if Thai cities had been excluded from the study, it seems likely that no change in the incidence of either HCV or HIV might have been found in association with NSPs. The original study needs urgent re-analysis to see if this is in fact the case.

Michael Copeman

Matthew G Law,* Robert G Batey† Statistician, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, 376 Victoria Street, Darlinghurst, NSW 2010; † Clinical Chair, Division of Medicine, John Hunter Hospital, Newcastle, NSW. mlawATnchecr.unsw.edu.au In reply: Copeman's criticism of the report Return on investment in needle and syringe programs in Australia1 is essentially that the comparison of the effectiveness of needle/syringe programs (NSPs) is confounded by other factors. This point, and its implications for the results, was extensively discussed in that report. Copeman suggests that the estimated reduction in HIV due to NSPs might largely be attributable to the inclusion of data from many cities in Thailand that do not have NSPs. This criticism is not supported by the data. A sensitivity analysis including only cities from developed countries was performed at the time of the report (see Methods, Section 3.1.2, page 131), but was not included among the report's results because of space constraints and because it didn't alter the main findings. The analysis of cities in developed countries showed an overall mean reduction in the annual rate of change in HIV seroprevalence of –30.0%, compared with –24.7% based on all cities, albeit with lower statistical significance (P = 0.105 v P = 0.057), reflecting the loss in power through exclusion of cities. Copeman's assertion that the report indicated that NSPs had no effect on rates of hepatitis C virus (HCV) infection is incorrect. The report estimated that, following the introduction of NSPs, HCV prevalence among injecting drug users declined by 2% per annum, compared with no introduction of NSPs (P < 0.001). The report is freely available on the Internet,1 and we encourage readers to look at it for themselves.

Matthew G Law · Robert G Batey

Objective: To compare outcomes, costs and incremental cost-effectiveness of heroin detoxification performed in a specialist clinic and in general practice.Design and setting: Randomised controlled trial set in a specialist outpatient drug treatment centre and six office-based general practices in inner city Sydney, Australia.Participants: 115 people seeking treatment for heroin dependence, of whom 97 (84%) were reinterviewed at Day 8, and 78 (68%) at Day 91.Interventions: Participants were randomly allocated to primary care or a specialist clinic, and received buprenorphine for 5 days for detoxification, then were offered either maintenance therapy with methadone or buprenorphine, relapse prevention with naltrexone, or counselling alone.Main outcome measures: Completion of detoxification, engagement in post-detoxification treatment, and heroin use assessed at Days 8 and 91. Costs relevant to providing treatment, including staff time, medication use and diagnostic procedures, with abstinence from heroin use on Day 8 as the primary outcome measure.Results: There were no significant differences in the proportions completing detoxification (40/56 [71%] primary care v 46/59 [78%] clinic), participating in postwithdrawal treatment (28/56 [50%] primary care v 36/59 [61%] clinic), reporting no opiate use during the withdrawal period (13/56 [23%] primary care v 13/59 [22%] clinic), and in duration of postwithdrawal treatment by survival analysis. Most participants in both groups entered postwithdrawal buprenorphine maintenance. On an intention-to-treat basis, self-reported heroin use in the month before the Day 91 interview was significantly lower than at baseline (27 days/month at baseline, 14 days/month at Day 91; P < 0.001) and did not differ between groups. Buprenorphine detoxification in primary care was estimated to be $24 more expensive per patient than treatment at the clinic. The incremental cost-effectiveness ratio reveals that, in this context, it costs $20 to achieve a 1% improvement in outcome in primary care.Conclusions: Buprenorphine-assisted detoxification from heroin in specialist clinic and primary care settings had similar efficacy and cost-effectiveness. Buprenorphine treatment can be initiated safely in primary care settings by trained GPs.

Amy E Gibson BSc(Hons), BA · Christopher M Doran PhD · James R Bell FRACP, MD · Anni Ryan Grad Dip (AOD Studies) · Nicholas Lintzeris MB BS, PhD

Healthy risk-taking is a normal part of adolescence. Young people who participate in multiple risk-taking increase the chance of damaging their health. There appears to be a growing range and prevalence of health-risk behaviours among young women, notably in their use of alcohol and marijuana. Research suggests that such health-risk behaviours may be related to psychological factors such as stress and depression. General practitioners have a central role in identifying and preventing health-risk behaviours and associated mental health problems in young people. Comprehensive assessment includes a series of screening questions about home, education (or employment), activities, drugs, sexuality and suicide for young people, known as the HEADSS technique.

Michael RC Carr-Gregg BA(Hons), MA, PhD, MAPS · Kate C Enderby BA, GradDipHealthPsych · Sonia R Grover MB BS, FRACOG