Exploring the relationship between solitary drinking and living without other adults on alcohol consumption during the COVID-19 pandemic.

AIMS: The COVID-19 pandemic presents the opportunity to learn about solitary drinking as many people were forced to spend time at home. The aim of this study is to examine the relationship between solitary drinking and living without other adults on alcohol consumption. METHODS: A longitudinal study with four survey waves (between May and November 2020) obtained seven-day drinking diary data from Australian adults living in New South Wales. In May, a convenience sample of 586 participants (Mage = 35.3, SD = 14.8; 65.3% women) completed the first wave. Participants then completed a survey in June (n = 319, 54.4% response rate), July/August (n = 225, 38.4% response rate), and November (n = 222, 37.9% response rate). Information about alcohol consumption including risky drinking (more than four drinks on one occasion), household structure, solitary drinking, and demographics were collected. We conducted random-effects panel bivariate and multivariable regression analyses predicting the number of standard drinks and risky drinking. RESULTS: Participants with solitary drinking occasions consumed more and had more risky drinking occasions than participants with no solitary drinking occasions, which was also found to be the case during lockdown. Living without other adults was associated with less consumption and less risky drinking than living with other adults. However, participants who lived without other adults and had frequent solitary drinking occasions (solitary drinking in >50% drinking occasions) reported more consumption than participants without a solitary drinking occasion. CONCLUSIONS: Individuals who consume alcohol alone and live without other adults or spend long periods of time at home may be more at risk of alcohol-related harm.

Revision of the Australian guidelines to reduce health risks from drinking alcohol.

INTRODUCTION: The Australian guidelines to reduce health risks from drinking alcohol were released in 2020 by the National Health and Medical Research Council. Based on the latest evidence, the guidelines provide advice on how to keep the risk of harm from alcohol low. They refer to an Australian standard drink (10 g ethanol). RECOMMENDATIONS: •Guideline 1: To reduce the risk of harm from alcohol-related disease or injury, healthy men and women should drink no more than ten standard drinks a week and no more than four standard drinks on any one day. The less you drink, the lower your risk of harm from alcohol. •Guideline 2: To reduce the risk of injury and other harms to health, children and people under 18 years of age should not drink alcohol. •Guideline 3: To prevent harm from alcohol to their unborn child, women who are pregnant or planning a pregnancy should not drink alcohol. For women who are breastfeeding, not drinking alcohol is safest for their baby. CHANGES AS RESULT OF THE GUIDELINE: The recommended limit for healthy adults changed from two standard drinks per day (effectively 14 per week) to ten per week. The new guideline states that the less you drink, the lower your risk of harm from alcohol. The recommended maximum on any one day remains four drinks (clarified from previously "per drinking occasion"). Guidance is clearer for pregnancy and breastfeeding, and for people aged less than 18 years, recommending not drinking.

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations.

OF RECOMMENDATIONS AND LEVELS OF EVIDENCE: Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity-frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient's needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the "teach-back" technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A). SUMMARY OF KEY RECOMMENDATIONS AND LEVELS OF EVIDENCE: Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A).

The political and scientific challenges in evaluating compulsory drug treatment centers in Southeast Asia.

BACKGROUND: In Vietnam, like many countries in Southeast Asia, the commonly used approach of center-based compulsory drug treatment (CCT) has been criticized on human rights ground. Meanwhile, community-based voluntary methadone maintenance treatment (MMT) has been implemented for nearly a decade with promising results. Reform-minded leaders have been seeking empirical evidence of the costs and effectiveness associated with these two main treatment modalities. Conducting evaluations of these treatments, especially where randomization is not ethical, presents challenges. The aim of this paper is to discuss political challenges and methodological issues when conducting cost-effectiveness studies within the context of a non-democratic Southeast Asian country. METHODS: A retrospective analysis of the political and scientific challenges that were experienced in the study design, sample size determination, government approval and ethics approvals, participant recruitment, data collection, and determination of sources, and quantification of cost and effectiveness data was undertaken. As a consequence of the non-randomized design, analysis of patient characteristics for both treatment types was undertaken to identify the magnitude of baseline group differences. Concordance between self-reported heroin use and urine drug testing was undertaken to determine the reliability of self-report data in a politically challenging environment. RESULTS: We demonstrate that conducting research around compulsory treatment in a non-democratic society is feasible, yet it is politically challenging and requires navigation between science and politics. We also demonstrate that engagement with the government decision makers in the research conception, implementation, and dissemination of the results increases the likelihood of research evidence being considered for change in a contentious drug policy area. CONCLUSIONS: Local empirical evidence on the comparative cost-effectiveness of CCT and MMT in a Southeast Asian setting is critical to consideration of more holistic, humane, and effective drug-dependence treatment approaches, but the garnering of such evidence is very challenging.

