Measuring Unmet Demand for Alcohol and Other Drug Treatment: The Application of an Australian Population-Based Planning Model

Bridging the evidence and the politics: Implementation trial of supervised injectable opioid treatment (SIOT) in Australia

Supervised Injectable Opioid Treatment (SIOT) targets people experiencing opioid dependence who have not benefited from existing treatments. In this population, SIOT has been demonstrated to be efficacious and effective, yet this modality of treatment has only been taken up in a few countries. In this commentary we describe the socio-political context and history to the recent establishment of an implementation trial of injectable hydromorphone in Sydney, Australia. These factors influenced choices about the trial design, including integration of SIOT within an existing opioid agonist treatment program, time-limited treatment, and an assessment of feasibility, acceptability, safety and cost. While all new drug policy initiatives occur within a specific socio-political and historical context, we hope this commentary provides reflections for other places considering the introduction of SIOT.

Unmet treatment need: The size of the gap for alcohol and other drugs in Australia

INTRODUCTION

Assessing unmet demand for alcohol and other drug (AOD) treatment requires accurately counting those in treatment and determining those in need of treatment. Using updated epidemiological and treatment data, this study sought to provide an updated estimate of the unmet demand for AOD treatment in Australia.

METHODS

Australian prevalence rates for alcohol, cannabis, methamphetamine and opioid use disorders were obtained from the Global Burden of Disease and research studies. The estimated proportion of people who would likely not seek or need treatment were subtracted from the diagnosed population. The number of people receiving treatment was estimated using AOD treatment databases and previous research.

RESULTS

An estimated 752,812 to 1,291,119 people met criteria for a substance use disorder in Australia in 2023. Removing the proportion of people who would not need or seek treatment resulted in between 406,697 and 668,497 people as the potential treatment population. The number of people who received treatment in Australia was estimated at 198,731 people. The unmet demand for AOD treatment was estimated to be between 207,966 and 469,767 in 2023.

DISCUSSION AND CONCLUSIONS

In Australia, we only treat between 30% and 48% of the population who would seek and benefit from AOD treatment. This is a conservative analysis that assumes only 40% of the alcohol and cannabis use disorder population would seek treatment. The findings from this analysis highlight the continued significant unmet treatment needs of people with substance use disorders. Treatment resources need to be doubled in order to address this unmet treatment population.

Exploring the potential of Self-Management and Recovery Training (SMART Recovery) mutual-help groups for supporting people who use methamphetamine: A qualitative study examining participant experience of initiation and engagement

INTRODUCTION

Improving support options for people who use methamphetamine is of critical national and global importance. The role of mutual-help groups within the treatment-seeking journey of people who use methamphetamine is unclear. Self-Management and Recovery Training ('SMART Recovery') mutual-help groups are led by a trained facilitator and support participants to work on individual goals, including, but not limited to abstinence. This study examined how people who use methamphetamine came to be involved in SMART Recovery mutual-help groups and factors associated with engagement.

METHODS

A sample of Australian SMART Recovery participants who self-reported using methamphetamine in the preceding 12-months (n = 18) discussed their history of substance use and experience of service provision in a semi-structured telephone interview. Interviews were audio-recorded, transcribed, and analysed using iterative categorization.

RESULTS

Participant initiation of SMART Recovery groups was described across two themes: i) delayed attendance and ii) use as an adjunct to other services. Factors associated with engagement were discussed in terms of: i) the 'fit' of SMART Recovery mutual-help groups; ii) coping and tolerance of discomfort; iii) the power of shared lived experience; iv) choice and autonomy; and v) short-term goal setting supports self-efficacy and the possibility of change.

DISCUSSION AND CONCLUSIONS

SMART Recovery mutual-help groups show promise for engaging people who use methamphetamine. There is a clear need to improve awareness of mutual-help group options amongst service users, providers and the general community. Offering choice over mutual-help groups may help to engage people earlier and support improved linkage between services.

People who use drugs and the right to health

Support for a human rights framework for drug policy has been growing for some years. This year, the UNODC published a chapter in the World Drug Report focussed on the right to health. In this paper, we draw attention to the conceptualisation of the right to health for people who use drugs. While one essential element is access to appropriate, high quality, and affordable healthcare, this needs to occur hand-in-hand with two other central components of the right to health - the right to conditions that promote health (the social, economic, legal, commercial, and cultural determinants of health) and the right to meaningful participation in healthcare decisions and in health policy. We consider these three components of a right to health against the current international drug control regime. More specifically we point to how the three drug conventions (1966 as amended 1972, 1971 and 1988) make explicit mention of the right to health. In this way, we argue that duties to respect, protect and provide the right to health for people who use drugs accrue through being a signatory to the drug conventions. Given that there does not appear to be international appetite to abandon the current treaties, and notwithstanding the strong impression that they reinforce a criminalisation approach to people who use drugs, the work herein may afford another avenue for effective advocacy about the right to health.

The impact of the COVID-19 pandemic on calls to an alcohol and drug helpline in Victoria, Australia, for alcohol, methamphetamine and cannabis use concerns

INTRODUCTION

Helplines are often the first contact with the alcohol and other drug (AOD) treatment system. We examined call data from an AOD helpline in Victoria, Australia, to explore the association between COVID-19 lockdown measures and frequency of calls.

METHODS

This was a retrospective analysis of AOD helpline data collected between January 2018 and September 2020, for alcohol, methamphetamine and cannabis use concerns. Linear and logistic regression analyses examined differences in pre-COVID-19 (January 2018 to March 2020) and during COVID-19 (March 2020 to September 2020) caller characteristics, and interrupted time-series analyses examined changes in frequency of calls relative to lockdown measures.

