Pattern and characteristics of ecstasy and related drug (ERD) presentations at two hospital emergency departments, Melbourne, Australia, 2008-2010.

OBJECTIVE: To describe patterns and characteristics of emergency department (ED) presentations related to the use of ecstasy and related drugs (ERDs) in Melbourne, Australia. METHODS: Retrospective audit of ERD-related presentations from 1 January 2008 to 31 December 2010 at two tertiary hospital EDs. Variation in presentations across years was tested using a two-tailed test for proportions. Univariate and multivariate logistic regressions were used to compare sociodemographic and clinical characteristics across groups. RESULTS: Most of the 1347 presentations occurred on weekends, 24:00-06:00. Most patients arrived by ambulance (69%) from public places (42%), private residences (26%) and licensed venues (21%). Ecstasy-related presentations decreased from 26% of presentations in 2008 to 14% in 2009 (p<0.05); γ-hydroxybutyrate (GHB) presentations were most common overall. GHB presentations were commonly related to altered conscious state (89%); other presentations were due to psychological concerns or nausea/vomiting. Compared with GHB presentations, patients in ecstasy-related presentations were significantly less likely to require intubation (OR 0.04, 95% CI 0.01 to 0.18), but more likely to result in hospital admission (OR 1.77, 95% CI 1.08 to 2.91). Patients in amphetamine-related cases were older than those in GHB-related cases (median 28.4 years vs 23.9 years; p<0.05), and more likely to have a history of substance use (OR 4.85, 95% CI 3.50 to 6.74) or psychiatric illness (OR 6.64, 95% CI 4.47 to 9.87). Overall, the median length of stay was 3.0 h (IQR 1.8-4.8), with most (81%) patients discharged directly home. CONCLUSIONS: Although the majority of ERD-related presentations were effectively treated, with discharge within a short time frame, the number and timing of presentations places a significant burden on EDs. ERD harm reduction and improved management of minor harms at licensed venues could reduce this burden.

Ethical questions must be considered for electronic health records.

National electronic health record initiatives are in progress in many countries around the world but the debate about the ethical issues and how they are to be addressed remains overshadowed by other issues. The discourse to which all others are answerable is a technical discourse, even where matters of privacy and consent are concerned. Yet a focus on technical issues and a failure to think about ethics are cited as factors in the failure of the UK health record system. In this paper, while the prime concern is the Australian Personally Controlled Electronic Health Record (PCEHR), the discussion is relevant to and informed by the international context. The authors draw attention to ethical and conceptual issues that have implications for the success or failure of electronic health records systems. Important ethical issues to consider as Australia moves towards a PCEHR system include: issues of equity that arise in the context of personal control, who benefits and who should pay, what are the legitimate uses of PCEHRs, and how we should implement privacy. The authors identify specific questions that need addressing.

Challenges of reliability and validity in the identification and monitoring of emerging drug trends.

There is increasing pressure on drug monitoring systems to achieve earlier detection and greater precision in reporting of emerging drug use trends. Such systems typically operate in settings where government interest and the drug use trends themselves can be fluid. To achieve the goal of informing timely policy and practice responses in this environment, drug use monitoring systems must be flexible and responsive, as well as reliable and valid. This paper explores three interrelated areas relevant to trend monitoring that can benefit from a clearer focus in terms of increasing validity and reliability: the research paradigm to which systems adhere; the selection of sources or drug use indicators utilized by systems; and the process of analysis used by systems to ensure valid results. The reliability and validity of currently utilized drug use related indicators is discussed, with a focus on the validity of data sources as measures of emerging drug use trends. The relevance and utility of current descriptives such as "lagged" and "leading edge" indicators are assessed. Five dimensions, against which the validity of drug use indicators may be assessed in a trend-monitoring context are proposed as an alternative. Faced with a lack of clear conceptual frameworks underpinning and driving monitoring systems, it is argued that a pragmatic research paradigm can be adopted as a basis for guiding selection of indicators and helping to make explicit the concurrent or supplementary triangulation and analysis procedures on which valid results are necessarily founded. The current trend of using triangulation as the primary means of ensuring the validity of systems is critically reviewed and a challenge is issued to the field to make the analysis process more overt. No external funding was received for this article.