A systematic review of modelling approaches in economic evaluations of health interventions for drug and alcohol problems.

BACKGROUND: The overarching goal of health policies is to maximize health and societal benefits. Economic evaluations can play a vital role in assessing whether or not such benefits occur. This paper reviews the application of modelling techniques in economic evaluations of drug and alcohol interventions with regard to (i) modelling paradigms themselves; (ii) perspectives of costs and benefits and (iii) time frame. METHODS: Papers that use modelling approaches for economic evaluations of drug and alcohol interventions were identified by carrying out searches of major databases. RESULTS: Thirty eight papers met the inclusion criteria. Overall, the cohort Markov models remain the most popular approach, followed by decision trees, Individual based model and System dynamics model (SD). Most of the papers adopted a long term time frame to reflect the long term costs and benefits of health interventions. However, it was fairly common among the reviewed papers to adopt a narrow perspective that only takes into account costs and benefits borne by the health care sector. CONCLUSIONS: This review paper informs policy makers about the availability of modelling techniques that can be used to enhance the quality of economic evaluations for drug and alcohol treatment interventions.

When self-direction meets conformity: Surfacing Schwartz's 10 basic human values in drug policy dialogue with lived/living experience participants.

BACKGROUND: Research on values is gaining in popularity within drug policy scholarship. To date, research has focused on analysing values within policy, through documentary analysis and interviews with key stakeholders. We extend this research enquiry to investigate the values that emerge from drug policy debate with those who have lived and/or living experience of using drugs. METHODS: We used workshop data collected from the ESRC-funded Drug Policy Voices project as the basis for our analysis. Within the workshops, participants were given a range of drug policy scenarios to discuss. We selected three scenarios for this paper which discussed policies related to cannabis, heroin, and MDMA/ecstasy. We coded the workshop data using Schwartz's ten basic values, which is a framework that perceives values as the core 'motivators of action' that underpin choices, attitudes and behaviours. RESULTS: We found that the values of 'self-direction', 'security' and 'conformity' were prominent across this participant group, when discussing these policy topics. Yet the drug policy preferences discussed in the workshops revealed that it is the combinations of values that nuance preferences. Security combined with self-direction supports policies that enhance personal responsibility for change; self-direction combined with hedonism supports freedom to use drugs, whereas self-direction combined with conformity and achievement supports recovery policies; and conformity combined with tradition and power supports abstinence-based drug prevention. CONCLUSION: Schwartz's ten basic values provided a useful framework for surfacing values that underpin drug policy preferences. These exploratory findings demonstrate that identifying values within dialogue is a complex process and reinforces opposing values can explain policy preference differences. More importantly, policy preferences were underpinned by combinations of values including those that are apparently opposing in Schwartz's circumplex.

Prioritizing measures to assess performance of drug treatment services: a Delphi process with funders, treatment providers and service-users.

BACKGROUND AND AIM: While many studies have examined outcome measurement as part of clinical trials and routine outcome collection at the person-level in alcohol and other drug (AOD) treatment services, there has been limited attention to measures required to assess performance at the service-level. In Australia, non-government services are primarily funded by government using public funds; however, there is no standardized approach to performance measurement. This study sought to establish a finite list of performance measures that represented consensus between funders, treatment providers and service-users. METHOD: A three-round Delphi process was undertaken with (i) funders of treatment (n = 10), (ii) treatment providers (n = 10) and (iii) treatment service-users (n = 10). Participants were asked to rate a range of measures on a 10-point Likert scale on how important they were to be included in contracts with funders. Measures with a median score > 7 and agreement among participants above 70% were the criteria for inclusion in the final set of measures. Qualitative data in the form of text responses provided by participants for their ratings in rounds 1 and 2 were also analysed. RESULTS: Participants rated 93 measures in round 1, which reduced to 78 measures in round 2 and 32 measures in round 3. Fifteen service-level measures and two system-level measures met criteria for inclusion in the final set of performance measures. The final set of measures cover a range of measurement types: outcomes (n = 5), access (n = 3), structural (n = 3), experience (n = 2), input (n = 2), process (n = 1) and output (n = 1). CONCLUSION: In Australia, performance measures for alcohol and other drug treatment services that represent a consensus among service-users, providers and funders focus upon demonstrating accountability for public funds, improving services and communicating key measures of success to future service-users and the broader community.

