Prevalence and correlates of alcohol dependence in adult prisoners vary according to Indigenous status

Alcohol relapse prevention health care after alcohol withdrawal in New South Wales prisons, Australia: A patient file review

INTRODUCTION

People who enter custody have complex health issues and comorbidities may include alcohol use disorders. We investigated clinical service provision and comorbidities recorded among individuals with a likely alcohol withdrawal syndrome within prison in New South Wales, Australia.

METHODS

For this clinical case series review, electronic medical data were used to identify 50 people entering custody between August and November 2018 who likely had a treated alcohol withdrawal syndrome. We aimed for a 3:2 ratio of men and women, and a 1:1 ratio of Aboriginal and non-Aboriginal individuals. Data were extracted using a purposefully designed tool which included current alcohol withdrawal management, comorbidities and alcohol relapse prevention approaches used or recommended.

RESULTS

Thirty-eight men and 12 women, of whom 22 were Aboriginal, were included. Twenty-nine individuals (58%) reported a history of medical comorbidities. Thirty-five (70%) reported using other substances and over half (60%) had a diagnosis of mental health disorders. Fourteen (28%) individuals had a record of receiving brief intervention and five (10%) of motivational interviewing. Twenty-three individuals (46%) were referred to and seen by drug and alcohol clinicians. Only seven (14%) of the sample had pre-release community care plans.

DISCUSSION AND CONCLUSIONS

Individuals treated for an alcohol withdrawal syndrome in New South Wales prisons have a high prevalence of medical comorbidities and other substance use. Clinical interventions focused on alcohol withdrawal management, and relapse prevention interventions were not recorded for most individuals. Service innovation and expansion are needed to increase the provision of post-withdrawal management.

Alcohol and other drug use before custody among Aboriginal and non-Aboriginal people in New South Wales, Australia

OBJECTIVE

Alcohol and other drug (AoD) use is a significant factor in the poor health status of people in prison. Our aim is to explore associations of alcohol consumption with tobacco and illicit drug use among Aboriginal and non-Aboriginal people in prison to inform health services, clinical care and support.

METHODS

We analysed the alcohol, tobacco and illicit drug use data of the 2015 Network Patient Health Survey of adults in custody in New South Wales (n=1,132). A comparative analysis of Aboriginal to non-Aboriginal participants including bi-variant and multivariant analysis was undertaken.

RESULTS

Significantly more Aboriginal than non-Aboriginal participants reported alcohol consumption before prison that was consistent with possible dependence. More Aboriginal than non-Aboriginal participants used cannabis on a daily or almost on daily basis before prison. There was significant association between alcohol and cannabis use among Aboriginal participants.

CONCLUSIONS

There are differences in Aboriginal and non-Aboriginal AoD use patterns, which should be considered when providing treatment and support programs within and post-release from prison.

IMPLICATIONS FOR PUBLIC HEALTH

Specific programs are needed to assist Aboriginal people in this population who co-use alcohol and cannabis.

Prevalence and correlates of alcohol dependence in an Australian Aboriginal and Torres Strait Islander representative sample: Using the Grog Survey App

INTRODUCTION

Little is known about the prevalence of current alcohol dependence in Indigenous Australian communities. Here we identify the frequency of reported symptoms, estimate the prevalence and describe the correlates of current alcohol dependence.

METHODS

A representative sample of Indigenous Australians (16+ years) was recruited from an urban and remote community in South Australia. Data were collected between July and October 2019 via a tablet computer-based application. Participants were likely dependent if they reported two or more dependence symptoms (ICD-11; in the last 12 -months), weekly or more frequently. Chi-square tests described the relationship between demographics, remoteness and alcohol dependence. Spearman correlations estimated the relationship between symptoms of dependence, consumption characteristics and demographics.

