Substance‐related disorders

The negative consequences of alcoholism are well established.1 Although there have been recent improvements in interventions, some of them acknowledging that abstinence may be rejected by problem drinkers,2 most treatments focus on readiness to change.3 This may be problematic for people with advanced dependence, as alcoholism is associated with: (a) psychological issues4 and memory loss,5 which may reduce motivation for treatment compliance; and (b) damage to the frontal lobes,6 which can reduce risk appreciation and forward planning. In other words, the disease itself serves to reduce readiness to change. This is further complicated for people with concomitant alcohol-related health problems such as hepatitis, cardiovascular illness, gastrointestinal disease, pancreatic cancer or stomach cancer, which typically require treatment with several, often carefully titrated, medications. Not only do these medications often interact with alcohol, but also managing them can be difficult for a person with chronic alcoholism. Support from family and friends can be critical. Unfortunately, these essential relationships are put under strain by the drinker’s behaviour.4 Moreover, doctors can have negative perceptions of dealing with people with alcohol-related issues.7 In other words, the disease itself serves to reduce support for change and treatment compliance. Recently, this became all too clear for me while caring for my father Mervyn. Despite my training in psychology, there were serious challenges in securing good quality care for him. I imagine it may be even more difficult for carers without any medical or psychological background. Case studyMervyn was a highly educated 58-year-old man who had retired from his profession to care for his wife. She had died of cancer 2 years before Mervyn first presented to hospital with alcohol-related symptoms. He had a history of smoking and alcohol use, drinking only at night for most of his adult life in a pattern consistent with heavy dependence, while maintaining a successful career. After the death of his wife, his drinking escalated, with binges lasting for weeks at a time. He became reclusive. He presented to hospital with confusion, disorientation, memory loss and hallucinations. He was unable to identify himself and began to have seizures and lose consciousness. He was clearly under the influence of alcohol, as confirmed by blood alcohol content analysis. Consistent with this, examination revealed dehydration, high fever, vitamin deficiency (particularly thiamine deficiency), and compromised liver function. Further tests revealed damage to the heart from septicaemia. After intravenous antibiotic treatment, detoxification and stabilisation, he underwent an aortic valve replacement. After the surgery, he was required to take warfarin daily and had weekly or fortnightly blood tests to check and adjust the dosage. He spent several months in hospital and then several weeks in a physical rehabilitation facility before returning home. Over the next 5 years, Mervyn returned to hospital every 1–4 months with alcohol-related illnesses that included recurring septicaemia, falls resulting in head injuries, hip injuries, burns, liver failure, kidney failure, heart attack, stroke, seizures, pancreatitis, gastric polyps, pancreatic cancer and stomach cancer. His hospital stays lasted between 2 weeks and several months at a time. Nearly all hospital visits were associated with correcting coagulation issues resulting from the interaction between warfarin and changes in alcohol intake, which frequently caused severe and protracted bruising and bleeding from the nose, ears and any areas of damaged skin (eg, head wounds from falls). Neuropsychological assessments, conducted twice during this period, revealed frontal lobe damage consistent with difficulty in risk evaluation and planning, and damage affecting language and balance. Together, this resulted in severely compromised social functioning, and activities that he could engage in for enjoyment were reduced. He became unable to live independently. Most of his time was spent in hospital or recuperating in physical rehabilitation or residential or community care. However, my family had extreme difficulty finding appropriate support for a severely physically and cognitively compromised person with chronic alcohol dependence. In particular, after an alcohol-related fall, he was “strongly encouraged” to leave one residential care home. It is important to acknowledge that this home was not necessarily the most appropriate place for him. Nonetheless, available alcohol rehabilitation programs and support groups required a certain level of self-awareness and a willingness to change that was arguably no longer possible for him. Treatment with naltrexone, which has demonstrated efficacy in reducing dependence,2 resulted in some transient positive change. After several years of decline in my father’s condition, my brother and I took on primary caregiver responsibilities, including medical and financial power of attorney. We sought new avenues of health care. With assistance, particularly from a thorough general practitioner and dedicated social workers, we managed to have Mervyn placed in community care accommodation with home nursing. Overall, he was able to access: increased family support; a non-judgemental and friendly living environment; and a multidisciplinary team, including his GP, nurses, social workers, physiotherapists, specialists and surgeons. This stabilised and minimised Mervyn’s drinking and improved his medication management. Unfortunately, by this time, he had developed fatal pancreatic cancer and died a short time later from a gastric obstruction. ReflectionA non-judgemental attitude is required.4 For many individuals, alcohol abuse can at least partially be explained by genetic factors;8 childhood exposure to alcohol and parental attitudes and drinking behaviours;9 and/or an unpleasant or traumatic triggering event.4 Certainly, it was clear that the loss of his wife triggered an extreme escalation in alcoholism for Mervyn. Moreover, once individuals begin down a path of alcohol abuse, the disease itself attacks cognition, motivation and support structures. Nevertheless, blame and negative judgement of individuals with alcohol problems persist. There is absolutely nothing to be gained by these attitudes, and everything to lose, for the patient and for their families. Outcomes are dependent on the person’s readiness to change.3,4 However, after a certain point, cognitive and social impairment makes this extremely difficult, if not impossible, for patients. What do we do then? Abstinence will not be the goal for everyone, and relapse is common.2,4 When managing treatment of concurrent, and often related, chronic illness, interactions between medications and alcohol as well as changes in alcohol intake must be considered, and we cannot assume abstinence. Lifestyle adjustments and psychosocial support are necessary.4 Indeed, when adequate psychosocial support was made available for Mervyn, the problems were stabilised, albeit at a significantly lower level of functioning and quality of life. The GP and social workers, in particular, played a critical role. This raises questions about why this type of support was not accessed earlier. Each time Mervyn was hospitalised, he was either intoxicated or experiencing withdrawal symptoms. Yet, especially early on, alcoholism was not addressed in his treatment plan. While medical staff were cognisant of his alcohol problem, we are uncertain whether he was assessed by a physician with specific expertise in diagnosing and managing alcoholism. Certainly, his acute physical problems were severe, and thus the attention of health care professionals was tunnelled toward immediate, life-threatening issues. Did the doctors’ focus on repairing physical damage result in a tendency to overlook the psychological component of the addiction? As all of the health problems stemmed from alcoholism, were they treating the symptoms rather than the disease? Further, was the alcoholism just another symptom of a more fundamental problem? The situation can be characterised by a hierarchical symptomatology model in which diseases, or disease clusters, represent symptoms of an underlying issue. Indeed, it could be argued that all of Mervyn’s health issues stemmed from deep grief over the loss of his wife. Thus, grief led to accelerated alcohol abuse, which in turn led to a spectrum of physical problems. If psychosocial support had been accessed earlier, would it have been possible to prevent or reduce the cognitive and psychological damage that led to the inability of the patient to engage and to be ready to change? This suggests that routine screening for problem alcohol use in middle-aged and older men, particularly following bereavement, would be beneficial. Certainly, patients displaying clear indications of a problem, as in this case, should be referred early to alcohol and drug services. It’s too late for Mervyn — but maybe in telling his story I can help save the life of another person.

Jillian Dorrian PhD(Psych)

Incorrect revenue amount: In “Cost-effectiveness of volumetric alcohol taxation in Australia” in the 19 April 2010 issue of the Journal (Med J Aust 2010; 192: 439-443), there was an error in the taxation revenue amount specified in the Abstract and Results section. In the Abstract (fourth sentence of Results paragraph), the wording should be “a tax on all alcohol at a spirits rate would reduce consumption by 23.85% and increase revenue by $3094 million”. In the text of the article (first paragraph of Results section), the wording should be “A volumetric tax set equal to the current spirits tax rate provided a substantially greater reduction (23.85%) in consumption of alcohol and an increase in taxation revenue of $3094 million”.

