Safety first: Beliefs of older peers supplying alcohol to underage friends.

ISSUE ADDRESSED: Underage drinkers most commonly source alcohol from older peers. However, few studies have examined older peers' supply-related beliefs and motivations. METHODS: A sample of 270 risky drinkers aged 18-19 years were interviewed in Australia where the legal purchase age is 18. They were asked about their provision to underage friends, awareness of secondary supply legislation (intended to prohibit such supply) and 24 psycho-legal beliefs around supply. RESULTS: Half (49%) provided alcohol to a 16- to 17-year-old friend to drink at a party they were both attending at least twice a year. Three-quarters reported provision was okay so long as the recipient(s) were in a safe environment, and 46% reported "everyone gives alcohol to teenagers if they are in a safe environment." There was significantly higher agreement that "my friends would think I was mean if I did not give alcohol to a friend under the age of 18" (37%), compared to "my friends would think I was uncool if I did not give alcohol to a friend under the age of 18" (26%). Two thirds (69%) felt more responsible for an underage friend's safety if they provided the alcohol. A multivariate logistic regression revealed supply was more likely if the supplier: was aged 18 compared to 19 (95% CI OR: 1.57, 4.84), male (1.06, 3.27), of a higher SES quintile (1.08, 1.80) and believed alcohol supply to minors was morally acceptable (1.01, 1.33) and normal (1.04, 1.38). Knowledge of regulatory strategies (68%) designed to prevent supply to minors, and their perceived deterrent value did not significantly impact supply. CONCLUSIONS: Supply of alcohol to underage peers was perceived as morally and socially acceptable in a group of 18- to 19-year-old risky drinkers. SO WHAT?: Opportunities include harm reduction initiatives that prioritise caring responsibilities towards friends, as opposed to relying on external enforcement measures alone.

Alcohol supply as a favour for a friend: Scenarios of alcohol supply to younger friends and siblings.

ISSUES ADDRESSED: Adolescents under the legal purchase age primarily source their alcohol through social networks. This study assessed the provision context from the perspective of both underage recipients and their suppliers who were older peers and siblings. METHODS: Interviewer-administered surveys were conducted with 590 risky-drinking (50 g alcohol per session, at least monthly) adolescents. Participants of legal purchase age (18- to 19-year-olds; n = 269) reported their provision to 16- to 17-year-olds under eight scenarios. Those aged 14-17 (n = 321) reported receipt of alcohol under the same scenarios plus two parental supply contexts. RESULTS: Purchase-age participants reported supply: to an underage friend (67%), an acquaintance (44%) or a sibling (16%) to drink at the same party; to a friend (43%) or sibling (20%) to take to another party (20%) and to a stranger near a bottle shop (5%). Supply to a friend at the same party was more likely if money was exchanged (60% vs 40%; P < 0.001). Almost all (98%) 14- to 17-year-olds reported receiving alcohol from an adult (including 36% from a parent for consumption away from the parent), with a similar pattern of receipt scenarios as those reported by the 18- to 19-year-olds. CONCLUSIONS: Provision of alcohol was more frequent with a friend than a sibling or stranger, in close environmental proximity, and if money was exchanged. SO WHAT?: As supply may be sensitive to monetary considerations, the incidence of underage receipt may be affected by community-wide pricing measures. Traditional alcohol availability regulations should be supplemented by strategies relating to the social nature of supply and demand.

Child Health Systems in the United Kingdom (England).

Child health in the United Kingdom has improved markedly over recent decades but has failed to match health gains and reductions in mortality achieved by other European countries. Child poverty and inequalities are rising in the United Kingdom. The National Health Service (NHS) is a universally accessible health service, funded by taxation and is free at the point of use. The NHS is undergoing substantial reform, aiming to improve care quality and experience, meet rising demands, and contain costs. The NHS is struggling to balance access with expertise for urgent and unscheduled care. There is increasing use of urgent and emergency care, and there are unexplained variations in outcomes. Quality of care for children and young people with chronic and long-term conditions, including transition services, is variable and sometimes poor. Many determinants of noncommunicable conditions are worsening. Key achievements include a universal service free at the point of use, providing generally accessible, and equitable care. Key challenges include increasing fragmentation of services, insufficient emphasis on preventive care, achieving an effective balance between access and expertise of care for children, and improving child health and well-being outcomes despite generally high quality inputs and high levels of spending.