RESULTS

A total of 775 Indigenous Australians participated. The most frequently reported symptoms were prioritising alcohol over other things and loss of control. Overall, 2.2% were likely dependent on alcohol (n = 17/775). Prevalence did not vary by remoteness. Participants who drank more and more frequently tended to report more frequent symptoms of dependence. In the urban site, men tended to report more frequent symptoms of dependence than women. Age, income and schooling were not linked to dependence.

DISCUSSION AND CONCLUSIONS

The prevalence of current alcohol dependence in this representative sample was similar to that of the general Australian and international estimates. Understanding risk factors for current alcohol dependence will be useful to inform the allocation of funding and support. Accurate estimates of the prevalence of current alcohol dependence are important to better identify specialist treatment needs.

An examination of chronic ill-health and lifestyle factors among inmates: searching for the healthy immigrant effect in New South Wales Prisons

PURPOSE

The purpose of this paper is to compare the rates of chronic health conditions and lifestyle factors between Australian-born and overseas-born inmates and to uncover predictive relationships between lifestyle factors and health outcomes for both groups.

DESIGN/METHODOLOGY/APPROACH

Data are presented from a cross-sectional study based on a sample of inmates from correctional sites in New South Wales (NSW). The inclusion of results here was guided by the literature relating to the healthy immigrant effect.

FINDINGS

Results indicate that a higher proportion of Australian-born inmates consumed alcohol at higher levels and were more likely to smoke on a daily or almost daily basis than overseas-born inmates. Australian-born inmates were also more likely than overseas-born inmates to have been diagnosed with cancer, epilepsy or hepatitis C. Physical activity predicted the number of diagnoses for Australian-born inmates while physical activity and smoking frequency predicted the number of diagnoses for overseas-born inmates.

PRACTICAL IMPLICATIONS

Overseas-born inmates make up a considerable portion of the prison population in NSW. A better understanding of those health and lifestyle factors that distinguish them from Australian-born inmates provides important insight regarding health promotion and the planning of service provision for those providing health care in this space.

ORIGINALITY/VALUE

Comparison of the health of immigrant and native-born prison inmates has not been undertaken before and promises to provide important information regarding those factors that distinguish a sizeable minority in the prison population.

Risky alcohol consumption prior to incarceration: A cross-sectional study of drinking patterns among Australian prison entrants

INTRODUCTION AND AIMS

Risky alcohol consumption is linked to poor health and criminal justice outcomes. This study aims to assess the prevalence and correlates of risky drinking in a sample of recently incarcerated Australians.

DESIGN AND METHODS

Consecutive cross-sectional data were collected from prisoners residing in 19 correctional facilities in six Australian states and territories as part of the National Prison Entrants' Bloodborne Virus and Risk Behaviour Survey Report. The sample consisted of 389 prisoners (339 men, 50 women). Risky alcohol consumption was estimated using the Alcohol Use Disorders Identification Test-Condensed questionnaire, with a cut-off score of ≥6. Potential correlates of risky alcohol consumption were assessed utilising univariate and multivariate analyses.

RESULTS

Over one-third (34.5%) of prisoners who were screened met the criteria for risky alcohol consumption. The five factors found to be independently and positively associated with risky alcohol consumption were Aboriginal and Torres Strait Islander (Indigenous) status, incarceration in prison in the Northern Territory, heavy tobacco use, cannabis use and abstinence from drugs in the 4 weeks prior to incarceration. Additionally, risky alcohol consumption was associated with current or past hepatitis B or hepatitis C infection.

DISCUSSION AND CONCLUSIONS

The findings highlight that risky alcohol consumption is common among prisoners across Australia. This is known to be associated with adverse health outcomes and re-offending, suggesting a need for alcohol interventions targeting prisoners.