Joshua M Byrnes · Linda J Cobiac · Christopher M Doran · Theo Vos

To the Editor: Australian and international evidence clearly demonstrates that controlling availability is one of the most effective means of reducing alcohol-related harm.1 In recognition of this, additional restrictions on availability have been introduced as part of both the Australian government’s Northern Territory Emergency Response (NTER) and the NT government’s Alcohol Management Plans.2 However, it has been widely asserted in public debate — particularly by those opposed to them — that these restrictions have had the unintended consequence of diverting people in remote communities from alcohol to cannabis consumption and that, as a consequence, there is an epidemic of cannabis use in remote communities.3 Generally, the international evidence is limited but indicates that the substitution of one drug for another is variable and complex, and not a simple one-to-one phenomenon.4 More specifically, there is a paucity of empirical data which could directly verify the assertion that cannabis has been substituted for alcohol as a consequence of the additional alcohol restrictions in the NT. However, while there may well have been some substitution, the increase in cannabis consumption was occurring before the NTER and NT government restrictions. In 2004, Clough and colleagues reported an increase in cannabis use in Arnhem Land (NT).5 Furthermore, in 2006, Putt and Delahunty reported an increase in Queensland, Western Australia and South Australia — jurisdictions that were not later subject to the NT restrictions.6 Thus, while there may have been some substitution of cannabis for alcohol following introduction of the NTER restrictions and Alcohol Management Plans, it seems clear that the increase in use of cannabis cannot be attributed primarily to these interventions. The problem, regardless of the cause, needs to be addressed, but it will not be addressed simply by relaxing alcohol restrictions.

Dennis A Gray

To the Editor: Cardiovascular disease (CVD) and mental disorders are the top two contributors to the total burden of disease in Indigenous Australians and make a substantial contribution to the excess morbidity and mortality in this group.1 There is increasing evidence that mental disorders are risk factors for, or consequences of, CVD.2 Awareness and better understanding of the intertwined relationship between mental disorders and CVD in Indigenous populations can provide opportunities for coordinated and seamless management of these conditions in health care systems. We investigated the association between mental disorders due to substance use and CVD in a remote Indigenous community in the Northern Territory. A cohort of 897 Aboriginal adults aged 20–74 years (85% of the community’s total adult population) was established through a population-based renal disease screening program in the community between 1992 and 1995.3 We followed up 784 participants, who were free of CVD at baseline, to 31 May 2005, using hospital and death records. The study was approved by the Behavioural and Social Sciences Ethical Review Committee of the University of Queensland. Substance use-related mental disorders were determined from participants’ hospital records, using International Classification of Diseases, ninth revision (ICD-9) codes 192, 291 and 303–305; and 10th revision (ICD-10) codes F10–F19. Cases of CVD were identified by the first CVD event recorded in participants’ hospital and death records, using ICD-9 codes 390–459 and ICD-10 codes I00–I99. We used the Kaplan–Meier method to calculate cumulative CVD incidence rates for those with and without substance use-related mental disorders. CVD hazard ratios were estimated using Cox proportional hazards models. During a median follow-up period of 10 years, 177 of the 784 participants (23%) had clinically diagnosed mental disorders due to substance use (mainly alcohol: 140 participants), and 243 (31%) developed CVD. Incidence rates of CVD were 71 (95% CI, 58–87) and 27 (95% CI, 23–32) per 1000 person-years for those with and without substance use-related mental disorders, respectively (Box). Participants with substance use-related mental disorders were 2.6 (95% CI, 2.0–3.3) times more likely to develop CVD than those without. After adjusting for CVD risk factors measured at baseline (age, sex, body mass index, smoking status, alcohol use, blood pressure, serum cholesterol level, diabetes and albuminuria status), the association remained statistically significant, with an adjusted hazard ratio of 2.6 (95% CI, 1.9–3.5). Our findings confirm an association between substance use-related mental disorders and CVD in an Indigenous population, after adjusting for potential confounders. Traditional health care systems tend to separate services and treatment for mental disorders from those for physical health problems such as CVD.4 This separation is even more evident in remote Indigenous settings, where primary health care practitioners are already overwhelmed in providing general medical care to community members, with mental health services being delivered infrequently by visiting psychiatrists.5 The observed intertwined relationship between these two common conditions calls for integration of mental health services into routine primary health care, and enhanced collaboration between primary care practitioners, cardiologists and psychiatrists, in an effort to curb the huge burden imposed by these diseases. The emerging Aboriginal mental health worker program in the NT has the potential to be an effective service model to bridge the gap between mental health care and day-to-day primary health care.5 Dedicated financial resources and ongoing support for recruitment, training and retention of Aboriginal mental health workers will be required for sustained integration of mental health care with primary care in Indigenous communities. Kaplan–Meier estimates of cardiovascular disease (CVD) incidence among Aboriginal adults with and without substance use-related mental disorders

Zhiqiang Wang · Damin Si · Wendy E Hoy

Objective: To evaluate the assessment and treatment outcomes of a prison hepatitis service.Design and setting: A retrospective, observational cohort study of prison inmates who attended hepatitis clinics from 1996 to 2005 at correctional centres in New South Wales.Patients: Inmates who attended the clinics, including a nested case–control series of patients who received antiviral treatment and age- and sex-matched patients who did not receive treatment.Main outcome measures: Demographic and clinical characteristics of patients who attended the service; correlates of selection for antiviral treatment; and clinical and virological outcomes of treatment.Results: Of the 1043 inmates who attended the clinics, 851 were men (82%) and 994 (95%) were referred for HCV infection; the mean age for this group was 33 years (range, 18–74 years). In the case–control series (185 treated and 186 untreated patients), selection for treatment was not biased by culturally and linguistically diverse background, current methadone treatment or psychiatric status. In the treated group, 76 of 138 genotyped patients had a genotype that is predictive of favourable treatment response, and a small minority of those with available liver biopsy results had established cirrhosis (7/119 patients). Of treated patients for whom complete follow-up data were available, 55% achieved sustained virological response and 100% adhered to therapy. In addition, treatment episodes were not especially complicated.Conclusion: Although the prison population has high rates of injecting drug use and poor mental health, imprisonment offers an opportunity for assessment and treatment of chronic HCV infection.

Leng Boonwaat RN, MPH · Paul S Haber BSc, MD, FRACP · Michael H Levy MB BS, MPH, FAFPHM · Andrew R Lloyd MB BS, MD, FRACP

Objective: To estimate the potential health benefits and cost savings of an alcohol tax rate that applies equally to all alcoholic beverages based on their alcohol content (volumetric tax) and to compare the cost savings with the cost of implementation.Design and setting: Mathematical modelling of three scenarios of volumetric alcohol taxation for the population of Australia: (i) no change in deadweight loss, (ii) no change in tax revenue, and (iii) all alcoholic beverages taxed at the same rate as spirits.Main outcome measures: Estimated change in alcohol consumption, tax revenue and health benefit.Results: The estimated cost of changing to a volumetric tax rate is $18 million. A volumetric tax that is deadweight loss-neutral would increase the cost of beer and wine and reduce the cost of spirits, resulting in an estimated annual increase in taxation revenue of $492 million and a 2.77% reduction in annual consumption of pure alcohol. The estimated net health gain would be 21 000 disability-adjusted life-years (DALYs), with potential cost offsets of $110 million per annum. A tax revenue-neutral scenario would result in an 0.05% decrease in consumption, and a tax on all alcohol at a spirits rate would reduce consumption by 23.85% and increase revenue by $3094 million. All volumetric tax scenarios would provide greater health benefits and cost savings to the health sector than the existing taxation system, based on current understandings of alcohol-related health effects.Conclusions: An equalised volumetric tax that would reduce beer and wine consumption while increasing the consumption of spirits would need to be approached with caution. Further research is required to examine whether alcohol-related health effects vary by type of alcoholic beverage independent of the amount of alcohol consumed to provide a strong evidence platform for alcohol taxation policies.