Pre-Drinking Behavior of Young Heavy Drinkers.

BACKGROUND: Pre-drinking has been linked to subsequent heavy drinking and the engagement in multiple risky behaviors. OBJECTIVES: The present study examined a group of adolescents who recently had a "big night out" to determine whether there were differences in their pre-drinking behavior based on age, gender, geographic location, and social setting. METHODS: Participants (n = 351, aged 16-19) representing the heaviest 20-25% of drinkers in their age group were recruited using nonrandom sampling from metropolitan (Melbourne, Sydney, Perth) or regional (Bunbury) locations across Australia and administered a survey by a trained interviewer. RESULTS: Almost half the sample pre-drank (n = 149), most commonly at a friend's house. Those aged 18-19 were more likely to pre-drink, and did so at higher quantities compared to their younger counterparts. Males and females reported similar pre-drinking duration, quantity and amount spent on alcohol. Compared to those in cities, regional participants consumed greater quantities over longer periods of time. Two-thirds of participants consumed alcohol in excess of national guidelines during their pre-drinking session. These participants were more likely to nominate price as a motivation to pre-drink and were less likely to report that someone else provided them alcohol. CONCLUSIONS: This study sheds light on the pre-drinking habits of a population of young risky drinkers, and highlights the need for policy makers to address this form of drinking to reduce alcohol-related harm among young people.

Diversity of Pediatric Workforce and Education in 2012 in Europe: A Need for Unifying Concepts or Accepting Enjoyable Differences?

OBJECTIVE: To evaluate differences in child health care service delivery in Europe based on comparisons across health care systems active in European nations. STUDY DESIGN: A survey involved experts in child health care of 40 national pediatric societies belonging both to European Union and non-European Union member countries. The study investigated which type of health care provider cared for children in 3 different age groups and the pediatric training and education of this workforce. RESULTS: In 24 of 36 countries 70%-100% of children (0-5 years) were cared for by primary care pediatricians. In 12 of 36 of countries, general practitioners (GPs) provided health care to more than 60% of young children. The median percentage of children receiving primary health care by pediatricians was 80% in age group 0-5 years, 50% in age group 6-11, and 25% in children >11 years of age. Postgraduate training in pediatrics ranged from 2 to 6 years. A special primary pediatric care track during general training was offered in 52% of the countries. One-quarter (9/40) of the countries reported a steady state of the numbers of pediatricians, and in one-quarter (11/40) the number of pediatricians was increasing; one-half (20/40) of the countries reported a decreasing number of pediatricians, mostly in those where public health was changing from pediatric to GP systems for primary care. CONCLUSIONS: An assessment on the variations in workforce and pediatric training systems is needed in all European nations, using the best possible evidence to determine the ideal skill mix between pediatricians and GPs.

"PMA sounds fun": negotiating drug discourses online.

In 2007, a young woman, Annabel Catt, died after consuming a capsule sold as "ecstasy" that contained para-methoxyamphetamine. In this paper, we describe how this death was depicted in online drug-user communities and illustrate how the meanings of drug use are negotiated in online settings. News articles, public online discussions, and online fieldwork formed the data. This paper demonstrates how dominant drug discourses may be resisted by drug users, drawing on theories of health resistance and Kane Race's concept of counterpublic health. Online environments may offer ways of engaging people who use drugs that acknowledge both pleasure and safety. The study's limitations are noted.

Advancing the implementation of take-home naloxone by community pharmacists: Testing the role of COM-B.