Brief intervention on Smoking, Nutrition, Alcohol and Physical (SNAP) inactivity for smoking relapse prevention after release from smoke-free prisons: a study protocol for a multicentre, investigator-blinded, randomised controlled trial

INTRODUCTION

Smoking remains the leading risk factor for disease burden and mortality worldwide. Heavy Smoking is often associated with poor Nutrition, Alcohol abuse and Physical inactivity (known as 'SNAP'). Australia's first prison smoking ban was introduced in the Northern Territory in July 2013. However, relapse to smoking after release from prison is normative. Holistic and cost-effective interventions are needed to maintain post-release abstinence to realise the potential public health impact of smoke-free prison policies. Rigorous, large-scale trials of innovative and scalable interventions are crucial to inform tobacco control policies in correctional settings.

METHODS AND ANALYSIS

This multicentre, investigator-blinded, randomised parallel superiority trial will evaluate the effectiveness of a brief intervention on SNAP versus usual care in preventing smoking relapse among people released from smoke-free prisons in the Northern Territory, Australia. A maximum of 824 participants will be enrolled and randomly assigned to either SNAP intervention or usual care at a 1:1 ratio at baseline. The primary endpoint is self-reported continuous smoking abstinence three months after release from prison, verified by breath carbon monoxide test. Secondary endpoints include seven-day point prevalence abstinence, time to first cigarette, number of cigarettes smoked post release, Health Eating Index for Australian Adults, Alcohol Use Disorder Identification Test-Consumption and International Physical Activity Questionnaire scores. The primary endpoint will be analysed on an intention-to-treat basis using a simple log binomial regression model with multiple imputation for missing outcome data. A cost-effectiveness analysis of the brief intervention will be conducted subsequently.

ETHICS AND DISSEMINATION

This study was approved by the University of New South Wales Human Research Ethics Committee (HREC), Menzies HREC and Central Australia HREC. Primary results of the trial and each of the secondary endpoints will be submitted for publication in a peer-review journal.

TRIAL REGISTRATION NUMBER

ACTRN12617000217303; Pre-results.

Cost-utility analysis of low-intensity case management to increase contact with health services among ex-prisoners in Australia

OBJECTIVES

The economic burden of incarceration is substantial in Australia. People released from prison are at high risk of poor health and this is an important predictor of recidivism. The 'Passports Study' was a randomised controlled trial of an intervention designed to increase health service utilisation after release from prison. The aim of this study is to conduct a cost-utility analysis of this transitional programme.

SETTING

Australia DESIGN: A hybrid simulation model was developed to estimate the changes to total economic costs and effectiveness expressed as quality-adjusted life-years (QALYs) from the adoption of the 'Passports' intervention compared with the control group. Model parameters were informed by linked data from Queensland Corrective Services, Medicare, Pharmaceutical Benefits Scheme, Queensland Hospital Admission Patient Data Collection, Emergency Department Information System and National Death Index. Health-related quality of life was measured using the Short-Form 8 Health Survey (SF-8). The primary outcomes were the costs and estimated QALYs associated with the intervention group and the control group. Probabilistic sensitivity analysis was conducted to test parameter uncertainties.

RESULTS

Compared with the control group where no attempt was made to encourage health service utilisation, an average participant in the intervention group incurred an extra cost of AUD 1790 and experienced slightly reduced QALYs, which indicated that the intervention was dominated in the baseline analysis. Probabilistic sensitivity analysis revealed that the transitional programme had a low probability of being cost-effective with the outcome measures selected.

CONCLUSION

The findings of this study do not provide economic evidence to support the widespread adoption of the Passports intervention. Due to the reductionist nature of the cost-utility approach, it may be that important health-related benefits have been omitted. Another research approach using a wider range of health-related measures might generate different conclusions.

Are Australian prisons meeting the needs of Indigenous offenders?

Background

The over-representation of Indigenous Australians in custody is well documented, yet little is known about whether the health and social needs of Indigenous prisoners are met in correctional facilities. This study sought to identify common areas of need in a representative sample of Indigenous people in custody, and consider how well prison services were addressing these issues.