Joshua M Byrnes BComm, MEconStud, MHealthEcon · Linda J Cobiac BEng(Hons), MEngSc, MPhil(Maths) · Christopher M Doran BEcon(Hons), PhD · Theo Vos MSc, PhD · Anthony P Shakeshaft MA(Psych), PhD

In the United States, policy experiments over a 20-year period have demonstrated that road crash deaths among young adults can be substantially reduced by raising the minimum legal drinking age to 21 years. A recent evaluation of the cost-effectiveness of policies for reducing alcohol-related harm in Australia found that, if the US experience were to be replicated in Australia, raising the minimum legal drinking age would be more cost-effective than random breath testing and drink-driving campaigns. Given the major political obstacles to increasing the minimum legal drinking age, we propose another policy that could achieve a similar reduction in road crash deaths — requiring licensed drivers to maintain a blood alcohol concentration (BAC) of zero until at least the age of 21 years (close to the current policy of zero BAC until age 22 years in Victoria), and preferably until 25 years. This would allow young Australians to drink or drive but not to combine these activities for at least the first several years of driving. If all Australian jurisdictions had adopted this policy in 2003, 17 deaths could have been be averted among young Australians as they aged from 18 to 21 years and many more serious injuries could have been prevented each year. If we had enforced a zero BAC until age 25, the number of deaths averted until age 25 years could have been as high as 50.

Wayne D Hall PhD · Angela L Wallace BSc, MPH · Linda J Cobiac BEng, MEngSc, MPhil · Christopher M Doran PhD · Theo Vos MSc, PhD

Alcohol consumption is a major risk factor contributing to the burden of disease in Australia. The National Preventative Health Taskforce recommends the long-term goal of reshaping Australia’s drinking culture to produce healthier and safer outcomes. A study of the cost-effectiveness of interventions to reduce alcohol-related harm in Australia suggests that policymakers could achieve over 10 times the health gain if they reallocated the current level of investment. The optimal package of interventions identified in the study comprises, in order of cost-effectiveness, volumetric taxation, advertising bans, an increase in the minimum legal drinking age to 21 years, brief intervention by primary care practitioners, licensing controls, a drink-driving mass media campaign, and random breath testing. Australia has a window of opportunity to significantly expand activities to reduce alcohol-related harm. It is important that federal and state governments take this opportunity to reform alcohol policy in Australia.

Christopher M Doran PhD · Wayne D Hall PhD · Anthony P Shakeshaft PhD · Theo Vos MSc, PhD · Linda J Cobiac BEng, MEngSc, MPhil

To the Editor: In April 2009, a registered nurse at the Sydney Medically Supervised Injecting Centre (MSIC) overheard two clients warning others about the effects of injecting from a particular glass vial, believing it had given them a “dirty shot” (bacterially contaminated injection). Seeing an unlabelled, discarded vial containing cloudy fluid, the nurse was concerned that it may have contained insulin, and assessed all four clients who reported injecting from similar vials. Three clients were sweaty, nauseated, and looked unwell, while only two (who had subsequently injected heroin) showed the pin-point pupils and hypoventilation typical of opioid use. Blood glucose levels confirmed likely insulin use, with the lowest reading being 1.5 mmol/L. MSIC staff made sweet drinks available, but one client became unconscious and required intramuscular glucagon and hospital admission. She was subsequently discharged without complications. Staff were concerned that insulin from an unknown source and of unknown concentraion was for sale in the local area, and immediately informed the local police and health and social welfare agencies. Thankfully, no further cases were noted, and no permanent harm resulted from this incident. The vial found at the injecting centre was later identified as Humulin 30/70 (Eli Lilly Australia, Sydney, NSW). Insulin-induced hypoglycaemia may result in brain damage and death.1 To our knowledge, this is the first case of inadvertent insulin injection in an injecting facility reported in the scientific literature. Given the unlikely nature of the substance, and that two clients showed physical signs consistent with opioid use because of subsequent heroin injection, their presentation in another setting could well have been confused with opioid overdose. We believe the MSIC was able to avert serious morbidity and possible death because of the presence of experienced staff able to provide immediate medical attention. The MSIC opened in 2001 in Kings Cross, Sydney, the first of its kind in the English-speaking world. The centre reduces morbidity and mortality from drug overdose, enhances access to health and social welfare services, reduces transmission of blood-borne viruses and reduces the incidence of drug injecting in public places.2 The main drugs injected at the MSIC include heroin, other opioids, cocaine and methamphetamines. There are now 70 such facilities around the world; these are legally sanctioned sites where people may inject previously obtained drugs under the supervision of qualified personnel. There is growing scientific evidence internationally to show that supervised injecting facilities reduce the harms associated with illicit drug injection.3-5 This case highlights their role in preventing harm associated with more unexpected drug injections.

Marianne E Jauncey · Anita P Trevan · Richard P Sulovsky

Objective: To determine the rate and risk of suicide and accidental fatal drug overdose (ie, overdose deemed not to have been suicide) in individuals who had been medically ascertained as having been sexually abused during childhood.Design: A historical cohort linkage study of suicide and accidental drug-induced death among victims of child sexual abuse (CSA).Setting and patients: Forensic medical records of 2759 victims of CSA who were assessed between 1964 and 1995 were obtained from the Victorian Institute of Forensic Medicine and linked with coronial data representing a follow-up period of up to 44 years.Main outcome measures: Rates of suicide and accidental fatal drug overdose recorded in coronial databases between 1991 and 2008, and rates of psychiatric disorders and substance use recorded in public mental health databases.Results: Twenty-one cases of fatal self-harm were recorded. Relative risks for suicide and accidental fatal overdose among CSA victims, compared with age-limited national data for the general population, were 18.09 (95% CI, 10.96–29.85; population-attributable risk, 0.37%), and 49.22 (95% CI, 36.11–67.09; population-attributable risk, 0.01%) respectively. Relative risks were higher for female victims. Similar to the general population, CSA victims who died as a result of self-harm were predominantly aged in their 30s at time of death. Most had contact with the public mental health system and half were recorded as being diagnosed with an anxiety disorder.Conclusion: Our data highlight that CSA victims are at increased risk of suicide and accidental fatal drug overdose. CSA is a risk factor that mediates suicide and fatal overdose.

