Substance‐related disorders

To the Editor: A “real world” study of smoking abstinence caught the attention of Australian media recently, who primarily focused on the commentary that “cold turkey” was the most successful approach for quitting smoking. Alpert and colleagues1 assessed the effects of nicotine replacement therapy (NRT) alone and/or in combination with behaviour counselling in 787 adult smokers from Massachusetts who had recently quit smoking. The participation rates at baseline and waves 2 and 3 were 46%, 56% and 68%, respectively. At each follow-up, almost one-third of participants reported that they had relapsed. Relapse rates were similar, regardless of NRT participation. This contradicted the higher quit rates seen with groups given NRT compared with the placebo or control groups reported in meta-analyses.2-4 Among previously heavy smokers, the lowest relapse rate was in those who received NRT and counselling; and among previously light smokers, the relapse rate was the lowest among those who did not receive NRT or counselling. In both groups, those who received only NRT had the worst relapse rates, a finding which reinforces the importance of adjunct counselling. Participants in the Alpert et al study1 self-reported NRT use. Quit status was not validated biochemically, which fails the Russell Standard5 of criteria applied to smoking cessation trials. Information on NRT dose, adherence, administration technique and reasons for shorter courses (eg, side effects, cost or perceived lack of benefit) were lacking. The longer term impact of NRT cannot be deduced from this study. The quality and quantity of psychological support received by each participant group was also unknown. It is unclear whether the study was adequately powered, given the small numbers of patients who completed a recommended course of NRT. Moreover, differential loss to follow-up threatens the study’s internal validity. Multiple attempts are often necessary before a smoker can successfully quit. Repeated yearly access to courses of NRT, as allowed under the Pharmaceutical Benefits Scheme (a 12-week supply of patches is allowed each year for clients entering a comprehensive smoking cessation support program), may confer a benefit in the longer term. There is no evidence for the effectiveness of cold turkey cessation, especially in moderate to heavy smokers. Nevertheless, those determined to quit without pharmacotherapy or additional support should be encouraged to try cold turkey cessation.

Johnson George

Objective: To assess whether patients receiving opioid substitution therapy (OST) in general practice cause other patients sufficient distress to change practices — a perceived barrier that prevents general practitioners from prescribing OST.Design, setting and participants: A cross-sectional questionnaire-based survey of consecutive adult patients in the waiting rooms of a network of research general practices in New South Wales during August – December 2009.Main outcome measures: Prevalence of disturbing waiting room experiences where drug intoxication was considered a factor, discomfort about sharing the waiting room with patients being treated for drug addiction, and likelihood of changing practices if the practice provided specialised care for patients with opiate addiction.Results: From 15 practices (eight OST-prescribing), 1138 of 1449 invited patients completed questionnaires (response rate, 78.5%). A disturbing experience in any waiting room at any time was reported by 18.0% of respondents (203/1130), with only 3.1% (35/1128) reporting that drug intoxication was a contributing factor. However, 39.3% of respondents (424/1080) would feel uncomfortable sharing the waiting room with someone being treated for drug addiction. Respondents were largely unaware of the OST-prescribing status of the practice (12.1% of patients attending OST-prescribing practices [70/579] correctly reported this). Only 15.9% of respondents (165/1037) reported being likely to change practices if theirs provided specialised care for opiate-addicted patients. In contrast, 28.7% (302/1053) were likely to change practices if consistently kept waiting more than 30 minutes, and 26.6% (275/1033) would likely do so if consultation fees increased by $10.Conclusions: Despite the frequency of stigmatising attitudes towards patients requiring treatment for drug addiction, GPs’ concerns that prescribing OST in their practices would have a negative impact on other patients’ waiting room experiences or on retention of patients seem to be unfounded.

Simon M Holliday FAChAM, FRACGP, FACRRM · Parker J Magin PhD, FRACGP · Janet S Dunbabin PhD · Ben D Ewald MClinEpid, PhD · Julie-Marie Henry RN, DipAppSc(Nursing) · Susan M Goode BSc(Hons), DipMgmt · Fran A Baker BMath · Adrian J Dunlop PhD, GradDipEpi

In keeping with tradition, the Christmas double issue, although heavier to carry, takes a lighter approach than usual. Inside, you will read about some of the issues — serious and less so — that can affect our enjoyment of the festive season. The downsides of alcohol consumption are accentuated at Christmas time, especially for teenagers and young adults. The finding by Kisely and colleagues (doi: 10.5694/mja10.10865) that the introduction of the alcopops tax did not significantly alter the number of alcohol-related harms in young people seems surprising. But the authors reflect on several plausible explanations for their findings; the most convincing is that raising the price of only one type of alcohol does not reduce overall alcohol consumption. In a Letter to the Editor, Doran et al (doi: 10.5694/mja11.11191) demand the urgent reform of alcohol taxation and pricing, and lament the omission of this issue from the recent Australian Government national tax forum held in Canberra on 4–5 October 2011. As the authors say, “too many Australians drink too much alcohol too often”. They argue that it is well established that the most effective method of alcohol control is to increase the price of all alcohol through volumetric taxation. We know that about 80% of alcohol consumed by people aged 14–24 years is done at risky or high-risk levels for acute harm (http://ndri.curtin.edu.au/local/docs/pdf/naip/naipaaifullreport.pdf). Alcohol is implicated in more than 60 medical conditions (Babor T, et al. Alcohol: no ordinary commodity. New York: Oxford University Press, 2003) including cancer (MJA 2011; 194: 479-482) and almost one in four road fatalities (http://www.rta.nsw.gov.au/roadsafety/downloads/crashstats2009.pdf). We have an obligation to protect our youth that we are yet to completely meet. We continue our Christmas custom of publishing articles on “bites and stings” with an interesting editorial by Kimble et al (doi: 10.5694/mja11.11319) on dog bites in children and their prevention, and research by Mills and colleagues (doi: 10.5694/mja10.11413) on an approach to rabies vaccination for Australian travellers. The case report by Garg et al (doi: 10.5694/mja11.10136) on propeller and jet-ski injuries during the Christmas season may dampen your enthusiasm for motorised water sports. For the keen fisherpeople in our profession, the case reports by Tran and colleagues (doi: 10.5694/mja10.10794) and Sanli and Danks (doi: 10.5694/mja11.11204) on ocular injuries from fishing may make you consider including safety goggles for your tackle box on your Christmas wish list. Read “Christmas Crackers” for a light-hearted take on some serious issues. Mollison’s (doi: 10.5694/mja11.10828) account of the suffering he endured from his self-inflicted mushroom poisoning may lead the mycophagists among you to add “be wary of ingesting wild mushrooms” to your catalogue of Christmas cautions. Lee and colleagues (doi: 10.5694/mja11.10808), winners of this year’s Christmas competition with their article on wife carrying, recommend a novel method of getting more exercise. Something to consider as an alternative to the traditional postprandial snooze on Christmas Day! I wish you moderation in all good things, a hearty dose of Penguinius collectionavidus infection (Kester, doi: 10.5694/mja11.11340), and a happy, healthy and restful festive season. Thank you for your support this year. We at the MJA look forward to working with you in 2012.

