Setting foot in private spaces: extending the hepatitis C cascade of care to automatic needle/syringe dispensing machines, a mixed methods study.

BACKGROUND: Global commitment to achieving hepatitis C virus (HCV) elimination has enhanced efforts in improving access to direct-acting antiviral (DAA) treatments for people who inject drugs (PWID). Scale-up of efforts to engage hard-to-reach groups of PWID in HCV testing and treatment is crucial to success. Automatic needle/syringe dispensing machines (ADMs) have been used internationally to distribute sterile injecting equipment. ADMs are a unique harm reduction service, affording maximum anonymity to service users. This paper explores the feasibility and acceptability of extending the HCV cascade of care to sites where ADMs are located. METHODS: The ADM users into Treatment (ADMiT) study was undertaken in a metropolitan region in Sydney, Australia. This mixed methods study involved analysis of closed-circuit television footage, ethnographic methods (fieldwork observation and in-depth interviews) and structured surveys. Researchers and peers conducted fieldwork and data collection over 10 weeks at one ADM site, including offering access to HCV testing and treatment. RESULTS: Findings from 10 weeks of fieldwork observations, 70 survey participants and 15 interviews highlighted that there is scope for engaging with this population at the time they use the ADM, and enhanced linkage to HCV testing and treatment may be warranted. Most survey participants reported prior HCV testing, 61% in the last 12 months and 38% had received HCV treatment. However, fieldwork revealed that most people observed using the ADM were not willing to engage with the researchers. Field work data and interviews suggested that extending the HCV cascade of care to ADMs may encroach on what is a private space for many PWID, utilized specifically to avoid engagement. DISCUSSION: Enhanced linkage to HCV testing and treatment for people who use ADMs may be warranted. However, data suggested that extending the HCV cascade of care to ADMs may encroach on what is a private space for many PWID, utilized specifically to avoid engagement. The current study raises important public health questions about the need to ensure interventions reflect the needs of affected communities, including their right to remain anonymous.

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).

Overdose Risk and Client Characteristics Associated With the Injection of Buprenorphine at a Medically Supervised Injecting Center in Sydney, Australia.

Background: Buprenorphine and buprenorphine/naloxone (BNX) were developed to improve the safety profile of opioid substitution treatment (OST) and reduce diversion and injection, yet continue to be injected, despite the risk of harm. Previous studies examining injection of these substances have relied on self-reported injection and overdose. Using data from the Uniting Medically Supervised Injecting Center (MSIC) in Sydney, this study aimed to assess the overdose risk associated with the use of buprenorphine and BNX and identify factors associated with injecting. Methods: Client data routinely collected from MSIC, a drug consumption room where clients can legally inject drugs under supervision, was used. Odds ratios (OR) to assess the risk of overdose and their associated 95% confidence intervals (95%CI) were calculated and compared to other substances. Univariate analysis using χ-square and multivariate logistic regressions were used to determine characteristics associated with buprenorphine and BNX injection. Results: Data from 1,020,782 injections by 15,832 individuals were analyzed. Risk of overdose was low for buprenorphine compared to other substances (OR 0.16; 95%CI: 0.07-0.19) and no overdoses occurred when BNX was injected. Injection of both buprenorphine and BNX was associated with male gender, homelessness, no income/reliance upon government payments, and prior imprisonment. Conclusions: Buprenorphine and BNX continue to be injected, albeit in small numbers. This is the first study to report on injection and overdose risk using direct observation, and has confirmed the lower overdose risk. MSIC clients who inject buprenorphine and BNX tend to be marginalized and may benefit from targeted harm reduction measures.

Vertical transmission of hepatitis C: Testing and health-care engagement.

