Telephone reminders are a cost effective way to improve responses in postal health surveys.

STUDY OBJECTIVE: To assess the effectiveness of a telephone reminder in increasing responses to postal surveys and to calculate the differential costs per completed questionnaire. DESIGN: Randomised controlled trial. SETTING: Australian university and rehabilitation medicine practice. PARTICIPANTS: The trial was conducted in 1999 among the 143 non-respondents to a questionnaire about work related neck and upper body disorders. The questionnaire was sent to two Australian female samples: 200 office workers (Sample A) and 92 former rehabilitation medicine patients (Sample B). A reminder letter, another copy of the questionnaire and a final letter were sent at two week intervals. Half of the non-respondents within each sample were randomly selected to receive a telephone reminder just after the second mailout of the questionnaire. All direct costs were calculated. MAIN RESULTS: Responses were significantly higher among those who received the telephone reminder intervention (relative risk 2.54, 95% confidence intervals 1.43 to 4.52). Analysed by intention to phone, 47% of non-respondents in Sample A and 38% in Sample B returned a complete questionnaire after the intervention, compared with 21% and 10%, respectively, in the control groups. For the 112 women (combined samples) who returned completed questionnaires before randomisation, the average cost per respondent was AUD14. There was a higher total cost for the intervention groups (AUD851 versus AUD386 for controls), but the significantly higher number of additional completed responses (31 versus 12) resulted in a 15% lower marginal cost per completed questionnaire in those groups. CONCLUSION: Telephone reminders are cost effective in improving responses to postal surveys.

'Sending the wrong signal': analysis of print media reportage of the ACT heroin prescription trial proposal, August 1997.

OBJECTIVE: To analyse and compare newspaper coverage about heroin during a period spanning two government policy decisions to approve, then prevent, a trial of heroin prescription to dependent users. METHOD: All articles published about heroin spanning the two policy decisions (1-19 August 1997) were collected from seven major Australian newspapers. Analyses included content and orientation analyses of all articles and discourse analysis of articles (excluding letters) containing value-laden statements about heroin prescription. Comparisons were made of content, orientation and subtextual themes employed by opponents and proponents of heroin prescription. RESULTS: 231 articles with references to heroin were identified from seven newspapers, 28% were published by The Daily Telegraph. This newspaper campaigned against the heroin prescription trial with 66% of news articles and 100% of opinion items negative in orientation, compared to averages of 11% and 16% of news and opinion articles published by comparison newspapers. Seven subtexts were identified in coverage opposing heroin prescription including "surrender in the war on drugs", "government as drug pedlar" and "deserving/undeserving citizens". Six subtexts supportive of heroin prescription were identified including "failure of prohibition" and "time for new approaches". CONCLUSION: The mid-1997 policy reversal on heroin prescription was due, in part, to the higher activity of opponents following approval of the trial and because proponents did not reframe discourses used to denigrate the proposal. IMPLICATIONS: To be successful, advocates of new policy need to recognise and reframe negative discourses to create new dominant themes which address the concerns of the public.

"They should have them all over the place": a health program for children of illicit drug users.

A peer-based support and advocacy group for illicit drug users in collaboration with a community nurse developed an innovative program for the children of users. The program provides well-baby checks, immunization monitoring, parenting advice, monitoring of children's safety, a free lunch and education about nutrition, as well as activities for the children and mothers. In addition, it allows mothers to have time out in a friendly, relaxed, safe, and nonjudgmental environment. The program has been running for more than 7 years, costs little, and gives a hard-to-reach population access to valuable health care.

What can a trial contribute to the debate about supervised injecting rooms?

Outlines the areas for evaluation of supervised injecting rooms, the limitations of any evaluation and how the evaluation results can be buttressed against misuse. Argues that forceful advocacy for the role of evaluation in political decision-making is needed.

The impact on retention of expansion of an Australian public methadone program.

Although rapid expansion of methadone programs has occurred in many countries, there are few studies of the impact on treatment success. The one public methadone maintenance program in Canberra was expanded from 85 places in 1991 to 350 places in late 1992. While this responded to a real need, it also led to a temporary increase in drop-outs. Retention was considerably improved in 1996 when clients began to be transferred from the public program to fee-for-service primary health care, but the improvement was also not sustained. In recent years, one-quarter to one-half of clients dropped out before stabilization. Multiple entries into treatment were common and overall retention was not affected by previous treatment episodes or length of time between episodes. Methadone programs should monitor retention as part of on-going evaluation and improvement of treatment policy.

A hierarchy of strategies heroin-using mothers employ to reduce harm to their children.

The present paper explores strategies that drug-using women employ to protect their children from drug-related harm. Twenty-two mothers were recruited through word-of-mouth, field recruitment, and flyers. Semi-structured interviews were used to collect mother's views on parenting and heroin use. Analysis was conducted using a standard qualitative software package. A hierarchy of seven strategies was identified: (1) stop using; (2) go into treatment; (3) maintain a stable small habit; (4) shield children from drug-related activities; (5) keep the home environment stable, safe, and secure; (6) stay out of gaol; and, if the children's needs still cannot be met, (7) place them with a trusted caregiver and maintain as active a parental role as possible. These strategies, derived innovatively from mothers' experiences, provide progressive goals for treatment and can also serve as measures of success. In addition, they may determine how well children fare in drug-affected families.