RESULTS

There were 14,340 calls for alcohol (n = 10,196, 71.10%), methamphetamine (n = 2522, 17.59%) and cannabis (n = 1622, 11.31%). Relative to pre-COVID-19, during COVID-19 there was an increase in the rate of change over time in number of alcohol calls (b = 0.39), increase in first-time alcohol callers (OR = 1.29), and reduction in first-time methamphetamine callers (OR = 0.80). During COVID-19, alcohol callers had lower Socio-Economic Indicators for Areas scores (b = -3.06) and cannabis callers were younger (b = -2.07). During COVID-19, there were reductions in alcohol calls involving counselling/support (OR = 0.87) and information provision (OR = 0.87), cannabis calls involving information provision (OR = 0.71) and methamphetamine calls involving referral (OR = 0.80).

DISCUSSION AND CONCLUSIONS

In the first 6 months of the pandemic, frequency of alcohol-related calls increased over time, and first-time alcohol-related callers increased. The number of calls for cannabis and methamphetamine remained stable. Results suggest the helpline was not used to its full capacity, suggesting a role for further promotion during times of crises.

Clinical profiles of people enrolling in alcohol and other drug treatment in Australia: Do youth differ from young adults and adults?

INTRODUCTION

To examine and compare age groups on socio-demographic, substance use, mental health, social and risk behaviour profiles of people entering alcohol and other drug (AOD) treatment in a large non-government organisation (NGO) in Queensland and New South Wales, Australia.

METHODS

Design-Cross-sectional study; analysis of baseline routine outcome measures (ROM) and AOD minimum datasets for drug and alcohol treatment services. Setting and participants-People enrolling in Lives Lived Well, a large NGO AOD service between November 2020 and October 2022. Main outcome measures-Socio-demographic, substance use, mental health, social factors and risk behaviours, by youth (≤24 years), young adults (25-35 years) and adults (>35 years).

RESULTS

Between November 2020 and October 2022, 9413 clients enrolled in Lives Lived Well (LLW) AOD services and completed baseline ROMs. Over one-fifth (21.9%) were youth (n = 2066), one-third (32.4%) were young adults (n = 3052) and just under half (45.6%) were adults >35 years (n = 4295). The most common primary drug of concern was cannabis for youth, methamphetamine for young adults and alcohol for adults >35 years. Nearly two-thirds (61.3%) reported moderate to severe symptoms of depression and 55.0% reported moderate to severe anxiety. Just under half (47.2%) screened positive for PTSD and two-in-five (40.4%) reported recent suicidal ideation. Co-occurring mental health symptoms were more common in youth compared with young adults and adults >35 years.

DISCUSSION AND CONCLUSIONS

Co-occurring mental health symptoms were high in the sample, particularly among youth. All age groups present with unique and complex socio-demographic and clinical profiles that are important to understand to provide the most appropriate and effective treatment.

"A little bit of hope goes a long way": Exploring the role of peer workers in alcohol and other drug rehabilitation services

INTRODUCTION

Peer workers operating within health care settings can offer unique perspectives based on their own lived experience. Within alcohol and other drug (AOD) rehabilitation services, the potential value of peer work is becoming increasingly recognised. This qualitative study aimed to evaluate a newly implemented peer worker program located across three rehabilitation services in Tasmania, Australia.

METHODS

Online interviews were conducted with eight clients, seven peer workers, and five non-peer worker employees with varied experience with peer worker programs. All interviews were audio-recorded and transcribed verbatim.

RESULTS

Guided by an overarching exploratory-descriptive methodological framework, thematic analysis generated three overarching themes: 1) Enhancing and supporting client experiences (what peer workers did in their role to improve client experiences, 2) Changing experiences with AOD rehabilitation (the unique benefits and changes that peer work brings to AOD rehabilitation services) and 3) Finding organizational value (how defining peer work and the feasibility of the peer worker role was challenged by different organizational factors). Overall, peer work was viewed as a positive addition to all rehabilitation services that was able to enhance client experiences through various mechanisms, such as by sharing their own stories, assisting with understanding, and creating safety. Peer work was also able to create change in AOD services, by instilling hope and reducing stigma. However, ongoing challenges with defining the peer worker role in a way that offers organizational recognition and financial security remain.

CONCLUSION

Peer workers offer a unique and valuable perspective when working within rehabilitation services. Through their own lived experience peer workers were able to support clients and assist them in their recovery. These findings highlight the potential benefit of peer work programs within AOD rehabilitation services.

Diagnosing and managing prescription opioid use disorder in patients prescribed opioids for chronic pain in Australian general practice settings: a qualitative study using the theory of Planned Behaviour

BACKGROUND

Chronic pain is a debilitating and common health issue. General Practitioners (GPs) often prescribe opioids to treat chronic pain, despite limited evidence of benefit and increasing evidence of harms, including prescription Opioid Use Disorder (pOUD). Australian GPs are worried about the harms of long-term opioids, but few are involved in the treatment of pOUD. There is little research on GPs' experiences diagnosing and managing pOUD in their chronic pain patients.

METHODS

This qualitative research used semi-structured interviews and a case study to investigate GPs' experiences through the lens of the Theory of Planned Behaviour (TPB). TPB describes three factors, an individual's perceived beliefs/attitudes, perceived social norms and perceived behavioural controls. Participants were interviewed via an online video conferencing platform. Interviews were transcribed verbatim and thematically analysed.

RESULTS

Twenty-four GPs took part. Participants were aware of the complex presentations for chronic pain patients and concerned about long-term opioid use. Their approach was holistic, but they had limited understanding of pOUD diagnosis and suggested that pOUD had only one treatment: Opioid Agonist Treatment (OAT). Participants felt uncomfortable prescribing opioids and were fearful of difficult, conflictual conversations with patients about the possibility of pOUD. This led to avoidance and negative attitudes towards diagnosing pOUD. There were few positive social norms, few colleagues diagnosed or managed pOUD. Participants reported that their colleagues only offered positive support as this would allow them to avoid managing pOUD themselves, while patients and other staff were often unsupportive. Negative behavioural controls were common with low levels of knowledge, skill, professional supports, inadequate time and remuneration described by many participants. They felt OAT was not core general practice and required specialist management. This dichotomous approach was reflected in their views that the health system only supported treatment for chronic pain or pOUD, not both conditions.