Post-retirement enlightenment syndrome: Worthy of investigation.

Post-Retirement Enlightenment Syndrome is a term used by some in illicit drug policy to reflect the experience of having politicians "come out" in favour of drug policy reform only after retirement. To date, the phenomenon has not been examined in any systematic manner. While discussions of the phenomenon on social media tend to be playful, they nevertheless express real frustration with the reluctance of privately supportive sitting politicians and policing officials to speak out in favour of non-punitive and/or harm reduction-oriented policies. In this commentary, we give an overview of the phenomenon of Post-Retirement Enlightenment Syndrome. We argue that these instances of sitting officials speaking out publicly in favour of drug policy reform, as well as instances in which such apparent "enlightenment" is not publicly expressed until after retirement, are potentially highly fruitful areas for investigation. Public positions on drug policy are invariably contoured by conditions of political possibility. We raise the call for both an unpacking and examination of the structural and relational aspects of "political will" and "political courage". Sitting and retired politicians each have a role in the drug policy landscape, whether as lawmakers or as high-profile and often respected commentators. This commentary argues that a more nuanced understanding of the conditions that may support or hinder the expression of public support for drug policy reform by political office bearers, whether sitting or former, has implications for advocates and researchers invested in policy change.

An overlooked effect: domestic violence and alcohol policies in the night-time economy.

BACKGROUND AND AIMS: Restrictive late-night alcohol policies are aimed at reducing alcohol-related violence but, to date, no evaluations of their impact on family and domestic violence have been conducted. This study aimed to measure whether modifying the drinking environment and restricting on-site trading hours affected reported rates of family and domestic violence. DESIGN, SETTING AND PARTICIPANTS: This study used a non-equivalent control group design with two treatment sites and two matched control sites with pre- and postintervention data on rates of family and domestic violence assaults within local catchment areas of four late-night entertainment precincts in New South Wales, Australia, covering a population of 27 309 people. Participants comprised monthly counts of police-recorded incidents of domestic violence assaults from January 2001 to December 2019. INTERVENTIONS AND COMPARATORS: Two variations of restrictive late-night interventions were used: restricted entry to late-night venues after 1:30 a.m., trading ceasing at 3:30 a.m. and other restrictions on alcohol service (Newcastle); and restricted entry to late-night venues after 1 a.m. and a range of restrictions on alcohol service (Hamilton). The comparators were no restrictions on late-night trading or modifications of the drinking environment (Wollongong and Maitland). MEASUREMENTS: Measurements involved the rate, type and timing of reported family and domestic violence assaults. FINDINGS: Reported rates of domestic violence assaults fell at both intervention sites, while reported domestic violence assaults increased over time in the control sites. The protective effects in Newcastle were robust and statistically significant across three main models. The relative reduction associated with the intervention in Newcastle was 29% (incidence rate ratio = 0.71, 95% confidence interval: 0.60-0.83) and an estimated 204 assaults were prevented across the duration of the study. The protective effects found in Hamilton were not consistently supported across the three main models. CONCLUSIONS: Increases to late-night alcohol restrictions may reduce rates of domestic violence.

Piloting a classification framework for the types of evidence used in alcohol policymaking.

INTRODUCTION: Most studies of alcohol policy have focussed on the role of industry. However, little is known about the evidence base used in alcohol policymaking or policymakers' actions in the field. Here, we mapped the different evidence types used in a case study to construct a classification framework of the evidence types used in alcohol policymaking. METHODS: Using a case study from the state-level in Australia, we used content analysis to delineate the evidence types cited across six phases of a policymaking process. We then grouped these types into a higher-level classification framework. We used descriptive statistics to study how the different evidence types were used in the policymaking process. RESULTS: Thirty-one evidence types were identified in the case study, across four classes of knowledge: person knowledge, shared knowledge, studied knowledge and practice knowledge. The participating public preferenced studied knowledge. Policymakers preferenced practice knowledge over all other types of knowledge. DISCUSSION AND CONCLUSION: The classification framework expands on models of evidence and knowledge used across public health, by mapping new evidence types and proposing an inductive method of classification. The policymakers' preferences found here are in line with theories regarding the alcohol industry's influence on policymaking. The classification framework piloted here can provide a useful tool to examine the evidence base used in decision-making. Further study of evidence types used in policymaking processes can help inform research translation and advocacy efforts to produce healthier alcohol policies.