AIM: To investigate hepatitis C virus (HCV) testing patterns and engagement with health care for women positive for HCV antibodies (anti-HCV) in pregnancy and their children through pregnancy and the first 2 years of the child's life. METHODS: At a large inner-city Australian hospital from 2010 to 2012, anti-HCV positive pregnant women were recruited into a cohort study from pregnancy to 2 years post-delivery. Maternal and child data were collected by questionnaire and medical record extraction. RESULTS: During the study 29 women participants delivered 31 children. HCV RNA was detected in 64% (18/28) of pregnancies, with injecting drug use, the most likely route of maternal infection. Relatively high maternal health-care engagement during pregnancy reduced after delivery. There was evidence of ongoing illicit drug use in the majority of women. Of the children, 58% (18/31) had some HCV testing confirmed but complete testing was confirmed for only 10% (3/31). Largely, testing was incomplete or unknown. No vertical transmission was identified. Forty-two percent (13/31) of children were placed in out-of-home-care. CONCLUSIONS: Potentially, there is a high risk of inadequate or incomplete HCV testing of vulnerable children. Ongoing maternal drug use, poor maternal health-care engagement and placement in out-of-home-care may increase the risk. Complete testing of all children at risk of vertically acquired HCV needs to be ensured.

Prescription Opioid Misuse and Public Health Approach in Australia.

The number of opioid prescriptions has increased significantly over the last few years due to multiple factors, such as physicians' heightened attention to pain management, greater prevalence of chronic pain due to the aging population, and the availability of sustained-release opioid preparations. Correspondingly, this has been associated with a rise in considerable harm due to opioid misuse, which is recognized as a national health priority in Australia. This article outlines the major public health approaches that have been introduced in Australia to address this issue. Opioid misuse can be addressed through establishing a real-time prescription drug monitoring program, ensuring adequate access to affordable and high quality medication-assisted treatment, and promoting physicians' use of the evidence-based guideline on appropriate opioid prescribing.

Estimating the number of people who inject drugs in Australia.

BACKGROUND: Injecting drug use is associated with considerable morbidity and mortality. Estimates of the size of the population of people who inject drugs are critical to inform service planning and estimate disease burden due to injecting drug use. We aimed to estimate the size of the population of people who inject drugs in Australia. METHODS: We applied a multiplier method which used benchmark data (number of people in opioid substitution therapy (OST) on a snapshot day in 2014) and multiplied it by a factor derived from the prevalence of current OST among people who inject drugs participating in the Australian Needle and Syringe Program Survey in 2014. Estimates of the total population of people who inject drugs were calculated in each state and territory and summed to produce a national estimate. We used the sex and age group distribution seen in datasets relating to people who inject drugs to derive sex- and age-stratified estimates, and calculated prevalence per 1000 population. RESULTS: Between 68,000 and 118,000 people aged 15-64 years inject drugs in Australia. The population prevalence of injecting drug use was 6.0 (lower and upper uncertainty intervals of 4.3 and 7.6) per 1000 people aged 15-64 years. Injecting drug use was more common among men than women, and most common among those aged 35-44 years. Comparison of expected drug-related deaths based on these estimates to actual deaths suggest that these figures may be underestimates. CONCLUSIONS: These are the first indirect prevalence estimates of injecting drug use in Australia in over a decade. This work has identified that there are limited data available to inform estimates of this population. These estimates can be used as a basis for further work estimating injecting drug use in Australia.

Has the Experience of Hepatitis C Diagnosis Improved Over the Last Decade? An Analysis of Canadian Women's Experiences.

Background In Canada, incidents of new hepatitis C virus infections are rising among women aged 15-29 years and now comprise 60% of new infections among this age group. A negative diagnosis experience continues to be a problem affecting women living with hepatitis C virus. With new effective treatments, nurses will have more involvement in hepatitis C virus care and diagnosis, which is a critical time to facilitate appropriate education and management. Purpose This study explored Canadian women's experience of hepatitis C virus diagnosis in order to develop recommendations to improve care at the point of diagnosis. Methods Purposive sampling was used to recruit and interview 25 women. Using narrative inquiry, we examined Canadian women's experience of hepatitis C virus diagnosis. Results Women's diagnosis experiences were shaped by the context of diagnosis, factors prompting the testing, the testing provider, and information/education received. The context of diagnosis foreshadowed how prepared women were for their results, and the absence of accurate information magnified the psychological distress that can follow an hepatitis C virus diagnosis. Conclusion Our findings provide a compelling case for a proactive nursing response, which will improve women's experiences of hepatitis C virus diagnosis and, in turn, enhance women's access to hepatitis C virus care and other healthcare services.