A pilot study of naltrexone-accelerated detoxification in opioid dependence.

OBJECTIVE: 1. To determine whether naltrexone-accelerated detoxification with minimal sedation is an acceptable and effective form of induction onto naltrexone. 2. To monitor outcomes of detoxified patients. DESIGN: Observational study. SETTING: Medical ward of a general hospital (for detoxification) and a community clinic (for follow-up) in Sydney, NSW, 1998. PATIENTS: 15 heroin users and 15 people seeking withdrawal from methadone. INTERVENTION: Detoxification used naltrexone (12.5 or 50 mg), with flunitrazepam (2-3 mg), clonidine (150-750 micrograms) and octreotide (300 micrograms) for symptomatic support. Patients remained awake and were discharged when they felt well enough. Follow-up was daily for four days and then weekly for up to three months for supportive care. MAIN OUTCOME MEASURES: Acute side effects; patient ratings of severity and acceptability of withdrawal; nights of hospitalisation; rates of induction onto naltrexone; retention in treatment over three months; and relapse to opioid use. RESULTS: Acute withdrawal with delirium lasted about four hours. Octreotide was crucial for controlling vomiting; with octreotide no patient required intravenous fluids. There were no major complications. Eighteen patients (60%) reported that it was a "quite" acceptable procedure, 18 (60%) required only one night's hospitalisation, and 24 (80%) were successfully inducted onto naltrexone (defined as taking naltrexone on Day 8). Three months later, six (20%) were still taking naltrexone (with four of these occasionally using heroin) and seven (23%) were abstinent from opioids, including five not taking naltrexone. Eleven had gone onto methadone maintenance, seven had relapsed to heroin use, and one had died of a heroin overdose. CONCLUSIONS: Rates of induction onto naltrexone were comparable with those reported for accelerated detoxification under sedation, suggesting that it can be performed successfully with minimal sedation. As in other studies of naltrexone maintenance, retention was low, and relapse to heroin use was common.

The long-term impact of childhood sexual abuse in Australian women.

OBJECTIVE: The aim of this study was to examine the association between childhood sexual abuse (CSA) and a range of adverse adult outcomes in a community sample of women using multivariate analysis which accounted for a number of potential confounding effects. METHOD: Retrospective study of cross-sectional data on the long-term impact of CSA, collected as part of a larger two-stage case-control study of the possible relationship between CSA and alcohol abuse. Data were appropriately weighted to adjust for the different selection probabilities of cases and controls. RESULTS: Significant associations were found between reporting CSA and experiencing domestic violence, rape, sexual problems, mental health problems, low self-esteem, and problems with intimate relationships even after taking into account a range of family background factors. Women who had experienced abuse involving intercourse were the most vulnerable to these negative outcomes. CONCLUSIONS: The findings indicate that the influence of CSA on adverse long-term effects is mediated and influenced both by the severity of the abuse experiences and by a range of family and social background factors.

The relationship between childhood sexual abuse and alcohol abuse in women--a case-control study.

AIMS: The aim of this paper was to examine the association between reporting childhood sexual abuse (CSA) and alcohol abuse in a community sample of women using multivariate analysis which took into account a range of potential confounding variables (such as a family history of alcoholism) and effect modifiers (such as having an alcoholic partner). DESIGN: A two-stage retrospective case-control study was used to investigate the relationship between reporting CSA and alcohol abuse in women. PARTICIPANTS: Seven hundred and ten women randomly selected from the Australian federal electoral rolls. MEASUREMENTS: The Alcohol Use Disorders Identification Test (AUDIT) was used to measure alcohol abuse. A series of questions based on those developed by Wyatt (1985) were used to ascertain the prevalence of CSA. FINDINGS: The final model showed that the relationship between a history of CSA and alcohol abuse reflected a complex interaction between CSA and a range of other factors in a woman's background. CSA was not by itself a significant predictor of alcohol abuse (OR = 0.61; 95% CI = 0.31-1.20). However, a history of CSA became significant in combination with co-factors which included: having a mother who was perceived as cold and uncaring; having an alcoholic partner; and believing that alcohol is a sexual disinhibitor. CONCLUSION: This study indicates that CSA alone is not a causative factor in the development of alcohol abuse among women and highlights the importance of examining the family background of women with alcohol problems.

A study of potential risk factors for sexual abuse in childhood.