Comparing probability and non-probability sampling methods in Ecstasy research: implications for the internet as a research tool.

The usage of Ecstasy and related drug (ERD) has increasingly been the focus of epidemiological and other public health-related research. One of the more promising methods is the use of the Internet as a recruitment and survey tool. However, there remain methodological concerns and questions about representativeness. Three samples of ERD users in Melbourne, Australia surveyed in 2004 are compared in terms of a number of key demographic and drug use variables. The Internet, face-to-face, and probability sampling methods appear to access similar but not identical groups of ERD users. Implications and limitations of the study are noted and future research is recommended.

Critical questions we should ask in a changing Australian preventative health landscape: Competing interests, intervention limits and permissible health identities.

The national health reform reviews conducted recently in Australia ('Henry Review', National Preventative Health Taskforce, National Health and Hospitals Reform Commission) have seen significant energy invested in articulating a new vision for health promotion and disease prevention in this country. This is an opportune time to think critically about the underpinning frameworks that we want to guide our decisions and actions in public health policy, practice and research. The purpose of this piece is to raise questions for debate in relation to the issues of competing professional interests and perspectives, intervention limits, permissible health identities; and what these might mean for the justification of health promotion and prevention interventions in a changing funding and policy environment.

Quantifying hepatitis C transmission risk using a new weighted scoring system for the Blood-Borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ): applications for community-based HCV surveillance, education and prevention.

BACKGROUND: The hepatitis C virus (HCV) is a major cause of drug-related morbidity and mortality, with incidence data implicating a wide range of HCV transmission risk practices. The Blood-Borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ) is a content valid instrument that comprehensively assesses HCV risk practices. This study examines the properties of a new weighted BBV-TRAQ designed to quantify HCV transmission risk among injecting drug users (IDU). METHODS: Analyses of cross-sectional surveys of Australian IDU (N = 450) were used to generate normative data and explore the properties of a weighted BBV-TRAQ. Items weights were assigned according to expert key informant ratings of HCV risk practices performed during the development stages of the BBV-TRAQ. A range of item weights was tested and psychometric properties explored. A weighting scheme was recommended based on the plausibility of normative subscale data in relation to research evidence and the ability of BBV-TRAQ scores to discriminate between HCV positive and negative participants. RESULTS: While retaining the psychometric properties of the unweighted scale and demonstrating good internal reliability. By taking into account the relative transmission risk of a broad range of putative HCV practices, the weighted BBV-TRAQ produced promising predictive validity results among IDU based on self-report HCV status, particularly among young and less experienced injectors. CONCLUSION: Brief, easy to administer and score, and inexpensive to apply, the utility of the BBV-TRAQ for community based education and prevention is enhanced by the application of item weights, potentially offering a valid surrogate measure for HCV infection among IDU.

Drug and alcohol treatment providers' views about the disease model of addiction and its impact on clinical practice: A systematic review.

ISSUES: Addiction treatment providers' views about the disease model of addiction (DMA), and their contemporary views about the brain disease model of addiction (BDMA), remain an understudied area. We systematically reviewed treatment providers' attitudes about the DMA/BDMA, examined factors associated with positive or negative attitudes and assessed their views on the potential clinical impact of both models. APPROACH: Pubmed, EMBASE, PsycINFO, CINAHL Plus and Sociological Abstracts were systematically searched. Original papers on treatment providers' views about the DMA/BDMA and its clinical impact were included. Studies focussing on tobacco, behavioural addictions or non-Western populations were excluded. KEY FINDINGS: The 34 included studies were predominantly quantitative and conducted in the USA. Among mixed findings of treatment providers' support for the DMA, strong validity studies indicated treatment providers supported the disease concept and moral, free-will or social models simultaneously. Support for the DMA was positively associated with treatment providers' age, year of qualification, certification status, religious beliefs, being in recovery and Alcoholics Anonymous attendance. Greater education was negatively associated with DMA support. Treatment providers identified potential positive (e.g. reduced stigma) and negative (e.g. increased sense of helplessness) impacts of the DMA on client behaviour. IMPLICATIONS/CONCLUSION: The review suggests treatment providers may endorse disease and other models while strategically deploying the DMA for presumed therapeutic benefits. Varying DMA support across workforces indicated service users may experience multiple and potentially contradictory explanations of addiction. Future policy development will benefit by considering how treatment providers adopt disease concepts in practice.