Overview of substance use and treatment from Australia.

This paper aims to provide an overview of drug and alcohol issues and their management in Australia. Overall, Australia has good health relative to the United States and other similar nations and generally similar rates of substance use disorders. A whole-of-government strategic approach has been developed for managing drug and alcohol problems, with a National Drug Strategy that has adopted a pragmatic approach to substance use problems through 3 "pillars"--demand, supply, and harm reduction. This approach has been attributed to Australia's remarkably low human immunodeficiency virus (HIV) prevalence among people who inject drugs (<2%). Most community primary health care is provided through Australia's universal health care scheme, which provides a rebate for nearly all medical services according to a scheduled fee. Inpatient and outpatient care, including drug and alcohol services, delivered at public hospitals are currently provided with no patient co-payments. The health of Australia's first peoples, Australian Aboriginals and Torres Strait Islanders, remains challenging primarily due to the transgenerational impacts of dispossession, social and economic disadvantage, and some cultural differences. Although substance use is a key issue for Australian Aboriginals, there are currently insufficient dedicated drug and alcohol services for this group. Notwithstanding this important exception, Australia's health and substance use is favorable relative to other developed nations, offering universal health care and a pragmatic drug and alcohol strategy.

Feasibility of ambulatory withdrawal management delivered in a NSW drug health service and correlates of completion.

OBJECTIVE: The aim of the present study was to assess short-term ambulatory withdrawal management (AWM) outcomes at a drug health service (DHS) in Sydney, Australia, in the absence of specific funding. METHODS: A clinic file audit review was conducted of patients who commenced AWM at the service during January 2009-June 2011. Successful completion was defined as daily attendance with ≤1 missed day, or transfer onto opioid substitution treatment. RESULTS: Of 110 episodes, 69 (63%) were completed. Median patient age was 35 years (range 18-71 years), and most patients (68%) were male. Patients presented primarily for cannabis (33%) or alcohol (30%) withdrawal, followed by heroin (19%) or other opioids (6%), and benzodiazepines (12%). Completion rates varied from 86% for non-heroin opioids to 31% for benzodiazepines. Older age was associated with increased completion: 76% of those aged >35 years completed compared with 50% of those ≤35 years of age. Only 46% of women who commenced withdrawal management completed compared with 71% of men. CONCLUSIONS Most people commencing AWM at the DHS completed the program, indicating AWM can be performed at public drug and alcohol clinics. Service improvements may help increase completion rates among women and patients withdrawing from benzodiazepines. What is known about the topic? WM is not a standalone treatment for substance dependence, but is commonly a first attempt at treatment. AWM is often more acceptable to patients, and cheaper, than in-patient services. What does this paper add? About two-thirds of patients entering an AWM program operating since 2001 continue to complete the program. What are the implications for practitioners? AWM can be carried out successfully through public drug and alcohol services, although clinic staff support is important.

Providing better access to oral health care for people receiving substance use treatment: A timely discussion.

Substance use disorders are a risk factor for poor oral health which in turn impacts quality of life. Resultant oral problems contribute to chronic illness, premature mortality, social stigma, embarrassment and reduced opportunities for employment and social interaction. Providing dental services to people with substance use disorders is often difficult due to high rates of oral disease, anxiety, behavioural and drug use changes, and lifestyle factors. Previous studies have demonstrated that alcohol and other drug service clients find accessing and navigating oral health services complex and suggest a multidisciplinary care approach to improve outcomes. In this commentary, we describe individual and structural barriers that limit the use of oral health care among people with substance use disorders, alcohol and other drug clinicians' challenges to integrating oral health into their practice and identify key issues for oral health services in delivering care. We draw on our experience to recommend a multidisciplinary approach be used to develop strategies in order to increase access to oral health services at a standard similar to the general population for clients of alcohol and other drug services.

Improving assessment and management of suicide risk among people who inject drugs: A mixed methods study conducted at the Medically Supervised Injecting Centre, Sydney.