CONCLUSIONS

Negative beliefs, negative social norms and negative behavioural controls decreased individual behavioural intention for this group of GPs. Diagnosing and managing pOUD in chronic pain patients prescribed opioids was perceived as difficult and unsupported. Interventions to change behaviour must address negative perceptions in order to lead to more positive intentions to engage in the management of pOUD.

Smartphone-delivered approach bias modification for reducing harmful drinking amongst middle-older age adults: Secondary analyses of a single-arm pilot study

INTRODUCTION

Novel, scalable, low-cost interventions are needed to reduce harmful drinking amongst middle-older adults. Approach bias modification (ApBM) is a promising form of cognitive training for preventing/reducing alcohol use that can be delivered via smartphone. This study explored the acceptability and preliminary effectiveness of smartphone delivered and personalised ApBM amongst Australians ≥55 years, an age cohort at risk of alcohol-related harms.

METHODS

Secondary analyses in a middle-older adult subsample (≥55 years, n = 289) of an open-label pilot study using a retrospective, repeated measures design. We explored acceptability (adherence, user mobile acceptability ratings, free-text responses) and preliminary effectiveness (changes in drinking quantity and frequency, craving, dependence and proportion drinking within government-recommended guidelines) of two sessions/week over 4 weeks of evidence-based ApBM training, adapted to include personalisation and smartphone delivery amongst Australians ≥55 years.

RESULTS

Although minor adaptations to training were suggested, the intervention was acceptable amongst survey completers, with 72% training adherence. Relative to baseline, there was a significant increase in the proportion of drinking within recommended single-session and weekly guidelines post-training (from 25% to 41% and 6% to 28%, respectively, p < 0.001), with past-week standard drinks significantly decreasing by 18% (p < 0.001) and significant reductions in drinking days, mean craving and dependence scores (p < 0.001).

DISCUSSION AND CONCLUSIONS

Findings suggest smartphone ApBM is acceptable amongst middle-to-older aged Australians and may support this 'at risk' cohort to remain within government-recommended alcohol consumption guidelines to optimise healthy aging, although, in the context of a single-arm study, preliminary results should be interpreted cautiously.

Using the National Mental Health Service Planning Framework to inform integrated regional planning: a case study in Tasmania, Australia

BACKGROUND

The aim of this study was to demonstrate the application of a needs-based mental health service planning model in Tasmania, Australia to identify indicative directions for future service development that ensure the equitable provision of mental health services across the State.

METHODS

The activity and capacity of Tasmania's 2018-19 mental health services were compared to estimates of required care by: (1) generating estimates of required care using the National Mental Health Service Planning Framework (NMHSPF); (2) collating administrative mental health services data; (3) aligning administrative data to the NMHSPF; and (4) comparing aligned administrative data and NMHSPF estimates to identify priority areas for service development. Findings were contextualised using information about service location, population demographics, and upcoming service development.

RESULTS

Bed-based services capacity reached 85% of the NMHSPF estimate. However, access to certain bed types was inequitable across regional areas. Access to jurisdictional clinical ambulatory team-based services was lowest in the South, while overall full-time equivalent staff capacity reached 58% of the NMHSPF estimate. Access to Primary Health Tasmania (PHT) primary care services was highest in the North West; access to Medicare services was highest in the South. Collectively, activity across primary care (PHT, headspace and Medicare) reached 43% of the NMHSPF estimate. Over half of Community Managed Mental Health Support Services were state-wide services.

CONCLUSIONS

This study demonstrates the application of a needs-based planning model for mental health services. Findings revealed service priority areas across Tasmania and highlight considerations for needs-based planning.

Informing a collaborative-care model for delivering medication assisted treatment for opioid dependence (MATOD): An analysis of pharmacist, prescriber and patient perceptions

BACKGROUND

Demand for medication assisted treatment for opioid dependence (MATOD) in Australia exceeds capacity, particularly in rural and regional areas. There is increasing recognition that community pharmacists are well-positioned to take on expanded roles in MATOD delivery, however there has been limited Australian research exploring attitudes of pharmacists, prescribers, and patients to collaborative models of care.

OBJECTIVE(S)

This study aimed to better understand enablers and barriers to a collaborative model for MATOD, to inform implementation in regions where increases in treatment capacity are urgently needed.

METHODS

Semi-structured telephone interviews were conducted with pharmacists (n = 11), prescribers (n = 6), and patients (n = 8) recruited from the Frankston-Mornington Peninsula region in Victoria, Australia, where transport and access to services have impacts on health care utilisation. The COM-B model was used to explore perceptions of pharmacists' capability, opportunity, and motivations for delivering collaborative care.

RESULTS

There was strong motivation among healthcare professionals to participate in a collaborative model of care, with the main perceived benefits including improvements in accessibility, convenience, and continuity of care, and leverage of pharmacists' high level of patient engagement. Key barriers identified by both pharmacists and prescribers included a perceived lack of pharmacist skills in some areas (capability) and resources (opportunity) to deliver collaborative care in a community pharmacy setting. Established relationships between all stakeholders (social opportunity) and communication between pharmacists and prescribers were identified as facilitators. Barriers and facilitators aligned with seven key areas: skills, confidence, relationships, patient selection, protocols, communication and resources.

CONCLUSIONS

Findings informed the development of a collaborative model that was individualised, protocol based, and supported by training and clear processes.

PROJECT IMPACT

This study identifies specific barriers and facilitators to a pharmacist-prescriber collaborative model of care for MATOD. The resulting model will be tested in a hybrid implementation-effectiveness trial in the Frankston-Mornington Peninsula region.