An overview of take-home naloxone programs in Australia.

INTRODUCTION AND AIMS: Take-home naloxone (THN) programs commenced in Australia in 2012 in the Australian Capital Territory and programs now operate in five Australian jurisdictions. The purpose of this paper is to record the progress of THN programs in Australia, to provide a resource for others wanting to start THN projects, and provide a tool for policy makers and others considering expansion of THN programs in this country and elsewhere. DESIGN AND METHODS: Key stakeholders with principal responsibility for identified THN programs operating in Australia provided descriptions of program development, implementation and characteristics. Short summaries of known THN programs from each jurisdiction are provided along with a table detailing program characteristics and outcomes. RESULTS: Data collected across current Australian THN programs suggest that to date over 2500 Australians at risk of overdose have been trained and provided naloxone. Evaluation data from four programs recorded 146 overdose reversals involving naloxone that was given by THN participants. DISCUSSION AND CONCLUSIONS: Peer drug user groups currently play a central role in the development, delivery and scale-up of THN in Australia. Health professionals who work with people who use illicit opioids are increasingly taking part as alcohol and other drug-related health agencies have recognised the opportunity for THN provision through interactions with their clients. Australia has made rapid progress in removing regulatory barriers to naloxone since the initiation of the first THN program in 2012. However, logistical and economic barriers remain and further work is needed to expand access to this life-saving medication.

Applied communitarian ethics for harm reduction: promoting a dialogue within the field.

This piece responds to critical points raised in commentaries on our 2005 HRD paper on the topic of harm reduction ethics, and clarifies other aspects of our original arguments that were misinterpreted. In our view, the goal of ethical engagement in harm reduction is not necessarily the production of an agreed moral framework, but instead reflection and awareness raising around the various values and beliefs underlying harm reduction, and consideration of how these influence policy, practice and research decisions and outcomes. This 'discursive authenticity' as Hathaway has called it, can help to define a new territory of authority for drug users as participants in harm reduction policy, practice and research.

Contemporary cocaine use patterns and associated harms in Melbourne and Sydney, Australia.

The aim of this paper was to explore the nature of cocaine use and harms through a cross-sectional survey of cocaine users interviewed in the two largest Australian cities of Sydney (n = 88) and Melbourne (n = 77) between October 2004 and January 2005. The study supported previous findings that Australian cocaine users could be classified broadly into two types. The majority of cocaine users interviewed were classified as socially and economically integrated. They were young, employed, well-educated people who generally snorted cocaine on a recreational basis, typically in conjunction with other illicit and licit drugs. A second group of socially and economically marginalised users, residing mainly in Sydney, injected cocaine often in conjunction with heroin. This group reported significantly higher levels of cocaine use, cocaine dependence, criminal behaviour and human immunodeficiency virus (HIV) risk-taking behaviour. Heroin use was found to predict independently higher levels of cocaine use, criminal behaviour, needle sharing and physical problems in this sample, suggesting that increased resources and coverage for combined heroin/cocaine users may have scope for reducing cocaine-related problems in the Australian community.

When is a little knowledge dangerous? Circumstances of recent heroin overdose and links to knowledge of overdose risk factors.