INTRODUCTION: People who inject drugs are 13 times more likely to die by suicide than the general population. Guidelines for responding to risk in this population are limited. Harm reduction services attended by people who inject drugs require targeted strategies to address the complexities of suicide risk among this population. METHODS: Co-design, engaging health professionals and people with lived experience informed the study. Mixed methods were used to understand the experience of managing suicide risk among clients attending the Medically Supervised Injecting Centre (MSIC) in Sydney. A survey was administered to assess staff confidence in managing risk. Focus groups were conducted with health professionals and MSIC clients to explore experiences of suicide management, response and opportunities for improvement. RESULTS: Half (N = 17) the MSIC staff surveyed reported over 10 years' experience working with this population. Confidence in managing suicide risk was low. Three key themes emerged from focus groups (N = 17): (i) Autonomy and the need to involve clients in the assessment process; (ii) Trust between clients and health professionals, and transparency in decision-making; and (iii) System barriers, described by health professionals as inadequate referral pathways for clients in distress, and by clients as negative experiences of care, including involuntary admission and not receiving medication (e.g. methadone). DISCUSSION AND CONCLUSIONS: Revised assessment guidelines and a tailored safety plan were developed. These resources are also suitable for other alcohol and other drug services. The challenge in managing suicide risk in harm reduction services is balancing duty of care with staff-client relationships and client engagement.

Assessment and treatment of hepatitis C virus infection among people who inject drugs in the opioid substitution setting: ETHOS study.

BACKGROUND: Access to hepatitis C virus (HCV) treatment remains extremely limited among people who inject drugs (PWID). HCV assessment and treatment was evaluated through an innovative model for the provision of HCV care among PWID with chronic HCV infection. METHODS: Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) was a prospective observational cohort. Recruitment was through 5 opioid substitution treatment (OST) clinics, 2 community health centers, and 1 Aboriginal community controlled health organization in New South Wales, Australia. RESULTS: Among 387 enrolled participants, mean age was 41 years, 71% were male, and 15% were of Aboriginal ethnicity. Specialist assessment was undertaken in 191 (49%) participants, and 84 (22%) commenced interferon-based treatment. In adjusted analysis, HCV specialist assessment was associated with non-Aboriginal ethnicity (adjusted odds ratio [AOR], 4.02; 95% confidence interval [CI], 2.05-7.90), no recent benzodiazepine use (AOR, 2.06; 95% CI, 1.31-3.24), and non-1 HCV genotype (AOR, 2.13; 95% CI, 1.32-3.43). In adjusted analysis, HCV treatment was associated with non-Aboriginal ethnicity (AOR, 4.59; 95% CI, 1.49-14.12), living with the support of family and/or friends (AOR, 2.15; 95% CI, 1.25-3.71), never receiving OST (AOR, 4.40; 95% CI, 2.27-8.54), no recent methamphetamine use (AOR, 2.26; 95% CI, 1.12-4.57), and non-1 HCV genotype (AOR, 3.07; 95% CI, 1.67-5.64). CONCLUSIONS: HCV treatment uptake was relatively high among this highly marginalized population of PWID. Potentially modifiable factors associated with treatment include drug use and social support.

A randomised controlled trial of financial incentives to increase hepatitis B vaccination completion among people who inject drugs in Australia.

OBJECTIVE: This study aimed to investigate the efficacy of modest financial incentives in increasing completion of an accelerated 3-dose hepatitis B virus (HBV) vaccination schedule (0, 7, 21days) among people who inject drugs (PWID). METHODS: Randomised controlled trial. Participants were randomly allocated to receive $30 Australian Dollars cash following receipt of vaccine doses two and three ('incentive condition'), or standard care ('control condition'). Serologically confirmed HBV-susceptible PWID. Two inner-city health services and a field study site in Sydney, Australia. The primary outcome was completion of the vaccination series. Additional assessments included self-reported demographic, drug use and treatment, and risk-taking histories. RESULTS: Compared to the control condition, significantly more participants in the incentive condition received all three vaccine doses, under intention-to-treat analyses (n=139; 87% versus 66%; p=.004); and within the specified window periods under per protocol analyses (n=107 received three vaccine doses; 92% versus 67%; p=.001). Multivariate analysis indicated that the incentive condition and longer injecting histories significantly increased the likelihood of series completion. Aboriginal/Torres Strait Islanders were significantly less likely to complete the series. CONCLUSIONS: Modest financial incentives, per-dose, increased adherence to the accelerated HBV vaccination schedule among PWID. Results have implications for increasing HBV and, potentially, other vaccine-preventable infections, among PWID.