Using novel methodology to estimate the prevalence of mental disorders in British Columbia, Canada

PURPOSE

A needs-based model of health systems planning uses a systematic estimate of service needs for a given population. Our objective was to derive annual prevalence estimates of specific mental disorders in the adult population of British Columbia, Canada and use a novel triangulation approach encompassing multiple data sources and stratifying these estimates by age, sex, and severity to inform Ministry partners, who commissioned this work.

METHODS

We performed systematic literature reviews and subsequent meta-analyses to derive an annual prevalence estimate for each mental disorder. We then generated age- and sex-specific estimates by triangulating published epidemiological studies, routinely collected province-wide health administrative data, and nationally representative health survey data sources. The age- and sex-specific estimates were further stratified by severity using the Global Burden of Disease severity distributions and published literature.

RESULTS

Anxiety disorders had the highest annual prevalence estimates (6.93%), followed by depressive disorders (6.42%). All other mental disorders had an annual prevalence of less than 1%. Prevalence estimates were consistently higher in younger age groups. Depressive disorders, anxiety disorders, and eating disorders were higher in women, while estimates for bipolar disorders, schizophrenia, and ADHD were slightly higher in men in younger age groups.

CONCLUSION

We generated robust annual prevalence estimates stratified by age, sex, and severity using a triangulation approach. Variation by age, sex, and severity implies that these factors need to be considered when planning for mental health services. Our approach is replicable and can be used as a model for needs-based planning in other jurisdictions.

Characteristics of clients entering women-only substance use treatment services in New South Wales

BACKGROUND

Women experiencing substance use disorders face barriers to treatment, including childcare, stigma and lack of gender/trauma-informed programming. Several non-government organizations in New South Wales run women-only treatment services to address these needs.

OBJECTIVES

We aim to assess characteristics of women entering treatment in these services.

DESIGN

Data on client characteristics from six women-only non-government organization substance use disorder treatment services in New South Wales between 2014 and 2018 were extracted from a database containing demographics, drug use and treatment characteristics and psychological distress (Kessler-10 scale) of women entering the services. Logistic regression models were used to estimate unadjusted odds ratio and adjusted odds ratio for treatment completion and different drugs on entry.

RESULTS

Data were available for 1357 women. Most (91%) episodes were for residential treatment. Women's mean age was 35.4 years (standard deviation = 9.8; range = 17-67). Residential clients tended to be younger than non-residential clients (35.1 vs 38.5 years, p < 0.001). Methamphetamine (43%) and alcohol (32%) were the most reported principal drug of concern. Women (89%) reported high levels of psychological distress (median Kessler-10 scale score = 27.5, range = 10-50), highest for women reporting alcohol as their principal drug. Overall, 43% of episodes resulted in treatment completion, most commonly for women entering residential treatment (45% vs 22%, p < 0.001) and for alcohol treatment (adjusted odds ratio = 1.42; confidence interval = 1.07-1.90; p < 0.001). Women with Kessler-10 scale scores indicating anxiety or depression at treatment entry were less likely to complete treatment than those with lower scores (adjusted odds ratio = 0.56; confidence interval = 0.38-0.80; p < 0.001).

CONCLUSION

Women entering women-only residential treatment tend to be younger and report methamphetamine as principal drug of concern. Women enter treatment with high degrees of psychological distress. Women's services need to ensure their programmes can respond to diverse needs of younger women presenting with methamphetamine use disorder and older women with alcohol use disorder experiencing high levels of psychological distress.

Polysubstance use in young people accessing residential and day-treatment services for substance use: substance use profiles, psychiatric comorbidity and treatment completion

BACKGROUND AND AIMS

People with substance use disorders (SUDs) frequently present to treatment with polysubstance use and mental health comorbidities. Different combinations of substance use and mental health problems require different treatment approaches. Our study aimed to: (i) identify the shared substance use classes among young people at treatment admission, (ii) determine which mental health symptoms, quality of life (QoL) and service types were associated with the identified substance use classes, and (iii) prospectively determine which substance use classes and service types were more likely to complete treatment.

DESIGN

Cross-sectional and prospective study using service and outcome data.

SETTING

Substance use treatment services in Queensland and New South Wales, Australia.

PARTICIPANTS

De-identified service and outcome measure data were extracted from the files of 744 clients aged 18-35 years (48% male) admitted into seven residential and four day-treatment programmes.

MEASUREMENTS

Substance use and severity among tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, opioids, sedatives and inhalants. Other variables included: depression, anxiety, post-traumatic stress and psychotic symptoms, as well as QoL.

FINDINGS

Latent class analysis identified three polysubstance use classes: wide-ranging polysubstance users (WRPU; 22.45%), primary amphetamine users (56.45%) and alcohol and cannabis users (21.10%). The WRPU class had higher odds of psychotic symptoms than the alcohol and cannabis use class [odds ratio (OR) = 1.30; 95% confidence interval (CI) = 1.11-1.11]; and double the odds of residential programme enrolment than those in the amphetamine use class (OR = 2.35; 95% CI = 1.50-3.68). No other class differences on mental health or QoL variables were found. Clients enrolled in day-programmes had higher odds of completing treatment.

CONCLUSIONS

There appear to be high levels of polysubstance use among young people entering substance use treatment in Australia. Wide-ranging polysubstance users were more likely to report psychotic symptoms and be enrolled into a residential programme than primary amphetamine users and alcohol and cannabis users.

The association between involuntary alcohol treatment and subsequent emergency department visits and hospitalizations: a Bayesian analysis of treated patients and matched controls

BACKGROUND AND AIMS

Many nations have provisions for involuntary treatment of alcohol dependence where the person is at serious risk of harm to themselves. To date, there has been little thorough evaluation of its effectiveness. This study aimed to determine if there were differences between involuntary and voluntary treatment for alcohol dependence on subsequent emergency and hospital care.

DESIGN

A retrospective cohort design using linked routinely collected administrative data on health-care utilization.

SETTING

Hospital and community-based alcohol treatment, New South Wales, Australia.