INTRODUCTION: Opioid-related overdose fatalities are rising despite the increased accessibility of take-home naloxone (THN). Targeted implementation strategies are needed to improve the distribution of naloxone. This study investigates the effectiveness of a short video targeting pharmacists that addresses implementation barriers. METHODS: A pre-post, mixed methods design was adopted to examine the effect of a brief behaviour change intervention (an educational video informed by the capability, opportunity, motivation affecting behaviour (COM-B) model), on factors affecting pharmacists' implementation of THN in Western Australia. Paired samples t-tests for were used to investigate intentions, knowledge, skill, confidence, feasibility, appropriateness, acceptability, attitudes, anticipated patient reactions, social support and implementation climate. Structural equation modelling examined the associations between constructs and to test the proposed mediation of motivation on capability and opportunity affecting intentions to discuss and provide THN. RESULTS: We analysed data from 102 participants. At follow-up and after all participants had viewed the video, participants had significantly improved intentions, skill, confidence, anticipated reactions, social support and perceptions that THN implementation was feasible, appropriate and acceptable. No significant differences were seen for attitudes, knowledge or implementation climate. The proposed mediation effect of motivation on the associations between opportunity and intentions and capability and intentions was not supported. DISCUSSION AND CONCLUSIONS: A short video directly targeting identified implementation barriers has the ability to improve key influences in the provision of THN. Dissemination of information to community pharmacists is a challenge. Implementation strategies addressing knowledge and targeting other levels of influence on intentions and behaviour are required.

Naloxone cascade of care among people who regularly inject drugs in Australia, 2020-2022.

BACKGROUND: Examining take-home naloxone (THN) uptake using a 'cascade of care' framework could help identify targets for increasing THN training and carriage among people who may witness or experience opioid overdose. We describe the THN cascade and factors associated with engagement among people who inject drugs. METHODS: People aged ≥18 years in Australia who inject drugs were interviewed from 2020 to 2022, reporting lifetime THN awareness and acquisition and past-month carriage. We examined factors associated with engagement using multivariable logistic regression. RESULTS: Of 2,149 participants (64 % men, mean age 44.5), 85 % had heard of naloxone, of whom 76 % were aware of THN programs. Of these, 72 % had ever participated in THN training/brief education, 92 % of whom had acquired THN. Of those who had ever acquired THN and reported past-month opioid use, 63 % always/often carried THN when using opioids. Past six-month opioid agonist treatment (OAT) (adjusted odds ratio [AOR] 2.55; 95 %CI 1.91-3.42) and ≥daily injecting (1.32; 1.01-1.73) were associated with awareness. OAT (1.79; 1.38-2.33), past-year opioid overdose (1.68; 1.18-2.42) and older age (1.02; 1.00-1.03) were associated with acquisition. Primarily injecting methamphetamine (versus heroin) in the past month was associated with lower awareness (0.43; 0.31-0.58) and acquisition (0.59; 0.44-0.78). Reporting no accommodation (squatting/sleeping rough) was associated with reduced odds of carriage (0.46; 0.24-0.88). CONCLUSION: Participants reported high THN awareness and acquisition, with lower carriage. Future efforts should focus on improving THN access and reducing barriers to carriage, particularly for people experiencing homelessness or who primarily inject non-opioids.

A multicentre case series of analytically confirmed gamma-hydroxybutyrate intoxications in Western Australian emergency departments: Pre-hospital circumstances, co-detections and clinical outcomes.

INTRODUCTION: Gamma-hydroxybutyrate (GHB) use is associated with high risk of accidental overdose. This study examined the pre-hospital circumstances, demographic characteristics and clinical outcomes of analytically confirmed GHB emergency department (ED) presentations in Western Australia (WA). METHODS: This case series was conducted across three WA EDs involved in the Emerging Drugs Network of Australia, from April 2020 to July 2022. Patient demographics, pre-hospital drug exposure circumstances and ED presentation and outcome characteristics were collected from ambulance and hospital medical records of GHB-confirmed cases. RESULTS: GHB was detected in 45 ED presentations. The median age was 34 years and 53.3% (n = 24) were female. Most patients arrived at the ED by ambulance (n = 37, 85.7%) and required immediate emergency care (Australasian Triage Score 1 or 2 = 97.8%). One-third of patients were admitted to intensive care (n = 14, 31.1%). Methylamphetamine was co-detected in 37 (82.2%) GHB-confirmed cases. Reduced conscious state was indicated by first recorded Glasgow Coma Scale of ≤8 (n = 29, 64.4%) and observations of patients becoming, or being found, 'unresponsive' and 'unconscious' in various pre-hospital settings (n = 28, 62.2%). 'Agitated' and/or 'erratic' mental state and behavioural observations were recorded in 20 (44.4%) cases. DISCUSSION AND CONCLUSIONS: Analytically verified data from ED presentations with acute toxicity provides an objective information source on drug use trends and emerging public health threats. In our study, patients presenting to WA EDs with GHB intoxication were acutely unwell, often requiring intensive care treatment. The unexpectedly high proportion of female GHB intoxications and methylamphetamine co-ingestion warrants further exploration.