Annette Katelaris MB BS, MPH, FRACGP

To the Editor: Alcohol misuse is one of the leading causes of preventable death, illness and injury in Australia because too many Australians drink too much alcohol too often. The evidence is clear on what are the most effective strategies to curb alcohol misuse at a population level.1 By far the most effective of these is increasing the price of alcohol by increasing alcohol taxes. Aside from some positive features, such as lower tax on low-alcohol and mid-strength beer and the higher tax on alcopops, the alcohol taxation regimen in Australia is flawed from both an economic and public health perspective. A review of the tax system led by Secretary to the Treasury, Ken Henry, concluded that “current taxes on beer, wine and spirits are incoherent”, and recommended taxation reform using a volumetric tax.2 The response from the federal government to this review has echoed the failures of previous Australian governments to avoid increasing taxes. An independent coalition called the National Alliance for Action on Action (NAAA) has been formed with the goal of reducing alcohol-related harm.3 The NAAA represents a broad-based alliance of major health and community organisations that advocate for more effective responses to Australia’s drinking problems. Recognising that there is no single solution, the NAAA has focused on three priority areas: alcohol pricing and taxation; alcohol marketing and promotion; and alcohol availability. The Australian Government’s national tax forum held on 4–5 October 2011 in Canberra was an ideal opportunity for an informed discussion about alcohol tax reform. However, despite acknowledgement by the government that the current system does not effectively target the health and social costs of alcohol abuse, alcohol taxation was not part of the tax forum agenda.4 This was disappointing. At an NAAA day of action on 6 July in Canberra, assurances were given by Treasurer Wayne Swan and Health Minister Nicola Roxon that alcohol tax would be discussed at the forum. These assurances were aired publicly and in a number of media forums. The forum discussion document indicates that this promise was not honoured.5 This complex issue has not been resolved. We feel it is vital for the health and wellbeing of the Australian community that the reforms recommended by the Henry review remain on the political agenda.

Christopher M Doran · Wayne D Hall · Brian R Vandenberg · Todd A Harper · Jane E Martin · Mike Daube

To the Editor: I read with interest the contrasting perspectives by Pirotta1 and Dwyer2 on the ethics of prescribing complementary and alternative medicine (CAM) interventions, and the subsequent letters on this subject published in the 17 October 2011 issue of the Journal. Individual CAM interventions should be assessed with the same evidence-based approach we would use for any other intervention. Furthermore, any evidence should be interpreted with the same caution as we do for conventional medicines. The efficacy of an intervention should be judged by the quality of the clinical evidence in the context of its scientific plausibility. Whether an intervention should be recommended depends on the context of the other known evidence-based management strategies and the patient’s individual clinical scenario. It is concerning that the supporters of the use of CAM in general practice appear to be willing to make recommendations for treatment in the absence of quality empirical evidence. Both Pirotta and Kotsirilos make the often-used argument that absence of evidence is not evidence of ineffectiveness.1,3 Pirotta suggests that we can turn to tradition1 and Kotsirilos implies that consumer demand indicates effectiveness.3 It should be acknowledged that both tradition and popularity are unreliable forms of evidence. The absence of quality evidence for an intervention should be a major barrier to recommending it, especially when known, effective alternatives exist. This is regardless of the philosophical tradition of the intervention. Even when there is evidence for efficacy, care must be taken in avoiding overreaching conclusions. For example, Kotsirilos interprets the relevant Cochrane review4 as supporting the use of cranberry for prevention of recurrent urinary tract infections in young women.3 That therapeutic recommendation is unjustified. Although the systematic review did find some evidence for cranberry, it noted problems with its quality and the lack of clarity of dosage and administration. The conclusion of the review in 2008 was that “further properly designed studies with relevant outcomes are needed”.4 A well designed randomised controlled trial was published earlier this year; it does not support the use of cranberry for this indication.5

Chun Wah M Tam

Objectives: To identify patterns of khat use among Somali-Australians in Australia and to explore their views about the links between khat use and personal health.Design, setting and participants: Qualitative study using semistructured focus groups among adult members of Somali communities in Brisbane, Sydney, Melbourne and Perth who volunteered to attend focus groups in January and December 2010.Main outcome measures: Emergent themes related to Somali-Australians’ understanding of the links between khat use and personal health.Results: Nineteen focus groups included 114 participants. Khat use was reported to be common among the Somali community, and more common among men than women. Khat was usually chewed in prolonged sessions, producing mild psychostimulant effects such as increased energy, enhanced mood, reduced appetite and reduced sleep. Khat was widely perceived to be a food, not a drug, and as harmless, or even beneficial, to the user’s health. Many users reported discontinuation effects such as lethargy, sleep disturbances and mood problems after sessions of heavy khat use, and some reported self-medicating with alcohol to cope with such problems. Problems of addiction to khat were identified by some participants, but not all believed it is addictive. Many khat users reported visiting their health professionals for treatment of adverse effects and failing to disclose their khat use.Conclusions: Health professionals require greater awareness of khat use and related health problems. Health promotion activities targeting communities with high levels of khat use are required to increase understanding of the potential risks of regular khat use, to promote harm-reduction strategies, and to increase awareness of services available for those experiencing harm. Health professionals should consider targeted screening for khat use among individuals from Horn of Africa communities who present to health services.