PARTICIPANTS

A total of 231 patients who were involuntarily treated for alcohol dependence and 231 matched controls who received treatment as usual within the period May 2012 to April 2018.

INTERVENTION AND COMPARATOR

Involuntary treatment comprised a 28-day mandated hospital admission which included supervised withdrawal, comprehensive assessment, rehabilitation and support followed by voluntary aftercare support for up to 6 months. Treatment as usual comprised three not mutually exclusive forms of intensive voluntary alcohol treatment: withdrawal management, rehabilitation and pharmacotherapies for alcohol dependence.

MEASUREMENTS

Outcome measures: changes in the number of emergency department (ED) visits and number of unplanned hospital admissions 12 months before and 12 months after completion of index treatment.

FINDINGS

Both groups showed a reduction in ED visits (incidence rate ratio (IRR) = 0.56, 95% credible intervals (CrI) = 0.39-0.78) and unplanned hospital admissions (IRR = 0.49, 95% CrI = 0.37-0.65). There was no statistically significant difference between the two groups (IRR = 0.77, 95% CrI = 0.58-1.03 for ED visits and IRR = 0.79, 95% CrI = 0.62-1.01 for hospital admissions). The Bayes factors were 0.925 and 0.936 for ED visits and unplanned hospital admissions, respectively, interpreted as weak evidence in support of the null hypothesis of no difference between the interventions.

CONCLUSIONS

Involuntary treatment of alcohol dependence was associated with reduced health service utilization in the year following treatment, and the outcomes did not differ from those of a matched control group.

Are market mechanisms associated with alcohol and other drug treatment outcomes?

BACKGROUND AND AIMS

The configuration of alcohol and other drug treatment service systems has been influenced by the uptake of market mechanisms for treatment funding and purchasing. This study measured the impact of market mechanisms for funding and purchasing alcohol and drug treatment services on client outcomes.

DESIGN

An observational cross-sectional study, employing multi-level analysis: episodes of care data, nested within person-level data, nested within treatment site and nested within organization.

SETTING AND PARTICIPANTS

One hundred and seventy-eight alcohol and other drug treatment service sites in Australia.

MEASUREMENTS

Client outcome variables were length of stay and successful treatment completion. Predictor variables were competitive tendering, number of funding contracts, recurrent funding, the ratio of episodes to staff, type of professions, years of clinical experience, staff turnover and type of provider (government; non-government). Analyses controlled for drug type, type of treatment received and client characteristics.

FINDINGS

There were no significant associations between the procurement and contracting variables and length of stay [incidence rate ratios (IRRs) ranged between 1.01 and 1.07, all P > 0.05; Bayes factors (BF) < 0.03], and inconclusive results for treatment completion [odds ratios (ORs) ranged between 1.04 and 1.15, all P > 0.05, BF = 0.51-0.63]. Having an alcohol and other drug (AOD) work-force relative to an 'other' work-force (IRR = 0.79, P = 0.021) and lower case-loads (IRR = 0.99, P = 0.047) may be associated with longer stay in treatment. Receiving services from a government compared to non-government provider may also be associated with less treatment completion (OR = 0.34, P = 0.023, BF = 2.14).

CONCLUSIONS

There appears to be no association between client outcomes and procurement and funding contract arrangements for alcohol and drug treatment services.

Comparing Cannabis Use Disorder in the General Population with Cannabis Treatment Seekers Using Multi-Source National Datasets: Who Receives Treatment?

INTRODUCTION

Given the increased prevalence of cannabis use in Ireland and increase in cannabis potency, this study aimed to estimate the size of the potential population in Ireland that may be in need of cannabis treatment and the percentage of people with cannabis use disorder (CUD) who actually access treatment. We also compared the profile of those with CUD in the general population to those who receive treatment for their cannabis use to explore whether certain subgroups are more or less likely to enter treatment.

METHOD

This was a retrospective, multi-source database study. Data were obtained from (1) Ireland's 2014/2015 national general population survey (GPS) on drug use and (2) treatment data from the Irish National Drug Treatment Reporting System (NDTRS) for 2015. The profiles of GPS cases with CUD and NDTRS cases were compared using 2-sided t tests designed for independent samples.

RESULTS

The prevalence of last year cannabis use among adults aged 15 and older was 6.5% and the prevalence of CUD was 2.6%, representing 94,515 of the Irish population. A total of 4,761 cases entered treatment for problem cannabis use. NDTRS treatment cases were significantly more likely than GPS cases to be unemployed (63.7% vs. 26.6%) and have no or primary level only educational attainment (56.3% vs. 21.2%). Over half (53.3%) of NDTRS cases first used cannabis before the age of 15 years, compared to 14.7% of CUD cases in the population.

DISCUSSION/CONCLUSION

Our findings suggest that earlier users and those with more complex or disadvantaged lives are more likely to seek treatment. A broad population health approach that engages multiple sectors such as health, social welfare, and education is recommended to ensure that there is increased opportunity for people with CUD to be identified and signposted towards treatment.

A Personalized Approach Bias Modification Smartphone App ("SWiPE") to Reduce Alcohol Use: Open-Label Feasibility, Acceptability, and Preliminary Effectiveness Study

Background

Approach bias modification (ApBM), a computerized cognitive intervention that trains people to “avoid” alcohol-related images and “approach” nonalcohol images, reduces the likelihood of relapse when administered during residential alcohol treatment. However, most individuals experiencing alcohol problems do not require, do not seek, or have difficulty accessing residential treatment. Smartphone-delivered ApBM could offer an easily accessible intervention to reduce alcohol consumption that can be personalized (eg, allowing selection of personally relevant alcohol and positive nonalcohol training images) and gamified to optimize engagement.

Objective

We examined the feasibility, acceptability, and preliminary effectiveness of “SWiPE,” a gamified, personalized alcohol ApBM smartphone app, and explored alcohol consumption and craving outcomes in people drinking at hazardous levels or above (Alcohol Use Disorders Identification Test [AUDIT] score ≥8) who wanted to reduce their alcohol use.

