Insertion of intrauterine contraceptive devices by registered nurses in Australia.

BACKGROUND: In spite of many advantages, intrauterine contraception (IUC) is underutilised in Australia: only 5% of Australian women using contraceptive methods in 2011 were using IUC. AIMS: In 2012, Family Planning New South Wales (FPNSW) commenced training registered nurses (RNs) to insert IUC. This article reports outcomes of insertion attempts by the first four trained RNs and suggests strategies for increasing IUC utilisation in Australia. MATERIALS AND METHODS: Data regarding client characteristics and outcomes of insertion attempts, including relevant adverse events that occurred during a 6-month follow-up period after the IUC insertions, were retrospectively extracted from the FPNSW clinical record system and analysed in SPSS. RESULTS: Of 207 insertion attempts by RNs, 91% were successful without Medical Officer (MO) assistance. The likelihood of insertion attempts being successful did not differ significantly between nulliparous and parous clients. Incidence of a postinsertion adverse event was equal to or less than rates in previous studies. All adverse events involved parous clients. CONCLUSIONS: We have shown that RNs who undertook competency-based IUC insertion training had a high rate of successful insertions and a low rate of adverse outcomes. Utilisation of IUC in Australia could be increased by engaging RNs as inserters, and it is timely to review the barriers that make it difficult for private medical services to employ RNs to insert IUC.

Outcomes of intrauterine device insertion training for doctors working in primary care.

BACKGROUND: Intrauterine devices (IUDs) are underused in Australia despite being one of the most effective, reversible methods of contraception. OBJECTIVE: The objective of this article is to report on the outcomes of a competency-based IUD training program by Family Planning NSW for general practitioners (GPs). METHODS: Pre-training and post-training questionnaires were used for a 12-month cohort study of GPs who undertook IUD insertion training. RESULTS: Twenty-two GPs (92%) completed the follow-up questionnaire; 19 participants reported attempting a total of 238 IUD insertions, 212 (89%) of which were successful. Few complications were reported. Most participants cited inadequate remuneration, time constraints and lack of appropriate patients as barriers to performing IUD insertion. Nearly all (96%) were confident with IUD insertion in multiparous women, but only 46% felt confident inserting in nulliparous women. There was evidence of a reduction in referrals to external IUD inserters following training. DISCUSSION: Training enabled GPs to insert IUDs in their practices, but more than two-thirds (68%) fitted fewer than 12 devices during follow-up. A number of barriers to IUD insertion in general practice can be addressed to improve community access.

Equity of access to treatment, and barriers to treatment for illicit drug use in Australia.

AIMS AND DESIGN: This study investigated equity of access to treatment and barriers to treatment for illicit drug use, using Andersen's behavioural model of health service utilization. SETTING AND PARTICIPANTS: The study involved 492 drug users who had received treatment and 193 who had not. MEASUREMENTS: Participants were interviewed to gather data relating to 19 predisposing, need and enabling variables. FINDINGS: Never-treated participants exhibited less need for treatment than those who had received treatment. They experienced less negative emotion, used their main drug less often, had fewer drug-related health problems and fewer drug-using friends, were less likely to have blood-borne virus infections and were more likely to be using drugs for 'fun'. They also had more negative attitudes towards drug treatment staff, were less likely to believe that appropriate treatment was available and less likely to believe that professional help was necessary to get off drugs. Prevalence of physical and mental health problems was high in both groups. CONCLUSIONS: The study documented significant unmet treatment need and identified several sources of inequity and barriers to treatment that would be amenable to policy and service development. Drug user organizations and peer educators and motivational interventions in primary care settings should be utilized to market the nature and benefits of treatment effectively, and to address the causes of drug users' negative attitudes towards treatment.

Follow-up difficulty: correlates and relationship with outcome in heroin dependence treatment in the NEPOD study.

Data collected from 317 heroin users who participated in four studies that were included in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence were analysed to examine predictors of follow-up difficulty and whether follow-up difficulty was related to heroin use outcomes. Participants who were no longer receiving treatment were more difficult to contact and more likely to be lost to follow-up. Participants treated in general practice settings were also more difficult to contact and more likely to be lost to follow-up than participants treated at specialist clinics. Contact difficulty among followed-up participants (either in or out of treatment) was unrelated to heroin use outcomes. The 21% of participants who were followed-up with just one contact attempt reported 20.0 heroin-free days in the previous month, increasing only slightly to 20.9 based on the 70% of participants eventually contacted after up to 20 attempts. The study examined three methods for imputing missing heroin use outcome data and concluded that imputation of missing outcome data by inserting corresponding baseline data may be too conservative.

Short-term outcomes of five heroin detoxification methods in the Australian NEPOD Project.