Substance use among pregnant women in NSW prisons.

INTRODUCTION AND AIMS: Little is published about pregnant women in custody. Existing data on the prevalence of substance use among incarcerated pregnant women or their needs are scant. This study sought to determine the prevalence and characteristics of women with substance use histories who present to prison pregnant in New South Wales (NSW), Australia. DESIGN AND METHODS: A retrospective review of prison medical health records was completed for pregnant women entering New South Wales custodial settings between January 2020 and June 2021. RESULTS: We identified 158 prison receptions among 141 pregnant women (median age 28 years [IQR 25-33 years]), 42 % identified as Aboriginal or Torres Strait Islander. Eighty four percent of the women (n = 119) reported recent use of one or more than one substance and 36 % had injected drugs. The most commonly used substances were (meth)amphetamine (60 %), cannabis (40 %) and opioids (28 %). We found discrepancies between drug problems self-reported at reception screening on entry to prison and self-reported drug use collected during the subsequent drug and alcohol specialist assessment while incarcerated. Most (88 %) women described their current pregnancy as unplanned and half (52 %) were unaware they were pregnant before incarceration. CONCLUSIONS: These findings highlight the high prevalence of substance use in incarcerated pregnant women and that many women are unaware of their pregnancy prior to incarceration. Findings emphasize the importance of timely and appropriate drug and alcohol assessment and treatment to minimize harm for both the mother and foetus and also underscore the urgent need for enhanced access to contraception for these women.

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

BACKGROUND: Women experiencing substance use disorders face barriers to treatment, including childcare, stigma and lack of gender/trauma-informed programming. Several non-government organizations in New South Wales run women-only treatment services to address these needs. OBJECTIVES: We aim to assess characteristics of women entering treatment in these services. DESIGN: Data on client characteristics from six women-only non-government organization substance use disorder treatment services in New South Wales between 2014 and 2018 were extracted from a database containing demographics, drug use and treatment characteristics and psychological distress (Kessler-10 scale) of women entering the services. Logistic regression models were used to estimate unadjusted odds ratio and adjusted odds ratio for treatment completion and different drugs on entry. RESULTS: Data were available for 1357 women. Most (91%) episodes were for residential treatment. Women's mean age was 35.4 years (standard deviation = 9.8; range = 17-67). Residential clients tended to be younger than non-residential clients (35.1 vs 38.5 years, p < 0.001). Methamphetamine (43%) and alcohol (32%) were the most reported principal drug of concern. Women (89%) reported high levels of psychological distress (median Kessler-10 scale score = 27.5, range = 10-50), highest for women reporting alcohol as their principal drug. Overall, 43% of episodes resulted in treatment completion, most commonly for women entering residential treatment (45% vs 22%, p < 0.001) and for alcohol treatment (adjusted odds ratio = 1.42; confidence interval = 1.07-1.90; p < 0.001). Women with Kessler-10 scale scores indicating anxiety or depression at treatment entry were less likely to complete treatment than those with lower scores (adjusted odds ratio = 0.56; confidence interval = 0.38-0.80; p < 0.001). CONCLUSION: Women entering women-only residential treatment tend to be younger and report methamphetamine as principal drug of concern. Women enter treatment with high degrees of psychological distress. Women's services need to ensure their programmes can respond to diverse needs of younger women presenting with methamphetamine use disorder and older women with alcohol use disorder experiencing high levels of psychological distress.

The reliability of sensitive information provided by injecting drug users in a clinical setting: clinician-administered versus audio computer-assisted self-interviewing (ACASI).