Methods

In this open-label trial, frequency and quantity of alcohol consumption, alcohol dependence severity, and craving were measured prior to participants downloading SWiPE. Participants (n=1309) were instructed to complete at least 2 sessions per week for 4 weeks. Recruitment and completion rates were indicators of feasibility. Functionality, aesthetics, and quality ratings were indicators of acceptability. Participants were prompted to report frequency and quantity of alcohol consumption weekly during training and 1 month after training. They completed measures of craving and dependence after 4 weeks of training.

Results

We recruited 1309 participants (mean age 47.0, SD 10.0 years; 758/1309, 57.9% female; mean AUDIT score 21.8, SD 6.5) over 6 months. Participants completed a median of 5 sessions (IQR 2-9); 31.2% (409/1309) completed ≥8 sessions; and 34.8% (455/1309) completed the posttraining survey. Mean Mobile Application Rating Scale scores indicated good acceptability for functionality and aesthetics and fair acceptability for subjective quality. Among those who completed the posttraining assessment, mean past-week drinking days reduced from 5.1 (SD 2.0) pre-training to 4.2 (SD 2.3) in week 4 (t₄₅₄=7.87; P<.001), and mean past-week standard drinks reduced from 32.8 (SD 22.1) to 24.7 (SD 20.1; t₄₅₄=8.58; P<.001). Mean Craving Experience Questionnaire frequency scores reduced from 4.5 (SD 2.0) to 2.8 (SD 1.8; t₄₃₅=19.39; P<.001). Severity of Dependence scores reduced from 7.7 (SD 3.0) to 6.0 (SD 3.2; t₄₃₅=12.44; P<.001). For the 19.4% (254/1309) of participants who completed a 1-month follow-up, mean past-week drinking days and standard drinks were 3.9 (SD 2.5) and 23.9 (SD 20.7), respectively, both significantly lower than at baseline (P<.001).

Conclusions

The findings suggest SWiPE is feasible and acceptable and may be effective at reducing alcohol consumption and craving in a predominantly nontreatment-seeking sample of adult Australians drinking at hazardous levels. SWiPE’s efficacy, relative to a control condition, now needs establishing in a randomized controlled trial. Smartphone-delivered personalized ApBM could be a highly scalable, widely accessible support tool for reducing alcohol use.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000638932; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000638932p

International Registered Report Identifier (IRRID)

RR2-10.2196/21278

A prospective, multisite implementation-efficacy trial of a collaborative prescriber-pharmacist model of care for Medication Assisted Treatment for Opioid Dependence: Protocol for the EPIC-MATOD study

BACKGROUND

Medication Assisted Treatment for Opioid Dependence (MATOD) is clinically effective and cost effective, yet a lack of MATOD prescribers in the community limits access to this treatment in Australia. These shortages are often greatest in regional and rural areas.

OBJECTIVE(S)

The Enhancing Pharmacist Involvement in Care (EPIC)-MATOD study will evaluate clinical and implementation outcomes among people with opioid dependence receiving MATOD through a collaborative pharmacist-prescriber model of care across multiple sites in a regional location (encompassing a mix of metropolitan and non-metropolitan areas) of Victoria, Australia.

METHODS AND ANALYSIS

The EPIC-MATOD study is a prospective, multisite, implementation trial of collaborative MATOD care. Pharmacists and prescribers will be recruited through the local network of opioid pharmacotherapy providers. Patients will be recruited through participating healthcare providers. After induction into the collaborative care model, patients and healthcare professionals will be followed up over 6- (patients) and 12-months (pharmacists and prescribers) in a hybrid implementation-efficacy study, with outcomes mapped to the RE-AIM framework. The primary clinical efficacy endpoint is patient retention in treatment at 26 weeks. The primary implementation outcome is treatment capacity, based on prescriber time required to provide treatment through collaborative care compared with traditional care. Secondary clinical endpoints include attendance for dosing and clinical reviews, substance use, mental and physical health and overall well-being. Implementation costs, acceptability, and provider engagement in collaborative care will be used as secondary implementation outcome indicators. Time and costs associated with collaborative care, and health service utilisation, will also be estimated.

PROJECT IMPACT

The study will provide important information on outcomes and acceptability of collaborative care for MATOD, as well as the cost and key considerations in delivering a collaborative model of care in Australia and other countries where similar treatment barriers exist.

Treatment outcomes of a lesbian, gay, bisexual, transgender and queer alcohol and other drug counselling service in Australia: A retrospective analysis of client records

INTRODUCTION

Substance use disorders are more prevalent among lesbian, gay, bisexual, transgender and queer (LGBTQ) people than among their heterosexual and cisgender peers. There has been limited alcohol and other drug (AOD) treatment research with LGBTQ people outside of North America. This study aimed to examine the treatment outcomes of clients attending a LGBTQ-specific AOD counselling service in Australia (ACON's Substance Support Service) and compare their client profile and treatment outcomes with LGBTQ and non-LGBTQ clients of similar mainstream services.

METHODS

This study was a retrospective analysis of the health records of 284 ACON clients and 1011 clients of five mainstream services in 2016-2018. Clients completed clinical interviews at treatment entry and periodically throughout treatment and completed measures of substance use, severity of dependence, psychological distress and quality of life.

RESULTS

Most ACON clients were seeking treatment for methamphetamine (58%) and alcohol use (26%). Among ACON clients, there were reductions in past month days of substance use and severity of dependence between treatment entry and counselling sessions 4, 8 and 12 (all P < 0.001). There were statistically significant reductions in psychological distress and improved quality of life among ACON clients. Despite ACON and the mainstream services having similar treatment approaches, their client profiles were markedly different in terms of sociodemographic characteristics, substance use and source of referral, which precluded comparison of treatment outcomes.