Sociometric network analysis in illicit drugs research: A scoping review.

BACKGROUND: Sociometric or whole network analysis, a method used to analyze relational patterns among social actors, emphasizes the role of social structure in shaping behaviour. Such method has been applied to many aspects of illicit drug research, including in the areas of public health, epidemiology, and criminology. Previous reviews about social networks and drugs have lacked a focus on the use of sociometric network analysis for illicit drugs research across disciplines. The current scoping review aimed to provide an overview of the sociometric network analysis methods used in illicit drugs research and to assess how such methods could be used for future research. METHODS: A systematic search of six databases (Web of Science, ProQuest Sociology Collection, Political Science Complete, PubMed, Criminal Justice Abstracts, and PsycINFO) returned 72 relevant studies that met the inclusion criteria. To be included, studies had to mention illicit drugs and use whole social network analysis as one of their methods. Studies were summarized quantitatively and qualitatively using a data-charting form and a description of the studies' main topics. RESULTS: Sociometric network analysis in illicit drugs research has grown in popularity in the last decade, using mostly descriptive network metrics, such as degree centrality (72.2%) and density (44.4%). Studies were found to belong to three study domains. The first, drug crimes investigated network resilience and collaboration patterns in drug trafficking networks. The second domain, public health, focused on the social networks and social support of people who use drugs. Finally, the third domain focused on the collaboration networks of policy, law enforcement, and service providers. CONCLUSION: Future illicit drugs research using whole network SNA should include more diverse data sources and samples, incorporate mixed and qualitative methods, and apply social network analysis to study drug policy.

Pill testing policy: A comparative analysis using the Advocacy Coalition Framework.

INTRODUCTION: Pill testing is regarded as a controversial harm reduction intervention and provides an ideal case study for examining how policy change comes about. Two Australian jurisdictions were analysed to explore factors that may account for policy change by comparing the ACT which allowed a pill testing trial, and NSW where pill testing has not been permitted. METHODS: The analysis was conducted using the Advocacy Coalition Framework (ACF). Data sources were first coded to establish the subsystem actors beliefs and advocacy coalitions; then coded using a deductive approach and classified against core dimensions of the ACF. An inductive approach was then applied to generate and link themes in the data. RESULTS: A dominant and minority coalition was identified in each jurisdictions' policy subsystem. The results show how in the ACT a dominant 'harm reduction' coalition shifted their secondary beliefs and introduced a pill testing policy. Whereas in NSW, a shift in both the secondary and policy core beliefs of the dominant 'law enforcement' coalition was required, something which rarely occurs according to the ACF. DISCUSSION AND CONCLUSIONS: The analysis supports the ACF's assertion that advocacy coalitions will respond to pressures for change by restricting change to secondary beliefs, while keeping policy core beliefs intact. It also demonstrates that secondary and policy core beliefs matter in the context of minority and dominant coalitions. Further research is needed to explore whether a minority coalition's strategic re-framing of an issue to align with the policy core beliefs of their opponents would have more success than advocating from their own belief paradigm.

Distinguishing personal use of drugs from drug supply: Approaches and challenges.

The ability to fairly and justly distinguish between drug possession for personal use and drug possession for supply is a central feature of drug laws across the globe. Whether such distinctions pertain to decriminalisation of simple possession, or to the penalties associated with drug offences, such differentiation remains a core problem for policymakers. In this commentary, taking 91 different jurisdictions into consideration, we identify five different approaches to distinguishing personal use from supply: four of these involved quantification of an amount of drug (whether in weight or number of doses). The other approach relied on case-by-case judgement. Drawing upon survey data of drug use from nine countries, we provide an example of how the quantity bears little resemblance to drug use patterns, and does not take heterogeneity of drug use into account. While the non-quantified approach can lead to discriminatory and racialised policing, all of the quantification approaches also pose problems, largely concerned with arbitrary amounts. There appears to be no perfect way to differentiate possession for personal use from intentions to supply. This commentary opens up a number of important policy-relevant research questions given this central feature of drug policy design.