Heather Douglas LLB, LLM, PhD · Merali Boyle LLB(Hons), BSc · Nicholas Lintzeris MB BS, PhD, FAChAM

Objective: To measure alcohol-related harms to the health of young people presenting to emergency departments (EDs) of Gold Coast public hospitals before and after the increase in the federal government “alcopops” tax in 2008.Design, setting and participants: Interrupted time series analysis over 5 years (28 April 2005 to 27 April 2010) of 15–29-year-olds presenting to EDs with alcohol-related harms compared with presentations of selected control groups.Main outcome measures: Proportion of 15–29-year-olds presenting to EDs with alcohol-related harms compared with (i) 30–49-year-olds with alcohol-related harms, (ii)15–29-year-olds with asthma or appendicitis, and (iii) 15–29-year-olds with any non-alcohol and non-injury related ED presentation.Results: Over a third of 15–29-year-olds presented to ED with alcohol-related conditions, as opposed to around a quarter for all other age groups. There was no significant decrease in alcohol-related ED presentations of 15–29-year-olds compared with any of the control groups after the increase in the tax. We found similar results for males and females, narrow and broad definitions of alcohol-related harms, under-19s, and visitors to and residents of the Gold Coast.Conclusions: The increase in the tax on alcopops was not associated with any reduction in alcohol-related harms in this population in a unique tourist and holiday region. A more comprehensive approach to reducing alcohol harms in young people is needed.

Steve R Kisely MD, PhD, FAFPHM · Joanne Pais MSc · Angela White MCP, PhD, MAPS(Clin) · Jason Connor PhD, MAPS · Lake-Hui Quek PhD · Julia L Crilly BNurs, MN(Hons), PhD · David Lawrence PhD

Stimulants increase the risks of psychosis and stroke Stimulant use disorders (rather than recreational use) account for most of the harms associated with illicit stimulant use, and are more likely to occur with frequent use and more efficient routes of administration (ie, injection and smoking rather than oral or intranasal use).1 A driving factor behind many of the problems associated with stimulant use in Australia is the long-standing history of methamphetamine injection.2 The majority of dependent methamphetamine users in Australia inject the drug and have been using for a decade or longer.1 In this issue of the Journal, Sara and colleagues highlight the substantial number of heavy stimulant users in Australia.3 They estimate that almost half the people who report taking stimulants on more than five occasions progress to problematic levels of use, meeting criteria for either misuse or dependence. This amounts to around 97 000 Australians in the past year. Such findings are a timely reminder that heavy stimulant use is an ongoing issue in Australia that cannot be ignored. Heavy stimulant use is associated with a number of public health concerns, the most salient of which is stimulant-induced psychosis. As Sara and colleagues point out, stimulant use disorders are concentrated among young men, who are the population subgroup at highest risk for developing psychosis, and the least likely to seek professional help for a mental disorder.4 Stimulants also exacerbate existing psychotic disorders and, in this context, they hinder the efficacy of antipsychotic drugs and increase the risk of violent behaviour.5 Heavy users are not only at increased risk of contracting HIV and other blood-borne viruses from injecting stimulants, but they are also at elevated risk of sexually transmitted diseases (including HIV) because stimulants increase libido.6 This situation creates a nexus for the spread of HIV between drug users and the broader population. Stimulants can further increase the risk of HIV transmission through immunopathological processes.6 As such, HIV prevention efforts for stimulant users need to focus on both safe injecting and safe sex practices. Stimulants increase the risk of cerebrovascular events,7 particularly young ischaemic stroke, as emphasised by Phillips and colleagues,8 also in this issue of the Journal. Stimulants increase the risk of stroke as a consequence of hypertension and other catecholamine-mediated vascular changes that occur during intoxication, while vascular abnormalities and cardiac pathology that occur with chronic use are also risk factors.7 Heavy tobacco and cannabis smoking, as well as the risk of infectious endocarditis as a result of intravenous use, compound the risk of cerebrovascular incidents in this population. Such public health concerns highlight the importance of early detection and intervention efforts. However, illicit stimulant use increasingly spans a broad segment of the population, including people who are well educated, employed and whose life situation would not otherwise point toward drug use. This “mainstreaming” of stimulant use, coupled with the community’s reluctance to disclose illegal drug consumption, can make stimulant use difficult to detect. Given that stimulant users commonly seek help from general practitioners for a range of health issues, offering a safe environment to talk about drugs, where confidentiality is assured and patients do not feel judged, is a critical first step in identifying harmful use. This can be done in a non-confronting way by discussing how stimulant use (both legal and illicit) might be a factor in the aetiology of certain conditions (eg, sleep problems, mood disturbances, hypertension), and whether such use is contraindicated for prescribed medications. Being proactive in this way, at the very least, imparts knowledge with which patients can self-manage their health. Once detected, it is important to appreciate that stimulant use disorders do not occur in isolation; they tend to co-occur with heavy use of cannabis, alcohol and tobacco, as well as with other mental disorders. Stimulant use can increase heavy drinking because it negates the sedating effects of alcohol intoxication. Cannabis and sedative drugs are often taken as a means of coping with the “come-down”, or after effects, of stimulant intoxication. Stimulants can also increase the risk of toxicity from medications prescribed to manage symptoms of depression that are almost ubiquitous among heavy stimulant users.9 The potential involvement of heavy stimulant use in physical and psychiatric problems seen within medical health care settings needs to be considered. Patients who desire treatment for stimulant use can be referred to generic drug and alcohol services (eg, counselling and residential rehabilitation), and specialised treatment programs have been established in some locations (eg, NSW Health’s stimulant treatment clinics10). There is little available in terms of evidence-based treatments. Intensive psychological interventions (eg, tailored cognitive behaviour therapy, contingency management) have shown some promise,6 although these interventions have not been widely implemented. More work is needed to develop and implement effective treatment options for heavy users of stimulants.