DISCUSSION AND CONCLUSIONS

ACON's clients showed reduced substance use and improved psychosocial wellbeing during treatment. The findings support the provision of LGBTQ-specific AOD services.

SMART Recovery International and COVID-19: Expanding the reach of mutual support through online groups

Background

Mutual support groups play an extremely important role in providing opportunities for people to engage in alcohol and other drug (AOD) treatment and support. SMART Recovery groups employ cognitive, behavioural and motivational principles and strategies to offer support for a range of addictive behaviours. COVID-19 fundamentally changed the way that these groups could be delivered.

Methods

A series of online meetings were conducted by the lead author (PK) and the SMART Recovery International Executive Officer (KM), with representatives from the SMART Recovery National Offices in the Ireland (DO), United States (MR), Australia (RM), and Denmark (BSH, DA), and the United Kingdom (AK). The meetings focused on discussing the impacts of COVID-19 on SMART Recovery in each of the regions.

Results

As a result of restrictions to prevent the transmission of COVID-19, the vast majority of SMART Recovery face-to-face meetings were required to cease globally. To ensure people still had access to AOD mutual support, SMART Recovery rapidly scaled up the provision of online groups. This upscaling has increased the number of groups in countries that had previously provided a limited number of online meetings (i.e., United States, England, Australia), and has meant that online groups are available for the first time in Denmark, Ireland, Hong Kong, Spain, Malaysia and Brazil.

Discussion

Whilst the urgent and rapid expansion of online groups was required to support people during the pandemic, it has also created an opportunity for the ongoing availability of online mutual support post-pandemic. The challenge for the research community is to critically evaluate the online delivery of mutual support groups, to better understand the mechanisms through which they may work, and to help understand the experience of people accessing the groups.

Basic care as exceptional care: addiction stigma and consumer accounts of quality healthcare in Australia

The discrimination faced by people understood to have alcohol or other drug addictions has been the subject of extensive research, with many studies documenting experiences of stigma within healthcare services. Building on this literature, we examine the role of stigma in shaping the healthcare expectations of people seen as affected by alcohol and other drug addictions. Our analysis draws on recent theorisations of stigma as a process of social production to analyse in-depth, qualitative interviews with 20 people who had recently attended an inpatient withdrawal management service. Participants describe as exceptional forms of care that are often taken for granted by other members of the community. We argue that routinised experiences of discrimination work to constitute basic care as exceptional. This finding is significant for two reasons: (1) people who consume alcohol and other drugs often have complex healthcare needs and already encounter obstacles to accessing the care they need, and (2) by positioning people who consume drugs outside the purview of healthcare, this dynamic obstructs their fundamental right to care. We conclude by reflecting on the implications of these findings for those who are often positioned as not entitled to high quality healthcare.

Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia

The COVID-19 crisis has had profound impacts on health service provision, particularly those providing client facing services. Supervised injecting facilities and drug consumption rooms across the world have been particularly challenged during the pandemic, as have their client group—people who consume drugs. Several services across Europe and North America closed due to difficulties complying with physical distancing requirements. In contrast, the two supervised injecting facilities in Australia (the Uniting Medically Supervised Injecting Centre—MSIC—in Sydney and the North Richmond Community Health Medically Supervised Injecting Room—MSIR—in Melbourne) remained open (as at the time of writing—December 2020). Both services have implemented a comprehensive range of strategies to continue providing safer injecting spaces as well as communicating crucial health information and facilitating access to ancillary services (such as accommodation) and drug treatment for their clients. This paper documents these strategies and the challenges both services are facing during the pandemic. Remaining open poses potential risks relating to COVID-19 transmission for both staff and clients. However, given the harms associated with closing these services, which include the potential loss of life from injecting in unsafe/unsupervised environments, the public and individual health benefits of remaining open are greater. Both services are deemed ‘essential health services’, and their continued operation has important benefits for people who inject drugs in Sydney and Melbourne.

Perceptions of purchasing and payment mechanisms in alcohol and other drug treatment services in Australia: A qualitative study involving alcohol and other drug service providers and purchasers of treatment

INTRODUCTION AND AIMS

Governments across the globe invest considerable amounts in funding alcohol and other drug (AOD) treatment. Little attention however has been paid to the ways AOD service providers are chosen and how they are paid. This study sought to examine the perceptions of Australian AOD treatment purchasers and providers regarding different purchasing and payment mechanisms.

DESIGN AND METHODS

Qualitative interviews with AOD treatment providers and purchasers (N = 197) were undertaken across the eight Australian states/territories and the Commonwealth. Data were collated against six main AOD treatment purchasing and payment mechanisms (as identified in the literature), then an inductive, comparative analysis to assign codes was conducted, followed by interpretive analysis to explore emergent themes.

RESULTS

Five main themes were identified in relation to AOD treatment payment and purchasing mechanisms: (i) applying private sector principles to purchasing; (ii) innovation, sector stability and addressing client needs; (iii) performance monitoring and measuring outcomes; (iv) the threat to designated funding for AOD treatment; and (v) the costs and benefits of having multiple funding sources.

DISCUSSION AND CONCLUSIONS

In many countries reforms are taking place in the health sector consistent with New Public Management principles. These principles, when applied to AOD treatment, have included introducing competition, output and outcomes-based funding models, standards and accountability. Purchaser and providers identified both strengths and weaknesses and highlighted the overarching concern that implementation of any (mix) of these mechanisms should always be underpinned by a client-centred and not a finance-centred approach.