OBJECTIVES: To describe the circumstances surrounding recent heroin overdose among a sample of heroin overdose survivors and the links to their knowledge of overdose risk. METHODS: A cross-sectional survey of 257 recent non-fatal heroin overdose survivors was undertaken to examine self-reported knowledge of overdose risk reduction strategies, behaviour in the 12 h prior to overdose and attributions of overdose causation. RESULTS: Most of the overdoses occurred in public spaces as a result of heroin use within 5 min of purchasing the drug. A substantial number of overdoses occurred with no one else present and/or involved the concomitant use of other drugs. While knowledge of at least one overdose prevention strategy was reported by 90% of the sample, less then half of the sample knew any single strategy. Furthermore knowledge of the dangers of mixing benzodiazepines and/or alcohol with heroin was associated with an increased likelihood of such mixing being reported prior to overdose. CONCLUSIONS: While heroin users can articulate knowledge of key overdose risk reduction strategies, this knowledge was not generally associated with a reduction in risk behaviours but was in some cases associated with increased reports of overdose risk behaviours. Further research is required in order to better understand this paradoxical effect, focussing on risk reduction education amenable to the social contexts in which heroin use takes place.

Prevalence of injecting drug use and associated risk behavior among regular ecstasy users in Australia.

BACKGROUND: The aim of the study was to investigate the prevalence of injecting drug use and associated risk behaviour among a sentinel sample of ecstasy users. METHODS: Cross-sectional surveys were conducted with regular ecstasy users as part of an annual monitoring study of ecstasy and related drug markets in all Australian capital cities. RESULTS: Twenty-three percent of the sample reported having ever injected a drug and 15% reported injecting in the 6 months preceding interview. Independent predictors of lifetime injection were older age, unemployment and having ever been in prison. Completion of secondary school and identifying as heterosexual was associated with a lower likelihood of having ever injected. Participants who had recently injected typically did so infrequently; only 9% reported daily injecting. Methamphetamine was the most commonly injected drug. Prevalence of needle sharing was low (6%), although half (47%) reported sharing other injecting equipment in the preceding 6 months. CONCLUSIONS: Ecstasy users who report having injected a drug at some time appear to be demographically different to ecstasy users who have not injected although neither are they typical of other drug injectors. The current investigation suggests that ongoing monitoring of injecting among regular ecstasy users is warranted.

Trends in morphine prescriptions, illicit morphine use and associated harms among regular injecting drug users in Australia.

This paper examines population trends in morphine prescriptions in Australia, and contrasts them with findings from annual surveys with regular injecting drug users (IDU). Data on morphine prescriptions from 1995 to 2003 were obtained from the Drug Monitoring System (DRUMS) run by the Australian Government Department of Health and Ageing. Data collected from regular IDU as part of the Australian Illicit Drug Reporting System (IDRS) were analysed (2001 - 2004). The rate of morphine prescription per person aged 15 - 54 years increased by 89% across Australia between 1995 and 2003 (from 46.3 to 85.9 mg per person). Almost half (46%) of IDU surveyed in 2004 reported illicit morphine use, with the highest rates in jurisdictions where heroin was less available. Recent morphine injectors were significantly more likely to be male, unemployed, out of treatment and homeless in comparison to IDU who had not injected morphine. They were also more likely to have injected other pharmaceutical drugs and to report injection related problems. Among those who had injected morphine recently, the most commonly reported injecting harms were morphine dependence (38%), difficulty finding veins into which to inject (36%) and scarring or bruising (27%). Morphine use and injection is a common practice among regular IDU in Australia. In some cases, morphine may be a substitute for illicit heroin; in others, it may be being used to treat heroin dependence where other pharmacotherapies, such as methadone and buprenorphine, are perceived as being unavailable or undesirable by IDU. Morphine injection appears to be associated with polydrug use, and with it, a range of problems related to drug injection. Further research is required to monitor and reduce morphine diversion and related harms by such polydrug injectors.

Realising the technological promise of smartphones in addiction research and treatment: An ethical review.