Rebecca McKetin BSc(Psychol)(Hons), PhD · Dan I Lubman PhD, FRANZCP, FAChAM

Objectives: To describe the prevalence of lifetime and 12-month stimulant use disorders in the Australian population, and to compare the prevalence estimates from a population survey with prevalence estimates derived using indirect methods.Design and setting: Data were drawn from the 2007 National Survey of Mental Health and Wellbeing, which sampled 8841 residents of private dwellings in Australia in 2007. Interviews were conducted by lay interviewers using the Composite International Diagnostic Interview.Main outcome measures: Lifetime and 12-month rates of stimulant use and stimulant use disorders (abuse, dependence) diagnosed according to the Diagnostic and statistical manual of mental disorders, 4th edition.Results: Lifetime prevalence of stimulant use disorders was 3.3%, and 12-month prevalence was 0.6%, equating to more than 97 000 Australians. Nearly half of those who had used stimulants on more than five occasions met criteria for a lifetime disorder. More than 8% of men aged 16–29 years met criteria for a lifetime stimulant use disorder. Prevalence estimates were consistent with recent estimates using indirect methods.Conclusions: Stimulant use disorders affect a significant number of Australians, and are most common in the age groups at greatest risk for development of psychosis.

Grant E Sara MM, MM(Psychother), FRANZCP · Philip M Burgess MA, PhD · Meredith G Harris BA(Hons), MPASR, MPH · Gin S Malhi MD, FRCPsych, FRANZCP · Harvey A Whiteford MB BS, MPH, FRANZCP

To the Editor: We write in response to the letter by Awerbuch1 and agree with many of his points. He has raised an interesting issue regarding the assertion that chronic pain is itself a disease,2 suggesting it would then logically follow that the patient becomes the final arbiter of whether he or she has the “disease” and hence which treatment may or may not be appropriate. A disquieting development in this regard is the recent Declaration of Montréal, produced at the International Pain Summit of the International Association for the Study of Pain in September 2010.3 This declaration states that access to pain management should be considered a fundamental human right. The position of diagnosis is uncertain, and the only specific treatment modality mentioned is opioid therapy. While we are sure that the Declaration is noble in intent, where does it place a clinician who has concerns about prescribing opioids to a patient who demands them? It adds the legal threat of a breach of human rights if the patient is disaffected with a doctor’s decision on opioid prescribing. As Awerbuch and others4,5 have stated, the public health consequences of prescribed opioids are not trivial. Assessing the appropriate circumstances for their use requires an understanding of clinical evidence and due care, not dogma, moral coercion or forays into jurisprudence.

Dilip Kapur · Phillip B Cornish · Carol A Snellgrove · David A Cherry

To the Editor: Kinner and colleagues described the high proportion of deaths among recently released prisoners in Australia.1 I had a patient with a history of intravenous drug use who, after a prolonged stay in hospital for osteomyelitis complicating a diabetic foot ulcer, including extensive inpatient rehabilitation, died due to drug overdose on the first weekend after discharge. This tragic death suggests a mortality risk for people with a history of drug misuse who are released from any long-stay institution, including hospitals. It may be appropriate for medical practitioners to discuss this risk frankly with such patients at discharge.

Emma L Duncan

To the Editor: A daunting idea for health care providers is the statistic that, for many medications, only about half of the patients given standard doses will receive the desired therapeutic benefit.1 In the past decade or so, it has been argued that some of this variation in response may be attributed to genetic differences between individuals in mechanisms responsible for the pharmacokinetics and pharmaco-dynamics of many drugs.2 The disparity in health standards among Aboriginal and Torres Strait Islander people compared with non-Indigenous groups is a cause for concern, and requires a concerted political effort to instigate adequate solutions.3,4 Some of the problems include a higher rate of diseases such as hypertension, diabetes, obesity, cardiac disease and depression.3,4 The range of medicines prescribed for these conditions is broad, and some people may not receive the full therapeutic benefit, or may have more severe side effects compared with others. Genetically determined variables contribute to the pharmacokinetics and pharmaco-dynamics of these drugs. Many medications used to treat such diseases are metabolised by the cytochrome P450 (CYP) hepatic enzyme systems, and/or their pharmacokinetics are altered by drug influx and efflux systems. Many of these mechanisms are under genetic control and their efficiency may vary between individuals. Despite this, there are few data on the pharmacogenetics of Indigenous populations generally, and the data on Aboriginal and Torres Strait Islander populations are particularly scant.5 Of the few genetic studies of Indigenous Australians, one found that CYP2C19 and CYP2D6 allele frequencies in a group from remote north-western Australia differed significantly from those for Australians of European ancestry, but were similar to those for East Asian populations.5 An altered CYP2C19 allele could mean alterations in levels of drugs such as phenytoin and clopidogrel, and an altered CYP2D6 allele could mean alterations in levels of drugs such as tricyclic antidepressants, selective serotonin reuptake inhibitors, codeine and tamoxifen. We urgently need to identify clinically relevant issues relating to the capacity of people from these groups to metabolise certain medicines. Screening for genetic variations in drug metabolism and transport mechanisms may highlight significant variations in capacity. This may influence whether people benefit from or are harmed by commonly prescribed medications for hypertension, type 2 diabetes, cardiac disease and depression. The high and increasing prevalence of these diseases among Aboriginal and Torres Strait Islander populations supports a detailed, methodical assessment of the genetics of their drug-metabolising capacity.