Margaret C Cutajar BA(Hons), DPsych(Clin) · Paul E Mullen MB BS, DSc · James R P Ogloff MA(ClinPsych), JD, PhD · Stuart D Thomas LLM, MSc, PhD · David L Wells MB BS, MA, DMJ · Josie Spataro PhD

To the Editor: The recent rapid increase in popularity of low-carbohydrate (“low-carb”) beers in Australia, such as Foster’s Pure Blonde and Lion Nathan’s Hahn Super Dry, may represent an insidious health risk. The perception that low-carb beers represent a healthy alternative may result in some consumers: confusing low-carb beers with low-alcohol beers; believing that there will be a significant health benefit associated with consumption of low-carb beers (such as weight loss); drinking more beer in the belief that there are fewer health consequences associated with low-carb beers; or drinking low-carb beer in situations where the consumption of regular beer may be contraindicated because of health conditions such as diabetes or cardiac vulnerability. Particularly vulnerable risk groups include younger people and especially young women, who are often highly body image-conscious, as well as others with weight or health problems. Nutritional information for some of the major beers on the market in Australia is shown in the Box.1-3 The new generation of low-carb beers contain about 0.9 g of carbohydrate per 100 mL. However, there is little, if any, difference in either the amount of alcohol or the total energy content of traditional and low-carb beers, suggesting “low-carb” may not be a nutritionally significant improvement. Given that alcohol is a known cause of short- and long-term problems such as cancer, cirrhosis of the liver, strokes and violent behaviour, we contend that the alcohol content of beer is a far more important health issue than its energy content. Additionally, the alcohol content itself contributes directly to energy intake (1 g of alcohol contributes 29.8 kJ of energy, compared with sugar’s 15.4 kJ).4 Consuming alcohol may also indirectly lead to weight gain because of its association with unhealthy eating behaviour, such as increased snacking, junk food consumption and overeating.5 The Box clearly demonstrates that drinkers are better off consuming low-strength beers in terms of both alcohol content and energy intake. Recognising this fact, the European Parliament adopted the resolution that “Beverages containing more than 1.2% by volume of alcohol shall not bear health claims”.6 We believe that the Australian Government, particularly through its current Review of Food Labelling Law and Policy, should move quickly to enact similar legislation to protect the Australian public from the marketing claims of brewing companies. The message should be made explicit: low-carb beers are not a “healthy choice”. Nutritional information for major beers on the market in Australia1-3 Beer Alcohol by volume Carb (g/100 mL) Energy (kJ/100 mL) Full strength Redback 4.7% 3.6 172 Hahn Premium 5.0% 3.2 172 Cascade Pale Ale 5.0% 3.0 170 Crown Lager 4.9% 3.1 169 Cascade Premium Lager 5.0% 3.0 169 Foster’s Lager 4.9% 3.1 168 Victoria Bitter 4.6% 3.0 165 Carlton Black 4.4% 3.3 161 Tooheys New 4.6% 3.1 161 Tooheys Extra Dry 5.0% 2.5 161 Melbourne Bitter 4.6% 2.9 158 Tooheys Old 4.4% 3.0 156 Carlton Draught 4.6% 2.7 155 Swan Draught 4.5% 2.7 153 XXXX Draught 4.5% 2.1 147 Mid–low strength XXXX Gold 3.5% 1.9 121 Hahn Premium Light 2.6% 3.1 119 Carlton Sterling 2.5% 3.1 114 Cascade Light 2.6% 3.0 114 Hahn Super Dry 3.5 3.5% < 1.0 104 Low-carb Carlton Dry 4.5% 1.9 139 Bondi Blonde 4.5% < 2.0 130 Tooheys Maxim 4.6% 1.6 126 Hahn Super Dry 4.6% 0.9 126 Pure Blonde 4.6% 0.9 125 Carb = carbohydrate.

Peter G Miller · Stephen P McKenzie · Florentine P de Groot · Sondra L Davoren · Evie R Leslie

To the Editor: Hellard and Wang1 are correct in emphasising the importance of the general practitioner in the management of hepatitis C virus (HCV) infection. As the authors note, HCV infection is a considerable source of morbidity and mortality in the community, and the infection may cause a substantial burden of illness in the future if it is not appropriately managed. The GP plays a pivotal role in managing HCV infection, being the first and most likely point of contact for patients. However, Hellard and Wang fail to note that the GP’s most useful role is to inform patients that “alcohol abstinence is strongly recommended before and during antiviral therapy”.2 The well recognised role of alcohol in disease progression is emphasised in the position papers of both the American Gastroenterological Association and the United States National Institutes of Health.2,3 From a public health perspective, it is difficult to think of a more cost-effective approach to the management of such a public health issue.

Anne E Duggan · John M Duggan

In reply: Duggan and Duggan are correct to highlight the well recognised role of alcohol consumption in progression of hepatitis C virus (HCV) infection. Alcohol consumption has been found to increase viral load and accelerate hepatic fibrosis in HCV infection.1,2 While studies have reported that a history of alcohol consumption adversely affects treatment outcomes (with some reporting a dose–response relationship),3,4 treatment success has also been reported among patients who continue to consume moderate amounts of alcohol during treatment.5 Although there are biologically plausible mechanisms through which alcohol consumption might negatively affect treatment, low rates of treatment success among drinkers may also be related to lack of adherence to treatment regimen in this population.1 To date, no study has specifically measured the effect of alcohol consumption during treatment while adequately controlling for the effects of compliance, disease progression and baseline viral load. Until studies are undertaken that measure the direct effect of alcohol consumption on treatment success, while adjusting for compliance, it seems reasonable to advise patients to decrease their level of alcohol consumption before and during HCV treatment. However, given that some patients have successfully completed treatment without abstaining from alcohol consumption, this should not be an automatic exclusion criterion.

Margaret E Hellard · Yung-Hsuan J Wang · Rachel Sacks-Davis

Objective: The belief that the full moon and disturbed behaviour are closely linked is alive and well, despite studies to the contrary. We investigated the possibility that there is an association between only extreme behavioural disturbance and the full moon.Design, setting and participants: We undertook an observational study of patients with violent and acute behavioural disturbance who presented to the emergency department of Calvary Mater Newcastle and patients with less severe behaviour for whom hospital security calls were made.Main outcome measure: Proportion of patients for whom presentation or security call occurred in each lunar phase, modelled as a Poisson process.Results: Of 91 patients with violent and acute behavioural disturbance, 21 (23%) presented during the full moon — double the number for other lunar phases (P = 0.002). Sixty (66%) had either alcohol intoxication or psychostimulant toxicity, and five attacked staff (biting [2], spitting [1], kicking [1] and scratching [1]). In contrast, 512 hospital security calls for patients with less severe behaviour were evenly distributed throughout the lunar cycle.Conclusion: Violent and acute behavioural disturbance manifested more commonly during the full moon.

Leonie A Calver · Barrie J Stokes BSc, MSc · Geoffrey K Isbister BSc, FACEM, MD

Objective: To describe the patterns of screening for hepatitis C virus (HCV) infection in methadone-maintained pregnant women and their infants.Design, setting and patients: Retrospective review of medical records from one rural and two metropolitan hospitals in New South Wales for pregnant women on methadone maintenance treatment and infants born to these women between 1 January 2000 and 31 December 2006, as well as records for pregnant women who were not on methadone treatment.Main outcome measures: Rates of anti-HCV antibody and HCV RNA testing for pregnant women and their infants, and ages at which infants attended follow-up appointments.Results: Of 295 pregnant women on methadone maintenance treatment, 288 were tested for anti-HCV antibodies (98%), compared with 1995 of 9987 women who were not on methadone treatment (20%) (P < 0.001). Seropositive results were obtained for 243 women in the methadone group (84%) and 54 in the non-methadone group (3%) (P < 0.001), of whom 44 (18%) and 17 (31%), respectively, were subsequently tested for HCV RNA (P = 0.03). HCV RNA test results were positive for 31 (70%) and 10 (59%) seropositive women in the methadone and non-methadone groups, respectively (P = 0.39). Of infants of HCV-seropositive methadone-maintained mothers, 27% of those for whom we had follow-up attendance data received HCV screening, and one of these infants tested positive for anti-HCV antibodies and HCV RNA.Conclusions: Screening for HCV infection in the high-risk population of pregnant women on methadone maintenance treatment and their infants is inadequate. This could lead to significant underdetection of active HCV infection in this high-risk population, and their infants. Current screening guidelines may therefore need to be revised.