Research aimed at identifying risk factors for childhood sexual abuse (CSA) is crucial for the development of preventative strategies. This study examined the relationship between a number of possible risk factors and CSA in a community sample of women using multivariate analysis and carefully operationalized variables. The variables significantly associated with CSA were physical abuse, having a mother who was mentally ill, not having someone to confide in, and being socially isolated. With the exception of physical abuse, different predictors emerged for abuse before and after age 12. Social isolation and experiencing the death of a mother were significant predictors for abuse before age 12, while the predictors of CSA after age 12 were physical abuse and a mentally ill mother. For abuse perpetrated by a family member, the significant predictors of CSA were physical abuse, having no one to confide in, having no caring female adult, and having an alcoholic father. For girls abused by someone outside of the family, the significant predictors were physical abuse, social isolation, mother's death, and having an alcoholic mother. While CSA can happen to any child, this study highlights circumstances that may increase the chances of abuse and should form the basis of prevention and intervention strategies.

The ACT heroin trial: intellectual, practical and political challenges.

An array of intellectual, practical and political challenges will be faced both if the Australian Capital Territory "heroin trial" does or does not eventuate. The intellectual challenges include the development of new methodologies and analytical tools for some of the outcome measures; the further development of a research process which involves all the relevant disciplines and interest groups; and capitalizing on an unprecedented opportunity to investigate the pharmacokinetics of heroin. The practicalities of setting up a trial also present a number of challenges, as does incorporating a health development approach. Political challenges include getting a sensible decision made about the trial, avoiding capture of the debate by supporters or opponents of drug law reform and avoiding unrealistic expectations. The major challenge if the trial does not go ahead is to implement other well-considered proposals which can be carefully evaluated.

Why? Who? How? Estimating numbers of illicit drug users: lessons from a case study from the Australian Capital Territory.

There is currently a resurgence of interest in estimating numbers of illicit drug users in Australia. Defining why numbers are needed, who is to be counted and how estimates should be derived are vital steps in the production of useful, valid estimates. We present a range of estimates of heroin users in the Australian Capital Territory which were developed as part of an investigation of the feasibility of prescribing heroin to dependent users. These produced estimates ranging from 433 to 1251 users. We conclude that household surveys, capture-recapture, and multipliers derived from nomination techniques have serious and often unrecognised limitations. Capture-recapture estimates, in particular, are unlikely to be useful, except at a local level. The best way forward for the derivation of national estimates for the National Drug Strategy is a three-pronged approach; national surveys, validated multipliers and monitoring of key indicators by drug-related services and agencies.

Drug use, binge drinking and attempted suicide among homeless and potentially homeless youth.

In order to assess the need for drug-related services for at-risk youth, a survey was conducted among young people aged 12-17 years who, owing to severe family discord, were currently living away from home (homeless) or had experienced periods away from home in the past 12 months (potentially homeless). Prevalence of use and of potentially harmful levels of use of alcohol and other licit and illicit drugs were higher than in a comparative population. Of the 155 people interviewed, 54% reported past physical abuse, 28% reported past sexual abuse, and 73% had a family alcohol or other drug history. Of the total, 62% had been in a youth refuge at some time in the past 12 months. Twenty four per cent had been to hospital as a result of alcohol or other drug use and 45% had attempted suicide. Female sex and an interaction between sexual abuse and binge drinking predicted suicide attempts. This study points to the need for a comprehensive approach to interventions for troubled youth which gives greater recognition to mental health issues related to family circumstances, including abuse.

Using ambulance service records to examine nonfatal heroin overdoses.

Overdoses are a preventable health hazard associated with heroin use. In the first study of its kind, we examined the records on nonfatal overdoses of the Australian Capital Territory (ACT) Ambulance Service from August 1990 to July 1993. There was a dramatic increase in the number of overdoses in the second half of 1992 and the first half of 1993, but the reasons for the increase are not clear. Most overdoses occurred in men aged under 30, indoors, and many cases were taken to hospital. Often there was no information on why the overdose occurred; when information was available, about half the cases were attributed to taking heroin in combination with other drugs. Suggestions for improving the quality of the data collected are made. These include more systematic recording by ambulance officers of the drug involved in the overdose and whether the drug was used alone or in combination with others, and linkage of ambulance service records with survey data and information from analysis of heroin purity.

Controlled heroin availability in Australia? How and to what end?

The general public, police, service providers, and users/ex-users were asked their views about options for trial design and trial outcomes with regard to a proposal for experimental controlled heroin availability. There was substantial agreement between the samples on issues concerning trial design. In general, the samples from the community, service providers and users/ex-users were more likely to report that a trial would result in positive outcomes, whereas the police sample was more likely to report that a trial would result in negative outcomes. This study illustrates the value of systematic consultation of key groups in exploring the options for change, raising potential difficulties, and highlighting different interests.

The Canberra Christmas overdoses mystery.

Our investigation of a cluster of three fatal overdoses casts doubt on the conventional wisdom that overdoses result from unregulated changes in the purity of street heroin. Use of alcohol or other sedatives can make an otherwise safe dose of heroin (or other opioids) lethal. In addition users can knowingly increase their dose, usually as an indulgence. Some media reporting of this cluster of deaths was accurate, but there was also sensationalization, perpetuating stereotypes about the drug market that may be untrue. Information flow within the using community was relatively accurate, but slow, possibly because it was the holiday season. Larger studies to substantiate our findings are needed. In addition, introduction of a user-organization-based epidemiological monitoring system for overdoses would be a valuable public health measure.