Joseph D Tucci

To the Editor: This year marks 10 years of successful operation of the Sydney Medically Supervised Injecting Centre — Australia’s only supervised injecting facility (SIF). It is one of 90 such facilities globally, with SIFs operating in eight different countries for up to 25 years. Legislation to lift the trial status of the Sydney centre was passed in the lead-up to the recent New South Wales state election, nearly a decade after the centre opened. Despite not having explicitly supported the centre while in opposition, at the Centre’s 10-year anniversary event on 6 May 2011, the newly elected Liberal–National coalition government signalled its willingness to contribute to bipartisan support of the centre. While the Sydney SIF has survived this transition into institutional “adulthood”, operation of the only other SIF in the English-speaking world, located in Vancouver, Canada, remains a politically sensitive issue. Indeed, the Supreme Court of Canada is currently deciding whether the right to establish and operate a SIF lies with the provincial or the federal government. The Australian and Canadian SIFs have much in common: both have a history of politicisation, both were established under trial conditions, and both have been subject to rigorous independent scientific evaluations. They have each contributed much to the large body of evidence showing the benefits provided by SIFs to individual drug users and to surrounding communities. Specifically, SIFs have been shown to reduce numbers of deaths from drug overdose,1 reduce numbers of ambulance call-outs2 and hospital admissions, improve client outcomes,3 enhance referral to drug treatment programs,4 improve public order (eg, by reducing injecting drug use and syringe disposal in public locations),5 and be cost efficient.6 No adverse consequences have been associated with their operation. There is widespread support for SIFs. This includes many Australasian specialist medical colleges as well as the Australian Medical Association and many scientific and research institutions. The majority of the Australian population also support SIFs, as shown in the recent National Drug Strategy Household Survey.7 Yet despite this, and the continually accumulating evidence showing the public health benefits of SIFs, the idea of establishing new facilities remains politically charged in the Australian context. In Melbourne, a local council recently urged the Victorian state government to consider establishing a SIF in an area with entrenched, street-based drug use. However, this was swiftly rejected, and calls for SIFs in other Australian states have been similarly refused by state governments. Indeed, the current legislation in NSW precludes the operation of any additional SIFs. But for the Sydney SIF, it appears that the repeated political hurdles which characterised its first decade of operation have finally diminished. In this single instance at least, the scientific evidence on SIFs has prevailed. Editor’s note: Ironically, after this letter was accepted for publication, the New South Wales Christian Democrat Fred Nile (Member of the Legislative Council) gave notice of intention to submit a Bill to close down the operation of the Sydney Medically Supervised Injecting Centre. No further details are available at time of going to press.

Marianne E Jauncey · Ingrid A van Beek · Allison M Salmon · Lisa Maher

To the Editor: A report in the Weekend Australian earlier this year described an increase in oxycodone-associated deaths, in parallel with an increase in prescriptions for the drug, sometimes known as “hillbilly heroin”.1 These increases are likely to reflect a change in doctors’ prescribing behaviour. Strong opioids were traditionally prescribed for cancer pain, often in the terminally ill, but since the 1980s they have been increasingly used for treating chronic non-cancer pain, despite an absence of new evidence of effectiveness or of whether opioids provide net benefit or harm to patients in this setting.2 Cancer patients are likely to die from their illness before the opioids have a chance to injure them, but patients with chronic non-cancer pain are not, and this is where oxycodone-associated deaths are more likely to occur. A contemporary view is that chronic non-cancer pain should be regarded as “a disease entity”,3 but equating a symptom with disease means that the patient becomes the sole arbiter of whether he or she is ill. The prescribing doctor has no means by which to objectively determine treatment outcomes. The notion of chronic non-cancer pain as a disease entity is based on neuropathological changes described as “central sensitisation”, which may result from nerve damage or from persistent peripheral nociceptive input.3 The concept is not intellectually challenging where there is objective evidence of either nerve damage or injury to somatic or visceral structures. Now, however, when medically inexplicable pain follows injury that may be so subtle as to be unassociated with any discernible abnormality, central sensitisation is invoked as the explanation du jour, without a critical assessment based on anatomical and physiological principles. Prescribing opioids in this setting may have inadvertently contributed to the reported increase in oxycodone-associated deaths. Guidelines exist for prescribing oral controlled-release opioid analgesics for chronic non-cancer pain.4-6 They advocate a signed patient–doctor agreement covering, among other things: the necessity for a single prescriber; a recommendation for all drug dispensing to be from the same pharmacy; no replacement for lost, stolen or destroyed prescriptions; and a requirement for consent for random urine and blood screens. However, these are just guidelines, not mandated, and there are no Australian data on compliance with them. Based on international data,7 the guidelines are likely to be more honoured in the breach than the observance. I advocate that a signed patient–doctor agreement should be mandatory in Australia before the prescription and dispensing of opioids for chronic non-cancer pain. This should be sighted by Pharmaceutical Benefits Scheme authorities before such dispensing is authorised, and a copy should be held by the dispensing pharmacy. A review of prescription guidelines for opioid analgesics in chronic non-cancer pain might reduce the epidemic of prescription drug misuse4 and mortality.