Global patterns in small-scale cannabis growers' distribution practices: Exploring the grower-distributor nexus.

BACKGROUND: While the supply of cannabis is commonly assumed to be dominated by criminal gangs, a sizable share of the domestic cannabis supply is provided by small-scale growers. This article examines the nature and scope of small-scale growers' distribution practices, with a particular focus on cross-country differences and variations between different types of grower-distributors, i.e., "non-suppliers", "exclusive social suppliers", "sharers and sellers" and "exclusive sellers". METHODS: Based on a large convenience web survey sample of predominantly small-scale cannabis growers from 18 countries, this article draws on data from two subsamples. The first subsample includes past-year growers in all 18 countries who answered questions regarding their market participation (n = 8,812). The second subsample includes past-year growers in 13 countries, who answered additional questions about their supply practices (n = 2,296). RESULTS: The majority of the cannabis growers engaged in distribution of surplus products, making them in effect "grower-distributors". Importantly, many did so as a secondary consequence of growing, and social supply (e.g., sharing and gifting) is much more common than selling. While growers who both shared and sold ("sharers and sellers"), and especially those who only sold ("exclusive sellers"), grew a higher number of plants and were most likely to grow due to a wish to sell for profits, the majority of these are best described as small-scale sellers. That is, the profit motive for growing was often secondary to non-financial motives and most sold to a limited number of persons in their close social network. CONCLUSION: We discuss the implications of the findings on the structural process of import-substitution in low-end cannabis markets, including a growing normalization of cannabis supply.

Surveying alcohol and other drug use through telephone sampling: a comparison of landline and mobile phone samples.

BACKGROUND: Telephone surveys based on samples of landline telephone numbers are widely used to measure the prevalence of health risk behaviours such as smoking, drug use and alcohol consumption. An increasing number of households are relying solely on mobile telephones, creating a potential bias for population estimates derived from landline-based sampling frames which do not incorporate mobile phone numbers. Studies in the US have identified significant differences between landline and mobile telephone users in smoking and alcohol consumption, but there has been little work in other settings or focussed on illicit drugs. METHODS: This study examined Australian prevalence estimates of cannabis use, tobacco smoking and risky alcohol consumption based on samples selected using a dual-frame (mobile and landline) approach. Respondents from the landline sample were compared both to the overall mobile sample (including respondents who had access to a landline) and specifically to respondents who lived in mobile-only households. Bivariate comparisons were complemented with multivariate logistic regression models, controlling for the effects of basic demographic variables. RESULTS: The landline sample reported much lower prevalence of tobacco use, cannabis use and alcohol consumption than the mobile samples. Once demographic variables were adjusted for, there were no significant differences between the landline and mobile respondents on any of the alcohol measures examined. In contrast, the mobile samples had significantly higher rates of cannabis and tobacco use, even after adjustment. Weighted estimates from the dual-frame sample were generally higher than the landline sample across all substances, but only significantly higher for tobacco use. CONCLUSIONS: Landline telephone surveys in Australia are likely to substantially underestimate the prevalence of tobacco smoking by excluding potential respondents who live in mobile-only households. In contrast, estimates of alcohol consumption and cannabis use from landline surveys are likely to be broadly accurate, once basic demographic weighting is undertaken.

Real or fake? Sourcing and marketing of non-prescribed benzodiazepines amongst two samples of people who regularly use illicit drugs in Australia.