This study included 380 participants in five heroin detoxification trials whose data were pooled to enable direct comparison of five detoxification methods in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD). Rapid detoxification achieved similar initial abstinence rates with either anaesthesia or sedation (average 59%), which were higher than was achieved by inpatient detoxification using clonidine plus other symptomatic medications (24%), which in turn was higher than outpatient detoxification using either buprenorphine (12%) or clonidine plus other symptomatic medications (4%). Older participants and those using more illicit drugs were more likely to achieve abstinence. Entry rates into ongoing postdetoxification treatment were as follows: buprenorphine outpatient (65%), sedation (63%), anaesthesia (42%), symptomatic outpatient (27%), and symptomatic inpatient (12%). Postdetoxification treatment with buprenorphine or methadone was preferred over naltrexone. Participants with more previous detoxification attempts were more likely to enter postdetoxification treatment. Given that outpatient detoxification was more effective with buprenorphine than with symptomatic medications and that rapid detoxification was more effective than the symptomatic inpatient method, the roles of the symptomatic methods should be reconsidered.

Is it really crystal clear that using methamphetamine (or other recreational drugs) causes people to engage in unsafe sex?

Many studies have found associations between unsafe sexual behaviour and use of crystal methamphetamine (and many other recreational drugs). Researchers and authors of relevant articles in popular media have often interpreted these associations as meaning that using 'crystal' directly causes people to engage in unsafe sex, and that interventions should aim to reduce crystal use in order to reduce the prevalence of sexually transmissible infections such as HIV. There is consistent evidence that crystal users are a high-risk group in terms of sexual behaviour. However, most relevant studies have provided only circumstantial evidence regarding a causal relationship. Promoting the idea that a particular recreational drug is a major direct cause of unsafe sex may have the unintended adverse effect of creating an excuse for engaging in unsafe sex, thereby increasing its use, and may incur opportunity costs by preventing limited available health promotion resources from being directed more usefully. This paper examines the limitations, in terms of demonstrating causality, of various types of study that have been published on this topic in relation to crystal use in particular. Researchers who investigate relationships between recreational drug use and behaviour, including sexual behaviour, should be careful about the wording of their conclusions and recommendations, and should consider the possibly counterproductive ways in which their findings might be represented in the media.

Randomized controlled trial of a novel cannabis use intervention delivered by telephone.

AIMS: To evaluate the efficacy of a telephone-based intervention consisting of four sessions of motivational interviewing (MI) and cognitive behavioural therapy (CBT) designed to assist individuals to reduce their cannabis use and related problems. DESIGN: Random allocation to intervention or delayed treatment control with 4- and 12-week follow-up assessments. SETTING: Counsellors from the Cannabis Information and Helpline (CIH), an Australian reactive telephone service, delivered the intervention to callers seeking treatment. PARTICIPANTS: A total of 160 participants were recruited by the CIH, with 110 participants completing the final follow-up assessment (69% retention). MEASUREMENTS: Cannabis use, dependence and related problems and other substance use were assessed at baseline and follow-up. FINDINGS: Intervention participants reported greater reductions in dependence symptoms [P < 0.001, d = 0.9 (0.5-1.3)] and related problems [P < 0.001, d = 0.5 (0.1-0.9)] compared with control participants at both follow-up assessments. Compared with control, intervention participants reported greater confidence to reduce cannabis use at 4 weeks [P = 0.002, d = 0.5 (0.1-0.9)], and in turn reported a greater percentage of abstinent days at 12 weeks [P = 0.019, d = 0.6 (0.2-1.0)]. CONCLUSIONS: A brief course of motivational interviewing plus cognitive behavioural therapy delivered by telephone can help to reduce cannabis dependence and promote abstinence in the short term.

Using taxes to curb drinking: a report card on the Australian government's alcopops tax.

INTRODUCTION AND AIMS: In 2008, the Australian government introduced an 'alcopops tax' on spirit-based ready-to-drink (RTD) beverages to reduce alcohol consumption and particularly binge drinking by young people. DESIGN AND METHODS: Data regarding sales of alcoholic beverages in Australia from 2004 to 2009 were used to examine the possible effects of the alcopops tax. In addition, population data were used to calculate and examine per capita consumption. RESULTS: Various measures of consumption of wine-based RTDs, spirits, cider, wine and beer remained fairly stable or increased annually from 2004 to 2009. Consumption of spirit-based RTDs increased annually from 2004 to 2007, but then decreased in 2008 and 2009. Per capita alcohol consumption in terms of pure alcohol increased annually from 11.52 litres in 2004 to a peak of 11.79 litres in 2007, but then dropped to 11.55 litres and 11.41 litres in 2008 and 2009, respectively. DISCUSSION AND CONCLUSIONS: Consumption of spirit-based RTDs dropped and consumption of other alcoholic beverages increased following the introduction of the tax. The increased consumption of other alcoholic beverages could be interpreted as indicating that RTD drinkers switched to purchasing spirits or wine-based RTDs or cider. However, those increases could also be interpreted as a continuation of long-term trends rather than a 'substitution effect'. It is impossible to know how much of the changes were due to the tax, to the 'global financial crisis', to adaptive marketing by the alcohol industry, to the Government's national binge drinking strategy, to mass media coverage of these issues or to other factors.