Mark S Awerbuch

Objective: To document trends in: (i) prescribing of morphine and oxycodone; (ii) hospital separations for overdose; (iii) presentations for treatment of problems associated with these drugs; and (iv) oxycodone-related mortality data in Australia.Design and setting: Cross-sectional study analysing prescriptions for morphine and oxycodone based on figures adjusted using Australian Bureau of Statistics estimated resident population and prospectively collected data from: (i) the National Hospital Morbidity Database on hospital separations primarily attributed to poisoning with opioids other than heroin (“other opioids”); (ii) the Alcohol and Other Drug Treatment National Minimum Data Set for treatment episodes where morphine or oxycodone were the primary or other drugs of concern; (iii) the National Coronial Information System on deaths where oxycodone was the underlying cause of death or a contributory factor.Main outcome measures: Population-adjusted numbers of (i) prescriptions for morphine and oxycodone by 10-year age group, (ii) hospital separations for “other opioid” poisoning, and (iii) treatment episodes related to morphine or oxycodone; and (iv) number of oxycodone-related deaths.Results: Prescriptions for morphine declined, while those for oxycodone increased. Prescriptions for both were highest among older Australians. Hospital separations for “other opioid” poisoning doubled between the financial years 2005–06 and 2006–07. Treatment episodes for morphine remained stable, while those for oxycodone increased. There were 465 oxycodone-related deaths recorded during 2001–2009.Conclusions: Oxycodone prescriptions in Australia have increased, particularly among older Australians. The increase may, in part, reflect appropriate prescribing for pain among an ageing population. However we are unable to differentiate non-medical use from appropriate prescribing from this data. In comparison to heroin, the morbidity and mortality associated with oxycodone is relatively low in Australia. There is a continued need for comprehensive training of general practitioners in assessing patients with chronic non-malignant pain and prescribing of opioids for these patients, to minimise the potential for harms associated with use of these medications.

Amanda Roxburgh MCrim, MPsych(Clin), MAPS · Raimondo Bruno BSc(Hons), PhD, MAPS · Briony Larance BSc(Psych)(Hons) · Lucy Burns MPH, GradDipHealthPolicy, PhD

CorrectionTypographical error in base number for calculation of estimates: In “Counting the cost: estimating the number of deaths among recently released prisoners in Australia” in the 18 July 2011 issue of the Journal (Med J Aust 2011; 195: 64-68), the incorrect number 50 504 was used as a basis for calculating some estimates instead of the correct number, 50 405. This has resulted in small errors in some numbers in two tables and one paragraph of the Results in the article. These errors are not substantive and do not alter the conclusions of the study. The numbers have been corrected in the online version of this report (http://www.mja.com.au/public/issues/195_02_180711/kin10879_fm.html).

Stuart A Kinner · David B Preen · Azar Kariminia · Tony Butler · Jessica Y Andrews · Mark Stoové · Matthew Law

Support for addiction medicine is the key Over the past decade or so, care of people affected by comorbidities of substance use disorder and mental health problems has been a focus of Australian state, territory and national campaigns. Despite these efforts, true coordinated treatment models remain the exception rather than the rule. Patients with “dual diagnosis” (a term that must now be close to its use-by date) present substantial challenges to existing treatment models. Various mechanisms conspire against these patients getting better: addictive substances exacerbate psychiatric symptoms; patients with mental illness may continue to use psychoactive drugs in an effort to attenuate symptoms; and substances of misuse in themselves can induce psychiatric disorders.1 Active use of substances often substantially interferes with psychiatric pharmacotherapies. For example, standard antidepressant treatment may not provide the expected benefits in patients with mood disorder and comorbid untreated addiction.2 The field of addiction medicine struggles to recruit doctors, while the level of complexity of patients and the expectations of the community for evidence-supported care across all health fields have increased. Workforce challenges are fed by the perception of clinical complexity, such as that associated with DSM-IV Axis II disorders and substance use.3 These “heart-sink” patients are often referred to alcohol and drug treatment services, where staff expertise in managing behaviours that interfere with treatment delivery may vary. In Australia, patients with substance use and high-prevalence mental health disorders tend to be treated by alcohol and other drug agencies, while those with low-prevalence disorders, many of whom have significant associated drug problems, are core clinical business for public mental health services. The heterogeneous nature of these services and the complexity of much of this patient group make it hard to know how well either sector performs this clinical work. The mantra is that we must deliver “integrated care” for optimal patient outcomes. Supporting this is the review by Smith and colleagues, which concludes that an approach that addresses psychiatric and substance use problems is likely to benefit outcomes in problem gamblers.4 Alcohol and nicotine are our most popular drugs and carry a corresponding burden of disease that dwarfs illicit substance use. Industries backing these drugs are powerful and tenacious, as seen by the response to recent moves to change tobacco packaging and introduce volumetric taxing of alcoholic beverages. Tobacco and cannabis use is associated with high levels of anxiety and depressive disorders, as evidenced in the 1997 and 2007 National Survey of Mental Health and Wellbeing.5 Nevertheless, in some inpatient psychiatric and alcohol and other drug treatment settings, smoking is not assertively addressed, sometimes based on the myth that cessation will exacerbate mental illness or interfere with recovery from other drug use. Such an idea is unsupported by the study of smokers by Segan and colleagues, which found that smoking cessation was not associated with an exacerbation of depression.6 Programs with enhanced approaches to co-occurring disorders often focus on screening and assessment mechanisms. Effective (and clinician-accepted) screening and assessment tools enable clinicians to identify comorbidity in patients and plan comprehensive management. Identification of comorbidities by both alcohol and other drug and mental health services is a good start, but does assume that integrated care is accessible. The availability of services, particularly those that are able to support mental health care in management of people with identified comorbid addictive disorders, remains a substantial challenge for Australia. Although medical care is yet be delivered by robots, technologies using online social networks, handheld devices, phone, text, internet and global positioning system functions, videoconferencing and software-assisted care have a huge scope in mitigating workforce issues. Computer-assisted treatments offer promise by addressing issues of access (given that care for comorbidity is often not reaching patients in need) and potentially ensuring structure and consistency in approach.7 Pleasingly, treatment approaches using new technologies are now seen as important enough to warrant Medicare telehealth items. Developing a workforce capable of providing good medical care of comorbid disorders requires a foundation of specialist support from psychiatry and addiction medicine. Given the burden of addictive diseases on the community, including those co-occurring with mental illness, the specialty of addiction medicine is embarrassingly poor in trainee and consultant positions, a balanced mixed public and private specialist sector, and a critical mass of clinical leadership. Over the past decade, Australia, like North America, has experienced increasing harm from prescription medication, with an exponential growth in numbers of patients with the trio of opioid addiction, mental illness and chronic pain (rendering the term “dual” diagnosis obsolete). Publicly funded health care, including mental health care, has always struggled to deliver services due to ever-tightening health budgets. If we want to grow the capacity of Australian health care to manage co-occurring disorders, we must recognise all the medical crafts that provide expertise and leadership in this area, and particularly in the field of addiction medicine.