Methods

The sample comprised 122 Aboriginal and Torres Strait Islander people in custody in Victoria. Participants were administered the Camberwell Assessment of Need Forensic-Short Version to ascertain the presence or absence of needs in custody. Statistical analyses to determine associations with re-offence were conducted.

Results

Findings indicated that prisons were able to meet the non-criminogenic needs of many offenders; however there was a limited capacity to address specific criminogenic needs. Psychological distress, substance abuse, poor treatment adherence and threatening behaviours were considered ongoing needs regardless of supports/interventions being provided. Moreover, these four unaddressed needs were all associated with future recidivism.

Conclusions

Effective prison treatment services focusing on these four areas of need are urgently required. Such initiatives require continuation post-release combined with additional assistance to uphold basic non-criminogenic needs acquired in prison.

Patterns of drug dependence in a Queensland (Australia) sample of Indigenous and non-Indigenous people who inject drugs

INTRODUCTION AND AIMS

Despite over-representation of Indigenous Australians in sentinel studies of injecting drug use, little is known about relevant patterns of drug use and dependence. This study compares drug dependence and possible contributing factors in Indigenous and non-Indigenous Australians who inject drugs.

DESIGN AND METHODS

Respondent-driven sampling was used in major cities and 'peer recruitment' in regional towns of Queensland to obtain a community sample of Indigenous (n = 282) and non-Indigenous (n = 267) injectors. Data are cross sectional. Multinomial models were developed for each group to examine types of dependence on injected drugs (no dependence, methamphetamine-dependent only, opioid-dependent only, dependent on methamphetamine and opioids).

RESULTS

Around one-fifth of Indigenous and non-Indigenous injectors were dependent on both methamphetamine and opioids in the previous 12 months. Psychological distress was associated with dual dependence on these drugs for Indigenous [adjusted relative risk (ARR) 4.86, 95% confidence interval (CI) 2.08-11.34] and non-Indigenous (ARR 4.14, 95% CI 1.59-10.78) participants. Unemployment (ARR 8.98, 95% CI 2.25-35.82) and repeated (> once) incarceration as an adult (ARR 3.78, 95% CI 1.43-9.97) were associated with dual dependence for Indigenous participants only. Indigenous participants had high rates of alcohol dependence, except for those dependent on opioids only.

DISCUSSION AND CONCLUSIONS

The drug dependence patterns of Indigenous and non-Indigenous people who inject drugs were similar, including the proportions dependent on both methamphetamine and opioids. However, for Indigenous injectors, there was a stronger association between drug dependence and contextual factors such as unemployment and incarceration. Expansion of treatment options and community-level programs may be required. [Smirnov A, Kemp R, Ward J, Henderson S, Williams S, Dev A, Najman J M. Patterns of drug dependence in a Queensland (Australia) sample of Indigenous and non-Indigenous people who inject drugs. Drug Alcohol Rev 2016;35:611-619].

Illicit and injecting drug use among Indigenous young people in urban, regional and remote Australia

INTRODUCTION AND AIMS

To examine patterns of illicit drug use among Australian Indigenous young people, identify correlates of frequent use separately in urban, regional and remote settings and characterise those who inject.

DESIGN AND METHOD

Cross-sectional design at 40 Indigenous events. Self-complete surveys were administered to Indigenous people aged 16-29 years using mobile devices.

RESULTS

2,877 participants completed the survey. One in five reported using cannabis at least weekly in the previous year, but the use of other drugs was less prevalent. Patterns of drug use were largely similar across regions, although more participants in urban and regional areas reported using ecstasy (12% vs 11% vs 5%) and cocaine (6% vs 3% vs 1%) and more reported weekly cannabis use (18% vs 22% vs 14%). Injecting was rare (3%) but those who did inject reported a high incidence of needle sharing (37%). Methamphetamine (37%), heroin (36%) and methadone (26%) were the most commonly injected drugs, and injecting was related to prison experience (AOR 5.3 95% CI 2.8-10.0).