Anthony J W Liu,* MB BS, FRACP, MPH · Ethan I An,* BMedSc, MB BS(Hons) · Henry G Murray MB ChB, MRCOG, FRACOG · Emma Tetstall BSc(Hons), MB BS(Hons) · Marcel J Leroi FRACP, FRCPA, MMed(ClinEpi) · Ralph K H Nanan Dr med Habil (Germany), FRACP

To the Editor: We wish to call for the removal of scheduling and legislative barriers in Australia that prevent easy access to naloxone for administration by peers to people suffering from a heroin overdose. Use of illicit opioids, typically heroin, remains the major cause of illicit drug-related mortality in this country, with at least one accidental opioid overdose currently occurring each day.1 Although population levels have not reached those seen during the peak in the late 1990s, geographically localised and transient increases in overdoses are evident.2 Death from heroin overdose typically occurs some time after use. In many cases, other people are present, and there is considerable scope for intervention to prevent death.3 Yet, in more than 70% of cases of fatal overdose, there is no intervention, and, where action is taken, calling an ambulance is seldom the first strategy, resulting in even greater risk of death.3 Opioid substitution treatment (with methadone or buprenorphine) is the mainstay of overdose prevention in Australia. Other interventions implemented here include outreach services and education for injecting drug users about the risks of overdose and how to respond to it.3 In 2000, Lenton and Hargreaves summarised the evidence for distributing the opioid antagonist naloxone for administration by peers to prevent deaths from heroin overdose. They concluded that an Australian research trial was needed.4 However, in 2001, the Australian heroin market was disrupted, heroin use and overdoses declined, and the trial did not proceed. Since then, emerging international evidence has demonstrated that injecting drug-using peers, family members and outreach workers can successfully administer naloxone to reverse heroin overdose — with few, if any, adverse effects.5 By December 2008 in the United States, 52 programs distributing naloxone for administration by peers were operating in 17 states, with over 1000 documented overdose reversals resulting from these programs.5 Most concerns about the intervention — such as the possibility of unsafe naloxone administration, reintoxication or more risky drug use — appear to have been unfounded, and naloxone administration by trained peers has been shown to be a remarkably safe intervention.5 In our view, the international evidence clearly indicates that increased naloxone availability will prevent many cases of fatal overdose, that conducting a trial in Australia is now unnecessary, and that naloxone should be made available without delay to be administered by peers in cases of opioid overdose. Careful monitoring and evaluation should be a part of this process. We call on all Australian states and territories to immediately enact Good Samaritan legislation to legally protect laypeople using naloxone in emergency situations. Naloxone should be reclassified from a Schedule 4 (S4) drug (available only on prescription) to S3 or S2 to make it available over the counter. As naloxone is no longer under patent,5 there may be little financial incentive for a drug company to pursue rescheduling. However, it could be rescheduled in Australia under provisions that allow state health authorities, professional associations or the National Drugs and Poisons Schedule Committee to initiate the process. Heroin overdose deaths are preventable. We need to take action now to enable peer-led intervention to reduce this serious outcome.

Simon R Lenton · Paul M Dietze · Louisa Degenhardt · Shane Darke · Tony G Butler

To the Editor: Eslick and Eslick believe that the television program The Simpsons causes children to smoke.1 What they gloss over is that in this show, only “losers” smoke. The characters Patty and Selma are old, ugly, mean-tempered, sexually frustrated sisters working in deadening jobs at the motor vehicle licensing office. They don’t just smoke, they chain-smoke — a well established television trope for sleaze and disease — and then they cough, hack, and wheeze. Krusty the Clown, if the name doesn’t tell you already, is a beaten-up, ageing, balding guy. He’s nasty, neurotic, and estranged from his father for abandoning his orthodox Jewish roots for the sinful life of television. Mrs Krabappel, the schoolteacher, is old, divorced, ugly, hates her job, hates her life, and hates children. It may be that children watch The Simpsons. I don’t know, and Eslick and Eslick cite no data that show they do. The questions, though, are: Do children understand what a loser is? Do they emulate losers, or shun them? Eslick and Eslick cite studies showing that any portrayal of smoking causes children to smoke.1 If this is so, why bother to differentiate between “neutral”, “positive” and “negative” portrayals of smoking? And what, precisely, do these labels mean? If, as they say, the “most notable characters” who smoke are these four loser characters, it is strange that they have coded most smoking instances as neutral rather than negative. Even if the authors have a valid labelling system, and even if neutral portrayals cause children to smoke, the question then becomes: is this effect greater than any countervailing effects, such as, perhaps, that of discouraging adults (and adults who are parents) from smoking, or that of creating a broad cultural association between smoking, social failure, and sickness? The logic of the argument put by Eslick and Eslick is that smoking should not be depicted at all in television programs that children watch. Given that children see people smoking in real life, and presumably look around them for some guidance as to whether they should do it too, it seems to me that it is actually commendable to tell them that only losers smoke. Strong evidence and argument that this approach does more harm than good would be very valuable.

Nicholas Jefferson-Lenskyj

To the Editor: The article by Eslick and Eslick1 caught my attention, as the sophisticated parodying of the tobacco industry on The Simpsons has been a much discussed topic among my tobacco-control colleagues. In the introduction to the article, the authors ask if the smoking and tobacco industry portrayals in this program are “just satire, or does the repetitive nature of characters smoking on The Simpsons have an influence on young children watching?” The study design employed cannot answer this question. I was surprised then that the authors concluded that the portrayals of smoking on The Simpsons negatively influence young children. The study results indicate that positive portrayals of smoking on the show are, in fact, extremely rare. It could equally be the case that the more numerous negative portrayals of smoking on this popular and subversive comedy reach young viewers in a way no government-sanctioned health promotion campaign can. Health education messages presented through social satire may not be politically correct, but this does not mean they are ineffective in communicating antismoking sentiments.2 The two most prominent smokers in The Simpsons, Patty and Selma Bouvier, are not characters that any teenager would aspire to be like — disgruntled, middle-aged sisters who live together, work in depressing jobs at the local Department of Motor Vehicles, Selma constantly bemoaning her lack of a husband and fantasising about 1980s heart-throb MacGyver, and Patty best known for her utter joylessness and cynicism. Surely these grim stereotypes would cause most young people to turn away from smoking, and not towards it? Tobacco-control policies themselves were recently lampooned in The Simpsons, with the Simpson family opening a pub in Ireland that illegally allowed patrons to smoke. Much mayhem ensues, and the Simpsons are eventually deported back to the United States for breaking the Irish antismoking laws.3 I am delighted that tobacco control has such universal momentum that it can be parodied on a pop-culture phenomenon like The Simpsons.