Matthew Y Frei MB BS, FAChAM · David M Clarke MB BS, PhD, FRANZCP

Objectives: To report smokers’ evaluations and uptake of Quitline–doctor comanagement of smoking cessation and depression, a key component of the Victorian Quitline’s tailored call-back service for smokers with a history of depression and to explore its relationship to quitting success.Design, participants and setting: Prospective study followed Quitline clients disclosing doctor-diagnosed depression (n = 227). Measures were taken at baseline (following initial Quitline call), posttreatment (2 months) and 6 months from recruitment (77% and 70% response rates, respectively).Main outcome measures: Uptake of comanagement (initiated by fax-referral to Quitline), making a quit attempt (quit for 24 hours), sustained cessation (> 4 months at 6-month follow-up).Results: At 2-month follow-up, 83% thought it was a good idea to involve their doctor in their quit attempt, 74% had discussed quitting with their doctor, and 43% had received comanagement. In all, 72% made a quit attempt, 37% and 33% were abstinent posttreatment and at 6 months, respectively, and 20% achieved sustained cessation. Among participants who discussed quitting with their doctor, those receiving comanagement were more likely to make a quit attempt than those who did not receive comanagement (78% v 63%). Participants with comanagement also received more Quitline calls (mean 4.6 v 3.1) — a predictor of sustained cessation. Exacerbation of depression between baseline and 6 months was reported by 18% of participants but was not related to cessation outcome.Conclusion: Quitline–doctor comanagement of smoking cessation and depression is workable, is valued by smokers, and increases the probability of quit attempts. Smoking cessation did not increase the risk of exacerbation of depression.

Catherine J Segan PhD · Ron Borland PhD, MSc · Kay A Wilhelm MD, MB BS, FRANZCP · Sunil S Bhar PhD · Ainslie T Hannan BAGD, BSW, BA(Hons) · David R Dunt PhD, MB BS · Ian T Ferretter HDTA

Objective: To examine changes in the prevalence of affective disorders and psychological distress among smokers and people with cannabis dependence between 1997 and 2007.Design, participants and setting: Cross-sectional analysis of the 1997 and 2007 National Survey of Mental Health and Wellbeing.Main outcome measures: The Composite International Diagnostic Interview generated diagnoses of cannabis dependence and affective disorders based on criteria of the Diagnostic and statistical manual of mental disorders, fourth edition. Psychological distress was measured using the Kessler Psychological Distress Scale. Logistic regressions examined the relationship between affective disorders, psychological distress and (i) smoking status (current, former and never-smoker) and (ii) cannabis dependence.Results: Affective disorders and psychological distress were more common among smokers than non-smokers and among cannabis-dependent participants in both years. The prevalence of affective disorders and psychological distress among smokers, ex-smokers and non-smokers did not change between 1997 and 2007. Psychological distress and affective disorders were more common in cannabis-dependent participants in 2007 than in 1997.Conclusion: Affective disorders were more common in current than never-smokers and in people with cannabis dependence than without. We did not find strong evidence that the prevalence of these disorders changed in smokers between 1997 and 2007, but we did find such evidence in cannabis-dependent people.

Rebecca R S Mathews MPH · Wayne D Hall PhD · Coral E Gartner PhD

Objective: To determine the relationship between personality disorders (PDs) and substance use severity, mental health symptoms and disorders and quality of life (QoL) among injecting drug users (IDUs).Design, setting and participants: A cross-sectional study of 103 IDUs accessing a needle and syringe program and a primary health centre in Melbourne, Australia.Main outcome measures: Presence of PDs was assessed using the International Personality Disorder Examination ICD-10 Screener. Axis I mental health disorders, psychological distress and QoL were also assessed.Results: Ninety per cent of participants scored positive for one or more PD. Having a Cluster A or Cluster B PD was associated with greater severity of substance use. The presence of a current mental health disorder was associated with all types of PD except dissocial PD. Only Cluster C PDs were associated with self-reported levels of psychological distress. Cluster C PDs were more strongly associated with substance use, mental health and QoL variables than Cluster A or B, although the number of PDs present had the strongest associations with these variables.Conclusions: IDUs had high rates of PD symptoms, which were associated with the presence of concurrent mental health disorders, more severe levels of psychological distress and substance use and low perceived QoL. IDUs require comprehensive models of care, including access to mental health practitioners with expertise in co-occurring disorders.

Tania M Gibbie BBSc(Hons), MPsych(Health) · Leanne Hides BBehSc(Hons), PhD(Clin) · Sue M Cotton BBSc(Hons), MAppSc(Statistics), PhD · Dan I Lubman PhD, FRANZCP, FAChAM · Campbell Aitken BSc(Hons), PhD · Margaret Hellard PhD, FRACP, FAFPHM

Objective: To analyse the links between other people’s drinking and mental health and to explore the effects on mental health of heavy and problematic drinkers both within and outside spousal relationships.Design, setting and participants: A secondary analysis of data obtained as part of the Alcohol’s Harm to Others survey from 2622 randomly sampled Australian adults interviewed by telephone between October and December 2008.Main outcome measures: Self-reported anxiety or depression and satisfaction with mental wellbeing; the presence of heavy and problematic drinkers in respondents’ lives.Results: Identification of at least one heavy drinker in the respondents’ social network of friends, family and co-workers was significantly negatively associated with self-reported mental wellbeing and anxiety or depression. If the heavy drinker was identified by the respondent as someone whose drinking had had a negative impact on their life in the past year, the adverse effect on mental wellbeing and anxiety was much greater.Conclusions: Our findings support a causal pathway between alcohol use and mental health problems by way of someone else’s drinking. The association with adverse mental health is substantial regardless of the type of relationship an individual has with the heavy drinker whose drinking has had an adverse effect on them.