Exclusion and hospitality: the subtle dynamics of stigma in healthcare access for people emerging from alcohol and other drug treatment

This article explores the role of drug use-related stigma in constraining access to healthcare services. Drawing on interviews with 20 people conducted shortly after leaving an Australian alcohol and other drug withdrawal management unit, the article explores their willingness and ability to access primary care, hospital and further services. It finds repeated descriptions of feeling ignored and shamed during efforts to access care, with some descriptions relating to subtle signs of disapproval or condemnation, and others to being ignored or dismissed. Some accounts additionally emphasise unwelcoming atmospheres, and exclusion by omission of signals of welcome and encouragement. The article goes on to consider, for the first time in this field, contemporary notions of welcome and hospitality as outlined within the cosmopolitanism tradition, asking whether they offer insights into how healthcare may become more accessible for people who regularly experience stigmatisation. In concluding, the article considers the need to think further about forms of exclusion that occur when social and individual histories of stigma are not institutionally recognised, and measures to counter these histories are not actively adopted.

Personalized Approach Bias Modification Smartphone App ("SWIPE") to Reduce Alcohol Use Among People Drinking at Hazardous or Harmful Levels: Protocol for an Open-Label Feasibility Study

Background

Alcohol accounts for 5.1% of the global burden of disease and injury, and approximately 1 in 10 people worldwide develop an alcohol use disorder. Approach bias modification (ABM) is a computerized cognitive training intervention in which patients are trained to “avoid” alcohol-related images and “approach” neutral or positive images. ABM has been shown to reduce alcohol relapse rates when delivered in residential settings (eg, withdrawal management or rehabilitation). However, many people who drink at hazardous or harmful levels do not require residential treatment or choose not to access it (eg, owing to its cost, duration, inconvenience, or concerns about privacy). Smartphone app–delivered ABM could offer a free, convenient intervention to reduce cravings and consumption that is accessible regardless of time and place, and during periods when support is most needed. Importantly, an ABM app could also easily be personalized (eg, allowing participants to select personally relevant images as training stimuli) and gamified (eg, by rewarding participants for the speed and accuracy of responses) to encourage engagement and training completion.

Objective

We aim to test the feasibility and acceptability of “SWIPE,” a gamified, personalized alcohol ABM smartphone app, assess its preliminary effectiveness, and explore in which populations the app shows the strongest indicators of effectiveness.

Methods

We aim to recruit 500 people who drink alcohol at hazardous or harmful levels (Alcohol Use Disorders Identification Test score≥8) and who wish to reduce their drinking. Recruitment will be conducted through social media and websites. The participants’ intended alcohol use goal (reduction or abstinence), motivation to change their consumption, and confidence to change their consumption will be measured prior to training. Participants will be instructed to download the SWIPE app and complete at least 2 ABM sessions per week for 4 weeks. Recruitment and completion rates will be used to assess feasibility. Four weeks after downloading SWIPE, participants will be asked to rate SWIPE’s functionality, esthetics, and quality to assess acceptability. Alcohol consumption, craving, and dependence will be measured prior to commencing the first session of ABM and 4 weeks later to assess whether these variables change significantly over the course of ABM.

Results

We expect to commence recruitment in August 2020 and complete data collection in March 2021.

Conclusions

This will be the first study to test the feasibility, acceptability, and preliminary effectiveness of a personalized, gamified ABM intervention smartphone app for hazardous or harmful drinkers. Results will inform further improvements to the app, as well as the design of a statistically powered randomized controlled trial to test its efficacy relative to a control condition. Ultimately, we hope that SWIPE will extend the benefits of ABM to the millions of individuals who consume alcohol at hazardous levels and wish to reduce their use but cannot or choose not to access treatment.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000638932p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000638932p

International Registered Report Identifier (IRRID)

PRR1-10.2196/21278

Redressing responses to the treatment gap for people with alcohol problems: The overlooked role of untreated remission from alcohol problems

Abstract. Aims: The “treatment gap” for people with alcohol problems has been identified as very large in the literature. An array of responses to the treatment gap have been focussed upon, including changing the perceptions of untreated people in order to make them want treatment more. A separate approach identifies the treatment system itself as the cause of the treatment gap. The aim of this paper was to consider research on untreated remission from alcohol problems to better understand responses to the treatment gap. Methodology: Three areas of existing published literature were thematically reviewed and synthesised: treatment gap research, untreated remission from alcohol problems research, and treatment planning and system design research. Results: Including rates of untreated remission from alcohol problems reduces the size of the treatment gap considerably. Treatment planning models which estimate unmet demand are better suited than unmet need when identifying gaps in service provision. Responding to the treatment gap requires broadening the treatment system beyond the specialised setting, and the assumptions associated with the process and expected outcomes of remission may need revisiting. Conclusions: Treatment planning models are useful when identifying gaps in service provision, but more sophisticated inclusion of untreated remission data is required. The treatment response may need to be diversified to support the life circumstances and perspectives of people with alcohol problems, with one example (outlined in this paper) being the provision of digital support services.

Development of a Needs-Based Planning Model to Estimate Required Capacity of a Substance Use Treatment System

OBJECTIVE

Substance use services and supports have traditionally been funded without the benefit of a comprehensive, quantitative planning model closely aligned with population needs. This article describes the methodology used to develop and refine key features of such a model, gives an overview of the resulting Canadian prototype, and offers examples and lessons learned in pilot work.

METHOD

The need for treatment was defined according to five categories of problem severity derived from national survey data and anticipated levels of help-seeking estimated from a narrative synthesis of international literature. A pan-Canadian Delphi procedure was used to allocate this help-seeking population across an agreed-upon set of treatment service categories, which included three levels each of withdrawal management, community, and residential treatment services. Projections of need and required service capacity for Canadian health planning regions were derived using synthetic estimation by age and gender. The model and gap analyses were piloted in nine regions.

RESULTS

National distribution of need was estimated as Tier 1: 80.7%; Tier 2: 10.4%; Tier 3: 6.1%; Tier 4: 2.6%; and Tier 5: 0.2%. Pilot work of the full estimation protocol, including gap analysis, showed the results triangulated with other indicators of need and were useful for local planning.

CONCLUSIONS

Lessons learned from pilot testing were identified, including challenges with the model itself and those associated with its implementation. The process of estimation developed in this Canadian prototype, and the specifics of the model itself, can be adapted to other jurisdictions and contexts.