Caller satisfaction with the Cannabis Information and Helpline.

We assessed caller satisfaction with an illicit drug helpline in Australia (the Cannabis Information and Helpline, CIH). A 10-min telephone interview was conducted with 200 volunteers who called the service during 2009 (121 called regarding themselves and 79 called regarding another person's cannabis use). Callers were a mean of 43 years of age and typically female (59%). Callers showed high levels of satisfaction with the service: the mean CSQ-8 score was 28.2 (SD = 4.3). Participants who found the service easy to access and those who felt their needs were met reported the highest satisfaction. A linear regression analysis was conducted to identify the significant predictors of participants' satisfaction with the CIH. The ease with which the participant was able to get through to a counsellor (standardized beta = 2.37, P < 0.02) and whether the participant felt that all their needs were met (standardized beta = -4.26, P < 0.001) were the only significant predictors of total satisfaction with the call. Despite the recognition that telephone services are possibly the easiest health-care service to access, ensuring consistent availability and accessibility remains paramount although not easy.

Streaming by case complexity: evaluation of a model for emergency department Fast Track.

OBJECTIVES: To evaluate a patient flow streaming system within a teaching hospital's ED, using functional principles to separate patients into two streams on the basis of complexity rather than acuity, severity or disposition. METHODS: The project used conceptual principles, such as patient complexity and 'lean thinking' theory, to create a new Fast Track patient stream, which was separately resourced. Data collected before and after implementation of the Fast Track system were analysed to evaluate the system. RESULTS: Following implementation of the system, significant improvements were observed in several key ED performance indicators. Mean waiting time was reduced from 55 to 32 min, mean treatment time was reduced from 209 to 191 min, compliance with New South Wales Department of Health waiting-time benchmarks increased from 59% to 77% and the percentage of patients who did not wait to complete their treatment halved from 6.2% to 3.1%. CONCLUSIONS: Key features in the success of the system included use of dedicated senior staff for Fast Track patients, and quarantining of clinical resources. The ED aiming to improve their waiting times and throughput should consider using complexity as a key criterion for triaging patients into separate streams. A low-complexity patient stream in the ED provides an ideal focus for advanced nursing practice.

Associations between crystal methamphetamine use and potentially unsafe sexual activity among gay men in Australia.

It has been suggested that crystal methamphetamine may have disinhibiting or aphrodisiac effects, which may lead to unsafe sexual behavior and increase the risk of HIV transmission. Using data from two Australian studies, the Sydney Gay Community Periodic Survey study and the Positive Health (PH) cohort study, we examined changes over time in use of crystal, other recreational drugs, and Viagra, and in a range of sex-related behaviors. Compared to non-users, crystal users reported having more sex partners, looking for sex in more types of venues, and being more likely to engage in unprotected anal intercourse with casual partners (UAIC) and in esoteric sex. Crystal users were also more likely to be using other recreational drugs and Viagra than non-users. Crystal use remained significantly associated with UAIC after adjustment for other relevant variables in a log-binomial regression analysis (adjusted prevalence rate ratio=1.26; 95% CI: 1.19-1.34). The other variables (HIV status, number of sex partners, number of types of venue where men looked for sex, Viagra use, other drug use) were independently associated with UAIC, and did not show confounding or mediating effects on the crystal-UAIC association. Nevertheless, these data did not allow reliable attribution of higher levels of these sex-related behaviors among crystal users specifically to the effects of crystal. The prevalence of crystal use among Australian men who have sex with men (MSM) increased between 2002 and 2005 (e.g., from 26% to 39% among HIV-+ MSM). However, the prevalence of UAIC remained stable or decreased over time in various study subgroups, as did the prevalence of other sex-related behaviors, suggesting that crystal use does not necessarily drive unsafe sexual behavior. Crystal use and unsafe sexual behavior can, and should, be considered and addressed separately in health promotion and community education campaigns.

Cost-effectiveness analysis of maintenance agonist treatments in the NEPOD.

A total of 551 participants were randomized to treatment in three heroin-dependence treatment trials participating in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD) project. A total of 272 patients (49%) received methadone maintenance, 238 (43%) received buprenorphine maintenance and 41 (7%) participants received levo-alpha-acetyl-methadol (LAAM). A total of 63% of participants in the methadone maintenance group were in treatment in the third month, with an average treatment episode lasting 69 days. This compares with 51% of participants in the buprenorphine maintenance group with an average treatment episode of 60 days and 71% of participants in the LAAM group with an average treatment episode of 75 days. The results of the cost-effectiveness analysis suggested that, for the primary outcome measure of imputed change in heroin-free days, compared with methadone maintenance, LAAM was the most cost-effective treatment, followed by buprenorphine maintenance. No statistically significant differences were found in the cost-effectiveness of methadone maintenance, buprenorphine maintenance and LAAM. Given the limited information available regarding the relative cost-effectiveness of pharmacotherapies for opioid maintenance treatment, the data reported herein provide valuable information to policy makers and treatment providers.