Becky Freeman

New guidelines and a multidisciplinary approach have the potential to help patients in need while minimising inappropriate use of opioids With an estimated community prevalence of about 20%, chronic non-malignant pain represents a significant but neglected and often poorly managed problem in Australia. In 2007, the cost of chronic pain to the community was estimated at $34 billion, which included burden of disease and productivity costs, each accounting for one-third of the total, and one-fifth ($7 billion) attributed to health system costs.1 Its prevalence and associated costs will rise as the population ages. The causes of chronic non-malignant pain are many, including rheumatic disorders, injuries and musculoskeletal degenerative disorders, and vary greatly with age, sex and other demographic characteristics. Many doctors currently approach such pain from a narrow biomedical perspective. This too often defaults to the use of opioids under pressures including time constraints, patient demands, and limited access to supports such as pain clinics and physical therapies. The introduction of sustained-release prescription opioids in Australia two decades ago promised a new era in chronic pain management. These agents were preferred because they offered prolonged analgesia with a potentially lower risk of dependence and drug-seeking behaviour. Previously, short-acting opioids had often been prescribed, causing problems when peak effects of analgesia and euphoria alternated frequently with troughs marked by pain and opioid withdrawal. This created conditions conducive to dose escalation and the eventual development of dependence. The shining promise of the sustained-release prescription opioids has been dulled by two main problems. First, the long-term effectiveness and net benefit of opioids in the management of patients with chronic non-malignant pain remain uncertain, reflecting the biopsychosocial complexity of the underlying conditions and the difficulties of performing clinical trials in such heterogeneous populations.2 Second, increasing consumption of sustained-release prescription opioids has been accompanied by some disturbing developments, first reported from the United States. In 2000, drug overdose deaths from prescription opioids, especially from unsanctioned use, began to outnumber deaths from heroin and cocaine.3 Between 1997 and 2007, admissions for treatment of “abuse” rose by 456% for opioid analgesics and 5% for heroin.4 Australia may be starting to follow these US trends, with substantial increases in consumption of oral prescription opioids since 1990,5 and reports of diversion, injection and related harms.6 However, the extent of inappropriate opioid prescribing and of unsanctioned opioid use in Australia cannot currently be determined. Our information systems are not standardised across jurisdictions, are unable to capture all prescriptions (both private and funded by the Pharmaceutical Benefits Scheme), and are not available to intending prescribers and pharmacists. Three overlapping groups — patients with chronic non-malignant pain, patients with malignant pain, and illicit users (of heroin or prescription opioids) — form a potential common market for opioids, with flow-on effects if any group is inadequately managed. The idea of a continuum between opioid use for pain management and addiction underpins the idea of “universal precautions in pain medicine”.7 Inappropriate prescription can lead to problematic use and opioid dependence. The heroin shortage that started in 2000 in Australia was followed by increasing injection of prescription opioids, especially in rural areas and jurisdictions where heroin was scarcest.8 Increasing demand for prescription opioids may arise where there is unmet demand for opioid substitution treatment with methadone or buprenorphine. People on low incomes may be tempted to request and on-sell prescription drugs to the black market as demand and prices increase. These considerations underpin the desirability of a broader biopsychosocial framework for the assessment of patients with chronic non-malignant pain, and a greater role for non-pharmacological interventions. Such interventions are scarce and underfunded in primary care. Australia has the most developed training program for pain medicine worldwide, but there are too few specialists and there is great demand for pain clinics. In an effort to bring these complex issues to the fore, the Royal Australasian College of Physicians (RACP) has released a prescription opioid policy;9 the Box contains a summary of its recommendations. Reflecting the complex nature of the subject, the report was prepared by an interdisciplinary group, including representatives from the RACP, the Royal Australian College of General Practitioners, the Royal Australian and New Zealand College of Psychiatrists and the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists. The challenge is to provide a better balance between two, sometimes competing, objectives — encouraging more appropriate opioid prescription for patients with chronic non-malignant pain while reducing unsanctioned use of opioids, whether by patients or illicit users. No single health discipline can overcome these complex problems, but a truly multidisciplinary approach has the potential to achieve great advances. The current situation not only results in frustration for patients and families, but also undermines the good standing of the medical profession. The present unhappy cocktail includes patients with chronic, complex painful conditions; doctors who lack succinct uniform guidelines, real-time prescription monitoring information and ready access to relevant specialist advice; and a setting where authorities must minimise diversion of prescription opioids. In 2008, unmet demand for opioid substitution treatment was estimated to exceed the 39 000 patients then in such programs.10 Better tailoring of such treatment to also meet the needs of people dependent on pharmaceutical opioids, many of whom have never previously sought help, may attract and retain more patients in effective treatment. This would most likely decrease the demand for black-market prescription opioids. Australia has a unique opportunity to improve management of patients with chronic non-malignant pain and people who become dependent on opioids; to reduce inappropriate prescribing of opioids; and to avoid the problems that have bedevilled the US. The most important step required is establishing a group with sufficient authority to achieve wide consensus on an action plan and then implement and coordinate national change across jurisdictions, professions and disciplines (especially general practitioners and pharmacists). As most management of chronic non-malignant pain occurs in general practice, little will be achieved unless and until GPs are provided with more support and better linkages to critical specialties. Summary of recommendations of the Royal Australasian College of Physicians report9 1. Establish a national expert advisory group to develop a coordinated approach to implementing the recommendations below, to improve management of chronic non-malignant pain and reduce problematic use of pharmaceutical opioids. 2. Develop guidelines for management of chronic non-malignant pain appropriate for and accepted by general practitioners, integrating non-pharmacological elements of treatment with pharmacological approaches within a biopsychosocial framework, and providing widely accepted standards for audit and feedback. 3. Enhance clinical practice, with improved support for GPs and better linkages to relevant specialties, especially pain medicine and addiction medicine. 4. Improve information systems, with one national, web-based system that includes private and Pharmaceutical Benefits Scheme prescriptions and provides information for prescribers and pharmacists in real time. 5. Standardise regulation and control across jurisdictions. 6. Minimise unmet demand for opioid substitution therapy, and revise it for people dependent on pharmaceutical opioids to decrease the demand for black-market prescription opioids. 7. Improve integration of College training programs in the fields of pain medicine, addiction medicine, psychiatry and general practice. 8. Increase applied research to reduce gaps in knowledge and improve health service delivery.

Alex D Wodak FRACP, FAChAM, FAFPHM · Milton L Cohen MD, FRACP, FFPMANZCA · Malcolm D H Dobbin PhD, FAFPHM, MPH · Richard A Hallinan BMed, FAChAM · Mary Osborn MPubHlth

We believe that a lack of adequate alcohol measures research is partly responsible for the failure of the Australian Government to pass legislation to equalise the excise applied to straight spirits and premixed spirits (“alcopops”). Current measures only assess total alcohol consumption rather than patterns of consumption, and do not adequately identify alcohol-related harm at a population level. Possible solutions include making further efforts to develop applied community-level measures and responding to the repeated calls for national collection and analysis of alcohol sales data. With the Australian Government able to retain the alcopops excise raised to date, there is a unique opportunity for greater collaboration between researchers and government to ensure high-quality and publicly relevant research is funded and conducted to address the current lack of adequate measures research. Measures research is a priority, as this is the basis for increasing the accuracy of data with which more cost-effective public policy and initiatives can be formulated and evaluated. The challenge is for researchers and the Australian Government to align their expertise to ensure revenue from public taxes engenders measurable public health benefit.