"It's professional but it's personal": Participation, personal connection, and sustained disagreement in drug policy reform.

While there is widespread agreement as to the importance of increasing participation in drug policy design, drug policy literature contains limited reflection on the practices that may support inclusion and collaboration amongst policy actors, particularly when disagreement and difference are an intrinsic part of participation. Drawing on qualitative interviews and ethnographic fieldwork with actors engaged in an Australian illicit drug policy reform campaign, this paper examines how particular modes of personal connection mattered in establishing and maintaining working relationships between a range of differently situated actors. Through engagement with this case study, we argue that modes of personal connection marked by qualities such as being frank; engaged; not forcing consensus; enacting respect; listening in order to understand; and acting in ways that respected the obligations and limits that came with people's roles while also recognising one another as more than those roles, were particularly important qualities that supported connection across difference. Such personal connections seem to have been even more important for the engagement of people representing more marginal positionalities. Arguing that personal connection is already an element of both inclusion and exclusion in drug policy creation, we suggest that policy actors interested in contributing to a more diverse and rigorous policy participation space attend to how people connect, with whom, and with what space for disagreement, while also taking seriously the labour of such connection across difference.

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.

Navigating the grey: Experiences of incremental cannabis reform in Australia.

INTRODUCTION AND AIMS: There have been many changes to cannabis laws across the globe, some dramatic but more often incremental. This study explored the experiences after an incremental cannabis law reform in the Australian Capital Territory, Australia. METHOD: Semi-structured interviews (n = 30) were conducted in March and April 2021, 14 months after the introduction of cannabis law reform, with people aged 18 and over who had grown and/or consumed cannabis in the previous 12 months. Participants were asked about recent and past cannabis use, growing cannabis and changes to their practices after the introduction of the legislation. RESULTS: Incremental cannabis law change resulted in regulatory grey areas. How people interpreted and navigated such grey areas were connected to their relative privileges, circumstances and histories. Those who were highly policed were more likely to experience the grey areas negatively. Those who were not highly policed found the grey areas confusing or 'half-arse' (insufficiently executed), but mostly experienced the new laws positively through new cannabis cultivation or perceived reduction in stigma and fear of arrest. Those with self-identified privilege were unconcerned with grey areas of the legislation. DISCUSSION AND CONCLUSION: Incremental policy change can result in grey areas that require some navigation. Vulnerable populations appear less likely to experience the full benefits of such incremental drug law reform. It is vital to attend to the inequities that can arise from incremental law reform so that positive experiences are shared across the population regardless of relative privilege.

The details of decriminalization: Designing a non-criminal response to the possession of drugs for personal use.

Internationally, policymakers are considering alternative, non-criminal responses to the possession of drugs for personal use, or 'simple possession'. We show that 'decriminalization' is not a simple, unified model; rather, there are meaningful differences in policies and options available as part of a non-criminal response. Responses include various decriminalization, diversion, and depenalization approaches. However, what details need to be considered in developing these approaches? In this paper, we eschew these labels and present an overview of key design features of non-criminal responses to simple possession and consider some of the equity considerations of the choices available, including reform architecture (the objectives and legal framework); eligibility criteria (population-, place-, and drug-based criteria); and actions taken (deterrence, therapeutic, and enforcement strategies). This paper does not evaluate individual features or models, but instead offers a practical framework that can be used to deliberate on potential reform decisions.

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.

Applying a 'harm to others' research framework to illicit drugs: political discourses and ambiguous policy implications.

During the past decade, 'alcohol's harm to others' (AHTO) has emerged as an international approach to studying alcohol problems and informing policy. The AHTO approach seeks to increase political will for alcohol policy by mapping, measuring and often costing harms beyond the person who drinks (e.g. family members, co-workers). In this paper we consider the implications of a 'harm to others' approach for illicit drugs. We ask whether it could and should be used as a policy tool, given the high risks of further stigmatizing people who use drugs. We consider the ways in which the concept and measurement of 'harm to others' may be either productive or potentially harmful, depending on the extent to which the AHTO is replicated for illicit drugs. Shifting the language may assist: the term 'harm from others' appears to carry less risk of stigma. In addition, all harms inclusive of drug supply and drug consumption need to be included if a full picture of harms that accrue to other people from illicit drugs is to be achieved.