DISCUSSION AND CONCLUSION

Attention is needed in relation to cannabis use, particularly among those Indigenous young people living in regional and urban settings. Also, although injecting is uncommon, it is associated with prison involvement. Priority must be given to reducing the numbers of Indigenous youth entering justice settings, delaying the age at first entry to justice settings, and reducing the risk of BBV acquisition while in custody through, for example, prison-based NSP, BBV education, and Indigenous-specific treatment that emphasises connection to country and culture. [Bryant J, Ward J, Wand H, Byron K, Bamblett A, Waples-Crowe P, Betts S, Coburn T, Delaney-Thiele D, Worth H, Kaldor J, Pitts M. Illicit and injecting drug use among Indigenous young people in urban, regional and remote Australia. Drug Alcohol Rev 2016;35:447-455].

A systematic review: Identifying the prevalence rates of psychiatric disorder in Australia's Indigenous populations

OBJECTIVE

This review aimed to draw on published literature to identify the prevalence rates of psychiatric disorders in Australia's Indigenous populations, Aboriginal and Torres Strait Islander peoples.

METHOD

A systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) model was conducted using the following electronic databases: PubMed, Scopus, Web of Science, MEDLINE, PsycINFO, PsycARTICLES, and Informit Indigenous and Health Collections. Studies were included for analysis if they were empirical quantitative studies reporting prevalence rates for any psychiatric disorder in Indigenous people.

RESULTS

Of the 1584 papers extracted by the search strategy, 17 articles met the eligibility criteria and were reviewed in detail. Methodology, sampling strategy and study design varied greatly across these 17 studies. Prevalence rates varied by disorder and are as follows: major depressive disorder (4.3-51%); mood disorders (7.7-43.1%); post-traumatic stress disorder (14.2-55.2%); anxiety disorders (17.2-58.6%); substance dependence (5.9%-66.2%); alcohol dependence (21.4-55.4%); and psychotic disorders (1.68-25%). While the number of studies on community-based Indigenous populations was limited, available evidence suggested that prevalence rates are higher in prison populations compared with community-based studies.

CONCLUSIONS

It was identified that there is limited evidence on the occurrence of psychiatric disorders for Indigenous people in the general community. More research in this area is essential to provide accurate and reliable estimates and to provide a baseline for evaluating the effectiveness of programs aimed at reducing the high mental health burden experienced by Indigenous Australians. Future research needs to ensure that standardised and validated methods are used to accurately estimate the prevalence of psychiatric disorders among Indigenous Australians.

Striking subgroup differences in substance-related mortality after release from prison

AIMS

To compare the incidence, timing and risk factors for substance-related death between Indigenous and non-Indigenous ex-prisoners in Queensland, Australia.

DESIGN

Retrospective cohort study.

SETTING

All adult prisons in the state of Queensland, Australia, linked to deaths registered in Australia.

PARTICIPANTS/CASES

We obtained records for all adults released from prison in Queensland, Australia from 1 January 1994 to 31 December 2007. Among this cohort of 42 015 individuals we observed 82 315 releases from prison and 2158 deaths in the community by the end of 2007, of which 661 were substance-related deaths.

MEASUREMENTS

Incarceration data were obtained from Queensland Corrective Services and linked probabilistically with deaths recorded in the Australian National Death Index.

FINDINGS

In the first year after release, Indigenous ex-prisoners were more likely to die from alcohol-related causes [hazard ratio (HR) = 1.9, 95% confidence interval (CI) = 1.1-3.1)] but less likely to die of drug-related causes (HR = 0.34, 95%CI = 0.21-0.53) than were non-Indigenous ex-prisoners. Among non-Indigenous prisoners only, the risk of substance-related death was significantly higher in the first 4 weeks [relative risk (RR) = 5.1, 95% CI = 3.7-6.9] when compared with the risk after 1 year post-release. Most evaluated risk factors for substance-related death were similar for Indigenous and non-Indigenous ex-prisoners; however, the hazard of death increased with age more for Indigenous ex-prisoners (HR = 1.7 per decade of age, 95% CI = 1.4-2.1) than for non-Indigenous ex-prisoners (HR = 1.3, 95% CI = 1.2-1.4).