Research with injecting drug users (IDUs) suggests greater willingness to report sensitive and stigmatised behaviour via audio computer-assisted self-interviewing (ACASI) methods than during face-to-face interviews (FFIs); however, previous studies were limited in verifying this within the same individuals at the same time point. This study examines the relative willingness of IDUs to report sensitive information via ACASI and during a face-to-face clinical assessment administered in health services for IDUs. During recruitment for a randomised controlled trial undertaken at two IDU-targeted health services, assessments were undertaken as per clinical protocols, followed by referral of eligible clients to the trial, in which baseline self-report data were collected via ACASI. Five questions about sensitive injecting and sexual risk behaviours were administered to participants during both clinical interviews and baseline research data collection. "Percentage agreement" determined the magnitude of concordance/discordance in responses across interview methods, while tests appropriate to data format assessed the statistical significance of this variation. Results for all five variables suggest that, relative to ACASI, FFI elicited responses that may be perceived as more socially desirable. Discordance was statistically significant for four of the five variables examined. Participants who reported a history of sex work were more likely to provide discordant responses to at least one socially sensitive item. In health services for IDUs, information collection via ACASI may elicit more reliable and valid responses than FFI. Adoption of a universal precautionary approach to complement individually tailored assessment of and advice regarding health risk behaviours for IDUs may address this issue.

Correlates of susceptibility to hepatitis B among people who inject drugs in Sydney, Australia.

Despite a safe, effective vaccine, hepatitis B virus (HBV) vaccination coverage remains low among people who inject drugs (PWID). Characteristics of participants screened for a trial investigating the efficacy of financial incentives in increasing vaccination completion among PWID were examined to inform targeting of vaccination programs. Recruitment occurred at two health services in inner-city Sydney that target PWID. HBV status was confirmed via serological testing, and questionnaires elicited demographic, drug use, and HBV risk data. Multinomial logistic regression was utilized to determine variables independently associated with HBV status. Of 172 participants, 64% were susceptible, 17% exposed (HBV core antibody-positive), and 19% demonstrated evidence of prior vaccination (HBV surface antibody ≥ 10 mIU/ml). Compared with exposed participants, susceptible participants were significantly more likely to be aged less than 35 years and significantly less likely to be receiving current opioid substitution therapy (OST) and to test hepatitis C antibody-positive. In comparison to vaccinated participants, susceptible participants were significantly more likely to be male and significantly less likely to report daily or more frequent injecting, current OST, and prior awareness of HBV vaccine. HBV vaccination uptake could potentially be increased by targeting younger, less frequent injectors, particularly young men. In addition to expanding vaccination through OST, targeting "at risk" youth who are likely to have missed adolescent catch-up programs may be an important strategy to increase coverage. The lack of an association between incarceration and vaccination also suggests increasing vaccination uptake and completion in adult and juvenile correctional facilities may also be important.

Examining Relational Dimensions of Service Encounters for Disadvantaged People Who Use Drugs.

INTRODUCTION: Disadvantaged groups in general, and people who use illicit drugs in particular, have consistently been found to mistrust welfare services and service providers. Therefore, knowledge is needed on the relational aspects of service design that facilitate engagement and supportive relationships with disadvantaged consumers. METHODS: We draw on qualitative interviews investigating the experiences of adults with histories of problematic drug use participating in a health justice partnership, to identify facilitators of engagement from the perspective of the consumers. FINDINGS: Common relational facilitators of engagement were identified. These included embedding the service into the local community, foregrounding proximity and relationships in the service encounters, giving consumers' agency, priorities, and concerns primacy over program aims, and safe services acting as gateways to accessing a wider range of resources, services, and programs. CONCLUSION/CONTRIBUTION: The findings suggest that the centrality of relationships may be further heightened in services seeking to assist people in positions of severe disadvantage, including the drug and alcohol arena. In addition, the findings highlight the importance of services paying greater attention to how social and community embeddedness shapes experiences of inclusion and exclusion and designing services best able to accommodate this. This research contributes to the broader understanding of consumer engagement with services by developing a more nuanced understanding of consumer refusal and resistance to service engagement. These findings are important in the development of justice programs for disadvantaged people and people who use illicit substances specifically.