BACKGROUND: Smartphone technologies and mHealth applications (or apps) promise unprecedented scope for data collection, treatment intervention, and relapse prevention when used in the field of substance abuse and addiction. This potential also raises new ethical challenges that researchers, clinicians, and software developers must address. AIMS: This paper aims to identify ethical issues in the current uses of smartphones in addiction research and treatment. METHODS: A search of three databases (PubMed, Web of Science and PsycInfo) identified 33 studies involving smartphones or mHealth applications for use in the research and treatment of substance abuse and addiction. A content analysis was conducted to identify how smartphones are being used in these fields and to highlight the ethical issues raised by these studies. RESULTS: Smartphones are being used to collect large amounts of sensitive information, including personal information, geo-location, physiological activity, self-reports of mood and cravings, and the consumption of illicit drugs, alcohol and nicotine. Given that detailed information is being collected about potentially illegal behaviour, we identified the following ethical considerations: protecting user privacy, maximising equity in access, ensuring informed consent, providing participants with adequate clinical resources, communicating clinically relevant results to individuals, and the urgent need to demonstrate evidence of safety and efficacy of the technologies. CONCLUSIONS: mHealth technology offers the possibility to collect large amounts of valuable personal information that may enhance research and treatment of substance abuse and addiction. To realise this potential researchers, clinicians and app-developers must address these ethical concerns to maximise the benefits and minimise risks of harm to users.

Transient changes in behaviour lead to heroin overdose: results from a case-crossover study of non-fatal overdose.

BACKGROUND AND AIMS: Heroin overdose is a serious consequence of heroin use and one of the leading causes of premature death and illness in Australia. Despite considerable research effort little is known about the effects of transient changes in heroin user behaviour and the links to overdose. This research is the first to use a suitable methodology to allow such ephemeral changes and their effects on non-fatal heroin overdose to be examined. METHODS: A case-crossover design was used in which non-fatal heroin overdose survivors' recall of risk behaviours in the 12 hours prior to overdose (hazard period) was compared to their recall of risk behaviours in the 12 hours prior to a selected non-overdose heroin injection (control period). RESULTS: A total of 155 participants were able to provide valid details of hazard and control periods. A dose-response relationship was observed between the self-reported amount of heroin used and likelihood of overdose (e.g. > AUD50, OR 12.97, 95% CI 2.54-66.31). The use of benzodiazepines (OR 28, 95% CI 3.81-205.79) or alcohol (OR 2.88, 95% CI 1.29-6.43), during the hazard period was related to overdose risk, but the effect of alcohol was attenuated by the effect of benzodiazepines. Shifting from private to public locations between control and hazard periods was also related to increased risk of overdose (OR 3.63, 95% CI 1.66-7.93). CONCLUSIONS: We demonstrate the value of a new methodology to explore heroin overdose, as well as discussing its limitations and ways to overcome them in future. In terms of our findings, overdose prevention messages need to highlight the impact of these transient changes in behaviour and to emphasize the risks of using higher doses of heroin as well as continuing to emphasize the risks of combining heroin with other central nervous system (CNS) depressants. Safer environments for heroin use, such as injecting rooms, may also reduce the chances of overdose.

Buprenorphine diversion and injection in Melbourne, Australia: an emerging issue?

AIMS: To examine indicators of buprenorphine diversion and injection among injecting drug users in Melbourne, Australia and to determine the factors associated with buprenorphine injection. DESIGN: Melbourne arm of the 2002 Illicit Drug Reporting System (IDRS) cross-sectional study. SETTING: Five Needle and Syringe Programme sites in Melbourne, Australia. PARTICIPANTS: A total of 156 current injecting drug users (IDU). Study eligibility criteria were at least monthly injection during the previous 6 months, and Melbourne residence for at least the preceding 12 months. MEASUREMENTS: Structured questionnaire covering demographic characteristics, drug use history, the price, purity and availability of drugs, criminal activity, risk-taking behaviours, health-related issues and general drug use trends. FINDINGS: Over one-third (37%) of the study sample reported injecting buprenorphine in their life-time and 33% reported injecting the drug in the last 6 months. Recent buprenorphine injection was associated with the injection of other drug types (i.e. polydrug injectors), opioid substitution treatment, injection-related health problems and involvement in crime. Almost half (47%) of those who reported recent buprenorphine injection reported obtaining the drug illicitly at least once during that time. CONCLUSIONS: Given the significant health harms associated with intravenous buprenorphine use (e.g. vein damage, abscesses and infections, precipitated withdrawal, blood-borne virus transmission, hospitalization and death), routine monitoring of the misuse of buprenorphine in Melbourne is warranted. These results suggest the need for development of effective countermeasures to address diversion and injection of buprenorphine in this setting.