Anthony Shakeshaft PhD · Christopher M Doran PhD · Joshua Byrnes BEcon

To the Editor: Since colonial times, alcohol has been central to Australia’s political, cultural and social fabric.1 In the past year, concern about alcohol misuse has re-emerged as a dominant feature in the political landscape. We analysed the New South Wales emergency department (ED) data collection, on the NSW Department of Health’s HOIST (Health Outcomes and Information Statistical Toolkit) database, to describe the epidemiology of ED attendances due to acute alcohol problems. Data from 43 hospitals that contributed reasonably complete diagnosis information since 2000 were used. Attendances were selected using codes for alcohol intoxication, alcohol dependence/withdrawal, or drug or alcohol blood test from the ninth and 10th revisions of the International classification of diseases (ICD-9 and ICD-10) or from the Systematized Nomenclature of Medicine — Clinical Terms (SNOMED-CT). Population rates by age, sex and year were calculated. To assess the association between alcohol-related ED presentations and large public social events, time series of 24-hour counts ending at midday were used (because most presentations for acute alcohol problems occur at night).2 Between 2005 and 2008, the rate of ED presentations for acute alcohol problems rose sharply from around 110 to almost 150 per 100 000 population (Box 1). Between 2000 and 2008, the highest rates of ED attendance involved 18–24-year-olds of both sexes, and 25–64-year-old men. The largest increase was among 18–24-year-olds. Notably, in that age group, the rate in women converged with that of men at 228 per 100 000 in 2004 and was then higher until it re-converged in 2008 at around 390 per 100 000. In all years, the rate of presentation in 10–17-year-olds was slightly higher for females than for males (Box 2). Among children aged less than 10 years, the rate was under four per 100 000 in all years. Many peaks in ED attendance coincided with large public gatherings, including New Year’s Eve celebrations and the closing of the 2000 Sydney Olympic Games. In 2007 and 2008 especially, the Sydney Gay and Lesbian Mardi Gras was associated with marked increases (Box 3), which may reflect underlying increases in alcohol use in the younger age groups that might be attracted to this now mainstream event. Because the coverage of the ED data collection was limited, these figures underestimate the true incidence. Nevertheless, most urban and larger rural hospitals were included. We were unable to include the far greater number of ED presentations in which alcohol use was a factor, but not the primary reason for presentation.3 The trends and rates we observed were similar to those found in a recent Victorian study of young people.4 The small decline in overall rate from 2000 to 2002 (Box 1) is consistent with declining per-capita consumption of beer and spirits, while the subsequent increase in young people, which flattened out in 2008, is similar to the trend in consumption of ready-to-drink alcoholic beverages over the same period.5 Studies of the types of beverages used before ED presentation are urgently required to assess whether this is a causal association. Analysis of routine ED databases can provide a timely insight into the social and epidemiological context of high-risk drinking. The rise in alcohol-related presentation among teenagers and young adults bodes poorly for subsequent long-term alcohol use disorders and other risk behaviours and their consequences.6 The correlation between peaks in ED presentations and large-scale social events suggests that the development of cultural norms may have a strong influence on individuals’ behavioural choices. 1 Number and rate of presentations to 43 emergency departments for acute alcohol problems, New South Wales, 2000–2008 Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 Number 6400 6215 6203 6762 6826 7652 9112 10119 10382 Rate per 100 000 population* 98.7 94.5 93.6 101.3 101.7 113.2 133.7 147.1 149.4 * Rates are an underestimate because not all NSW emergency departments are included. 2 Population rate of presentations to 43 emergency departments for acute alcohol problems,* by year, sex and age,† New South Wales, 2000–2008 * Rates are an underestimate because not all NSW emergency departments are included. † Values not shown for people aged < 10 years because all values were below 4/100 000 population. 3 Daily counts* of presentations to 43 emergency departments for acute alcohol problems, New South Wales, 2000–2008 * Counts are aggregated over 24-hour periods, ending at midday.

David J Muscatello · Sarah V Thackway · Daniel A Belshaw · David McGrath

Reintroducing the alcopops tax is important, but more comprehensive reform of alcohol taxation and other broader measures are needed To those Australians who believe that alcohol consumption in this country is causing too much damage, and that a public health-focused, evidence-based alcohol policy can make a difference, the defeat of the “alcopops” legislation in the Senate in March this year was a disappointment. However, this is no reason to stop national action to reduce damage from alcohol. The thousands of Australians whose lives are damaged by alcohol, and the hundreds each year whose deaths could be prevented, are too important.1 Concerned organisations need to collaborate and advocate for a comprehensive, evidence-based approach to reducing the alcohol toll. Their ultimate goal should be to move to a more moderate and responsible drinking culture in Australia. The first question is what to do with the more than $400 million raised from the alcopops tax. Our elected representatives are to be congratulated on voting in May to retain it, rather than handing it back to the alcohol industry. Judging by past performance, had it gone to DrinkWise, it would have been spent on soft-sell advertising, which the great body of evidence suggests has no impact on alcohol consumption or consequent harms.2,3 The alcopops revenue should be directed to independent public health agencies to develop evidence-informed interventions that aim to reduce consumption and consequent harms. The Alcohol Education and Rehabilitation Foundation is one such entity, established using tax revenues generated in similar circumstances from beer sales. The national Preventative Health Taskforce has already developed a framework to prevent alcohol-related harms,4 and will soon deliver a final report and recommendations for action, including an overarching National Prevention Agency, which will need funds. With additional funding, the National Health and Medical Research Council (NHMRC) could give special priority to alcohol-related research. Funding of agencies such as VicHealth and Healthway in Western Australia, which were originally supported by tobacco revenues, could also be considered. The Royal Australasian College of Physicians welcomes the federal government’s initiative to reintroduce the alcopops tax legislation in the current sitting of Parliament, but encourages the government to go further. Although there was evidence the alcopops tax was followed by reduced overall alcohol consumption,5 if the government wishes to address the full range of alcohol-related harms — which include much more than binge drinking in young people — it should comprehensively reform alcohol taxation. Controlling price is by far the most effective, and cost-effective, single intervention available to control consumption and consequent harms.2,3,6 A comprehensive reform of alcohol tax is needed, with public health as a principal objective. Specific elements could include: taxing beverages on the basis of their alcohol content — a volumetric system; a minimum price per standard drink; and additional taxation based on evidence of harm associated with particular beverage types. A proportion of alcohol-related tax revenues should be directed towards prevention and treatment of alcohol-related problems. The Australian public will probably support such taxes.7 Taxation policy is crucial but must be part of a broader approach. There is good evidence for the effectiveness of controlling the availability of alcohol by regulating the number, nature and opening hours of alcohol venues.2,3,8 The forthcoming review of the Northern Territory’s Liquor Act provides an opportunity to encourage alcohol legislation to genuinely focus on preventing alcohol-related harms, and not just on regulating the sale of alcohol. The role and practice of alcohol promotion should also be closely examined. Loosening the link between alcohol advertising, sponsorship and sporting organisations may be an important way to encourage Australian drinking culture to evolve in a healthier direction. Some alcohol tax revenues could be directed towards replacing alcohol-industry sponsorship, as was done for tobacco in several states, or buying back alcohol advertising during sports programs, as suggested by the Australian Medical Association.9 Although prevention is essential, many people and their families are already suffering from the effects of alcohol. More treatment programs are urgently needed, particularly in rural and remote areas, where alcohol problems are even more common than in the cities, and for groups with particular needs, such as Aboriginal people, who need tailored programs. Finally, a strong vision and framework would bind all these strategies together. The National Alcohol Strategy10 expires this year, and another is needed: one that more closely follows the evidence of what really works in reducing harm. Much good work to reduce the harms from alcohol has been done in Australia by individuals and organisations such as the Public Health Association of Australia and the Australian Drug Foundation. However, much more is needed, as the level of harm is still unacceptable, especially among young people. We in the health profession need to play a greater advocacy role, in partnership with others within and beyond the health sector, such as the Cancer Councils, and social welfare and community organisations. The Royal Australasian College of Surgeons Trauma Committee, with its experience in road trauma and interpersonal violence, has indicated a strong interest in being involved. We need to be part of, and to help build, active coalitions. We should heed the lessons learned from the fight against tobacco. Although there are important differences between alcohol and tobacco, much is similar in the need to change the culture surrounding their use, and in the large and powerful industries that profit from their sale. Overcoming these obstacles will require an alliance of organisations, with a common understanding of the key issues, goals and ways to achieve them, and persistence in their pursuit. With thousands of lives lost or damaged, and billions of dollars wasted every year,1 this is our challenge and our responsibility.

on behalf of the Royal Australasian College of Physicians Alcohol Advisory Group.*