CONCLUSIONS

In Australia, patterns of substance-related death in ex-prisoners differ markedly according to Indigenous status. Efforts to prevent substance-related deaths in ex-prisoners should consider heterogeneity in the target population and tailor responses accordingly.

Predictive validity of the AUDIT for hazardous alcohol consumption in recently released prisoners

BACKGROUND

This study aimed to assess the predictive validity of the Alcohol Use Disorders Identification Test (AUDIT) among adult prisoners with respect to hazardous drinking following release, and identify predictors of post-release hazardous drinking among prisoners screening positive for risk of alcohol-related harm on the AUDIT.

METHODS

Data came from a survey-based longitudinal study of 1325 sentenced adult prisoners in Queensland, Australia. Baseline interviews were conducted pre-release with follow-up at 3 and 6 months post-release. We calculated sensitivity, specificity and area under the receiver operating characteristic (AUROC) to quantify the predictive validity of the AUDIT administered at baseline with respect to post-release hazardous drinking. Other potential predictors of hazardous drinking were measured by self-report and their association with the outcome was examined using logistic regression.

RESULTS

At a cut-point of 8 or above, sensitivity of the AUDIT with respect to hazardous drinking at 3-month follow-up was 81.0% (95%CI: 77.9-84.6%) and specificity was 65.6% (95%CI: 60.6-70.3%). The AUROC was 0.78 (95%CI: 0.75-0.81), indicating moderate accuracy. Among those scoring 8 or above, high expectations to drink post-release (AOR: 2.49; 95%CI: 1.57-3.94) and past amphetamine-type stimulant (ATS) use (AOR: 1.64; 95%CI: 1.06-2.56) were significantly associated with hazardous drinking at 3 months post-release. Results were similar at 6 months.

CONCLUSIONS

Among adult prisoners in our sample, pre-release AUDIT scores predicted hazardous drinking six months after release with acceptable accuracy, sensitivity and specificity. Among prisoners screening positive on the AUDIT, expectations of post-release drinking and ATS use are potential targets for intervention to reduce future hazardous drinking.

Validating a screening tool for mental health and substance use risk in an Indigenous prison population

INTRODUCTION AND AIMS

The Indigenous Risk Impact Screen (IRIS) is a validated culturally appropriate and widely used tool in the community for assessing substance use and mental disorder. This research aimed to assess the utility of this tool in an Indigenous prison population.

DESIGN AND METHODS

The study used data collected from a cross-sectional study of mental health among Indigenous inmates in Queensland custodial centres (n = 395, 84% male). Participants were administered a modified version of the IRIS and International Classification of Diseases-10 diagnoses of substance use, depressive and anxiety disorders obtained using the Composite International Diagnostic Interview (CIDI). The concurrent validity of the modified IRIS was assessed against those of the CIDI.

RESULTS

Three hundred and twelve people screened as high risk for a substance use disorder and 179 were high risk for mental problems. There were 73% of males and 88% of females diagnosed with a mental disorder. The IRIS was an effective screener for substance use disorders, with high sensitivity of 94% and low specificity of 33%. The screener was less effective in identifying depression (sensitivity 82%, specificity 59%) and anxiety (sensitivity 68%, specificity 60%).

DISCUSSION

The IRIS is the first culturally appropriate screening instrument to be validated for the risk of drug and alcohol and mental disorder among Indigenous adults in custody.

CONCLUSIONS

This study demonstrated that the IRIS is a valid tool for screening of alcohol and drug use risk among an incarcerated Indigenous population. The IRIS could offer an opportunity to improve the identification, treatment and health outcomes for incarcerated Indigenous adults.