Jason A Ferris BPsych(Hons), MBioStats · Anne-Marie Laslett BDSc, MDSc, MPH · Michael Livingston BAppSc(Maths), BInfTech, BA(Hons) · Robin Room MA, MSoc, PhD(Soc) · Claire Wilkinson BASc, DipModLang(Japanese)

Objective: To examine the association of adolescent depression and anxiety symptoms with alcohol abuse or dependence in young adulthood.Design, setting and participants: Cohort study of the health and wellbeing of adolescents and young adults in Victoria, assessed at 8 waves (periods) of data collection, from age 14 to 24 years, between 1992 and 2003. Young people who participated in the cohort study at least once during the six adolescent assessment points (conducted 6 months apart, from age 14 to 17 years), at least once during young adulthood and who were alive at Wave 8 (n = 1758).Main outcome measure: Alcohol abuse or dependence assessed using the alcohol and substance abuse modules of the Composite International Diagnostic Interview at age 24 years.Results: Adolescents with moderate to high levels of depression and anxiety symptoms (measured by the revised Clinical Interview Schedule) had an increased risk of alcohol abuse or dependence in young adulthood, compared with young adults with low levels of adolescent depression and anxiety symptoms, after adjusting for potential confounding factors. Risk was higher for those with symptoms at more than two adolescent assessment points (odds ratio [OR] 1.9; 95% CI, 1.7–2.0) and for those with symptoms at one or two assessment points (OR 1.3; 95% CI, 1.2–1.4), compared with those with no above-threshold symptoms in adolescence.Conclusions: Adolescents with depression and anxiety symptoms are at increased risk for alcohol use disorders into young adulthood. They warrant vigilance from primary care providers in relation to alcohol use well into adulthood.

Maria McKenzie BBSc(Hons) · Anthony F Jorm PhD, DSc · Helena Romaniuk BSc, MSc, PhD · Craig A Olsson PhD · George C Patton MB BS, MD

Objective: To determine whether the addition of cognitive behaviour therapy and motivational interviewing (CBT/MI) to standard alcohol and other drug (AOD) care improves outcomes for young people with comorbid depression and substance misuse.Participants and setting: Participants were young people with comorbid depression (Kessler Psychological Distress Scale score ≥ 17) and substance misuse (mainly alcohol and/or cannabis) seeking treatment at two youth AOD services in Melbourne, Australia. The study was conducted between September 2006 and September 2008. Sixty young people received CBT/MI in addition to standard care (SC) (the SC+CBT/MI group) and 28 received SC only (the SC group).Main outcome measures: Depressive symptoms and AOD use in the previous 30 days, measured at baseline and at 3-month and 6-month follow-up.Results: Compared with participants in the SC group, those in the SC+CBT/MI group showed significant reductions in depression and cannabis use and increased social contact and motivation to change substance use at 3-month follow-up. However, at 6-month follow-up, the SC group had achieved similar improvements to the CBT/MI group on these variables. All young people achieved significant improvements in functioning and quality of life variables over time, regardless of treatment group. No changes in AOD use were found in either group at 6-month follow-up.Conclusion: The delivery of CBT/MI in addition to SC may achieve accelerated treatment gains in the short term.

Leanne M Hides BBehavSc(Hons), PhD(Clin) · Kathryn S Elkins BA(Hons) · Antonietta Scaffidi BSc(Hons), PGDipPsych · Sue M Cotton PhD · Steve Carroll DPsych · Daniel I Lubman MB ChB, FRANZCP, PhD

Objective: To determine whether the presence of comorbid depression influences response to psychological treatment for methamphetamine use.Design: Randomised controlled clinical trial.Setting and participants: Our study was conducted between 2001 and 2005 at two sites in Australia: the Hunter Region of New South Wales and the city of Brisbane, Queensland. The 214 participants, who were all using methamphetamine at least once a week in the month prior to the study, were self-referred or referred from health services or drug and alcohol clinical services. Participants were divided into two groups based on whether or not they had depressive symptoms at baseline.Interventions: The control group received only a self-help booklet; the two treatment groups received either two or four counselling sessions involving cognitive behaviour therapy and motivational interviewing techniques to manage methamphetamine use.Main outcome measures: Changes in methamphetamine use and depression at 5 weeks and 6 months after baseline.Results: Over 70% of participants met criteria for depression at baseline, and depression was associated with significantly greater severity of methamphetamine use and related issues. Benzodiazepine use was significantly higher among depressed than non-depressed participants. Reductions in methamphetamine use between baseline and 5 weeks were independently predicted by comorbid depression, in favour of increased change among those with baseline depression. Depressed participants who received three or four counselling sessions showed a significant reduction in depression at 5 weeks. However, reductions in methamphetamine use and depression compared with baseline were no longer evident at 6 months.Conclusions: Over the short term, comorbid depression did not negatively affect response to treatment, with some evidence of a dose–response treatment effect for reduction in depression. This was not maintained at 6 months, indicating that methamphetamine-focused treatment may not enable people with comorbid depression to make sustained improvement at the level of their counterparts without depression.Trial registration number: ACTRN12611000355976.

Frances J Kay-Lambkin BSc(Psych)(Hons), PhD · Amanda L Baker BA(Hons), MPsych, PhD · Nicole M Lee BSc(Hons), MAPS, PhD · Linda Jenner BHSc, MAppSc · Terry J Lewin BComm(Psych)(Hons)