To the Editor: The federal government is to be applauded for its decision to re-introduce the “alcopops” tax Bill to Parliament and to try to retain the $300 million raised so far for expenditure on services, programs and research to reduce alcohol-related harm in Australia. The alcopops tax was paid by consumers in the form of higher retail prices, which will fall dramatically if the government again fails to pass legislation to retain the tax. If it transpires that the government cannot retain the revenue already raised, it should be given to an independent public health body (such as the National Health and Medical Research Council [NHMRC]) and not to DrinkWise via distillers and distributors, as has been suggested.1 DrinkWise is a “putatively independent body that was originally funded by the alcohol industry”;2 six of the 11 current members of its board are senior alcohol industry figures. The alcohol industry profits from drinking that contributes significant harm to individuals and communities,2 and it can be relied upon to oppose policies that are known to reduce alcohol consumption across the population.3,4 DrinkWise and similar industry-backed organisations around the world promote industry-friendly programs that do not have an evidence base or are ineffective (such as education campaigns or tepid television advertising),5 while lobbying against the adoption of effective evidence-based interventions, such as higher taxes on alcohol, as these would affect profits.2-4 The Chief Executive of DrinkWise, Chris Watters, recently revealed the organisation’s position on the alcopops tax, reportedly asserting that it did not recommend “fiddling with alcohol tax” because it was “old thinking” and that “the facts just don’t stand up”, and noting that DrinkWise funds many educational programs across the country.6 There is a clear consensus among public health experts worldwide that increasing the price of alcoholic beverages is one of the most powerful and cost-effective strategies that governments have at their disposal to reduce unhealthy alcohol use.7-10 Other effective strategies include drink-driving legislation, random breath testing, increasing the minimum legal age for drinking or purchasing alcohol, restrictions on trading hours and numbers of licensed premises, and better enforcement of existing liquor laws. In contrast, comprehensive reviews of the evidence show that, by themselves, alcohol education programs are ineffective.11,12 Alcohol industry-sponsored agencies have adopted similar public relations strategies to those used by the tobacco industry.3 These strategies distract attention from their concurrent lobbying against the adoption of policies that would actually make a difference. The laudable policy action taken thus far by the government in its attempt to implement the alcopops tax would be enhanced by supporting an independent body, such as the NHMRC, that has transparent funding strategies and criteria, based on an independent peer-review system, to distribute funding for alcohol-related research. We, along with the more than 50 other scientists and health experts listed at <http://www.webcitation.org/5gbwQWf9J> who endorse and are signatories to this letter,13 will not seek or accept funding from DrinkWise. We call on other researchers and community agencies to consider their positions.

Peter G Miller · Kypros Kypri · Tanya N Chikritzhs · Steven J Skov · George Rubin

In reply: I write in response to the letter from Miller and colleagues, recently published online.1 Their letter is an attempt to influence non-government senators as the Australian Government reintroduces the Bill to increase the tax on some alcoholic beverages. There must have been a better way to do this than by besmirching the good work of DrinkWise and its directors. DrinkWise Australia is not an industry-dominated body. It has a balanced board of six members from the alcohol industry and six distinguished community members. Miller and colleagues should know that, in criticising DrinkWise, they also attack the reputations of board members Professor Ross Kalucy, Chair of Psychiatry at Flinders University; Noel Turnbull, Adjunct Professor in Communications at the Royal Melbourne Institute of Technology; Neil Comrie, former Chief Commissioner of Victoria Police; and Terry Slater, who led the Australian Government’s public health programs before heading up the National Food Authority and the Therapeutic Goods Administration. The sixth community representative position on the board is currently vacant and has been offered to the federal health department. DrinkWise does not advocate for or lobby government in respect of alcohol taxation policy for a very sensible reason — alcohol industry leaders advocating for or agreeing on matters affecting price could constitute a breach of the Trade Practices Act 1974 (Cwlth). DrinkWise programs are strictly evidence-based, drawing on specifically funded high-level independent research executed by leading academics at universities including Griffith, Macquarie, Monash, Deakin, Flinders, and the Hunter New England Institute. Moreover, the DrinkWise “Kids Absorb Your Drinking” advertising campaign was developed through qualitative, quantitative and ethnographic research, as well as the findings of an extensive literature review by child heath experts and academics.2-9 Campaign tracking results show that 28% of adults surveyed in March 2009 reported having reduced the amount of alcohol they drink in front of their children in the previous 12 months. When parents who had seen the DrinkWise advertising were asked about its impact on their drinking behaviour, 39% said they were more self-conscious of how they drink in front of their children, 18% had changed their drinking patterns, and 14% had actually cut down how much alcohol they consume when their children are around.10 DrinkWise Australia: receives funding from the federal government and the alcohol industry for the development of both its evidence base and its programs; has no associations with any international alcohol or tobacco lobby groups; undertakes research through Australian universities to develop the evidence base for its interventions; does not interfere with specification of the research hypotheses, research design and techniques, or publication of results; ensures that the research it funds is undertaken in accordance with the universities’ protocols for conducting independent research; and grants the researchers it funds a “non-exclusive, royalty-free, perpetual license to use, reproduce, adapt and publish Project IP [intellectual property] for research, education, academic and consulting purposes”.11 I was particularly surprised that the letter’s authors would trivialise the importance of education in successful drug intervention programs and instead advocate for increased reliance on supply-side strategies. DrinkWise delivers interventions in a variety of settings, not only through the Kids Absorb Your Drinking campaign, but also through practical tools such as a website (http://www.drinkwise.com.au), information materials and discussion forums, as well as working at the grassroots level with groups such as local government, school organisations, community newspapers, Sports Challenge Australia and the Good Sports program. Educational programs informed by scientific literature, that are implemented and evaluated effectively and not used as a standalone intervention strategy, can work.12 We at DrinkWise hope that anyone with a strong commitment to public health will be able to work with us and not against us. This will ensure that we will be able to continue to run evidence-based initiatives to reduce alcohol-related harm in Australia.

Trish M Worth

To the Editor: Skov puts the case for an alcohol taxation policy in Australia.1 Few people, if any, in public health would disagree that alcohol is a serious public health issue in Australia, and few would doubt that higher prices will reduce consumption. But why tax the consumers directly? Why not tax the providers? I propose a tax on the advertising budget of alcoholic beverage producers. Further, this tax should be weighted according to the alcoholic content of the products they sell. Yes, this would mean higher prices for drinkers, but set in this way the incentive mechanism is to get sales and consumption down, firstly by reducing advertising, and secondly by lowering the amount of alcohol in what is sold. It has been estimated that more than a quarter of a billion dollars are spent each year on advertising alcoholic beverages in Australia.2 An average 200% tax, graded by alcoholic content of products, would mean a lot of money for the government! It might well make up for the estimated loss from the defeated “alcopops” tax of $1.6 billion over 4 years.3 Indeed, we should hope that it would not bring in half a billion dollars a year, as both advertising budgets and average alcohol content fall. An advertising tax would almost certainly make much greater inroads into reducing alcohol consumption than would the alcopops tax. It would raise the price for consumers, but to a lesser extent for lower alcohol-content beverages. It would severely discourage advertising, especially of high alcohol-content drinks, and would encourage manufacturers to produce beverages that are lower in alcohol. Any increase in cost to the consumer through taxation risks being regressive and might make the poor even poorer if they continue to drink, with a consequent impact on their health. This needs to be watched. But using the revenues raised to devise a targeted counselling program for those who do want to reduce their consumption (and for those who perhaps cannot do so without help) cannot be beyond the wit of Treasury and the health department.

Gavin H Mooney