INTRODUCTION: There is concern around non-prescribed benzodiazepine use, particularly with increasing detections of counterfeit products containing high-risk novel compounds. The aims of this study were to investigate how and which non-prescribed benzodiazepines are being sourced; forms, appearance and packaging; and awareness of risks associated with non-prescribed benzodiazepines. METHODS: Data were collected from a sample of Australians who inject drugs or use ecstasy and/or other illicit stimulants on a monthly or more frequent basis, and who reported past 6-month use of non-prescribed benzodiazepines (n = 235 and n = 250, respectively). Data were collected on source, diversion from a known/trusted prescription, product name and aesthetic characteristics for the last non-prescribed benzodiazepine obtained. RESULTS: Amongst participants who injected drugs, 71% reported that their last non-prescribed benzodiazepines were diverted from a known/trusted prescription, compared to 59% of participants who used ecstasy/other stimulants. Sourcing via cryptomarkets was rare. Across both samples, the majority reported last obtaining substances sold/marketed as diazepam or alprazolam. Participants sourcing via non-diverted means were twice as likely to obtain alprazolam. Known sourcing of novel compounds was rare. Amongst participants who used ecstasy/other stimulants, 36% reported confidence in the content/dose of non-prescribed benzodiazepines even when the source is unknown. DISCUSSION AND CONCLUSIONS: Most participants obtained substances sold as classic/registered benzodiazepines, mostly via diverted prescriptions, with a substantial minority potentially unaware of counterfeits circulating. While diverted use undeniably presents risks, tightening of prescriptions in Australia could inadvertently lead to greater supply of novel benzodiazepines as seen internationally, reinforcing prioritisation of demand and harm reduction strategies.

Developing a single-session strategy for the implementation of take-home naloxone by community pharmacists using COM-B and design-thinking.

Background: Despite the overwhelming evidence of its effectiveness, there is poor implementation of take-home naloxone by pharmacists. Barriers have been explored and mapped to the capability, opportunity, motivation-behaviour (COM-B) model of behaviour change, yet no theoretically informed implementation strategies that target known barriers have been developed. Single-session implementation strategies have been proposed as a simple, scalable way to target multiple barriers. Methods: Qualitative participatory methods, incorporating design-thinking principles, were used to develop the key messages of a single-session implementation strategy. The key messages were drafted against COM-B mapped implementation barriers identified in the literature. A participatory workshop involving a pre-mortem exercise and incorporating design-thinking principles were used to refine the messages and generate methods for dissemination. Messages were mapped to interview questions to naturally illicit stories and delivered via storytelling from a pharmacist, a general practitioner, and a person with lived experience of using naloxone. Results: A 3 minute 40 second video and a two-page printable infographic were developed and hosted on a website, with links to additional downloadable resources as a single-session implementation strategy. Email was the preferred method for receiving simple professional development communications, with social media also widely accessed. Discussion: Implementation science, behavioural change theory, and participatory design methods are a complementary combination to develop implementation strategies. Some pharmacists questioned the participatory design approach to developing an implementation strategy, as it was outside of their comfort zone. However, the participatory process involving end-users resulted in unique ideas that are unlikely to have been generated using more traditional consultative approaches. The delivery as a single-session implementation strategy allows for widespread dissemination and delivery at scale.

Are cannabis use problems comparable across individuals using for recreational and medical purposes? An international cross-sectional study of individuals who use self-grown cannabis.

BACKGROUND: Little is known about cannabis use problems among individuals who use cannabis for medical purposes and whether rates and determinants of cannabis use problems in medical users differ to those observed among individuals using for recreational reasons. This study examines whether Severity of Dependence Scale (SDS) scores differ across individuals who use self-grown cannabis for the following reasons: "recreational only", "medical and recreational" and "medical only". Furthermore, the study tests whether cannabis use frequency, cannabis strain, and type of cannabis influences the strength of the association between purpose of use and cannabis use problems. METHODS: Data (n = 5,347) were collected from a subsample of the Global Cannabis Cultivation Research Consortium project, focusing on small-scale cannabis growers in 18 countries. Robust regressions analyzed differences in SDS scores across the three use motivation groups. RESULTS: Compared with respondents reporting only recreational motivations of cannabis use, those with medical (with and without recreational) motivations were associated with lower SDS scores (B: -0.190 and B: -0.459, p < 0.001 respectively). Daily use was associated with significantly higher SDS scores across all cannabis motivation groups, albeit the magnitude of the association was significantly smaller among individuals with medical motivations of use. CONCLUSION: The extent to which people experience cannabis use problems, and the determinants of these problems may differ depending on whether cannabis use is motivated by recreational or medical purposes. As such, the findings of the current study suggest that public education efforts, harm reduction approaches and policy responses should be tailored depending on whether cannabis is used for recreational or medical purposes.

Drug policing down under: An investigation of panic consumption, internal concealment and the use of drug amnesty bins among a sample of Australian festivalgoers.

BACKGROUND: The use of drug detection dogs and other punitive policing methods remain common at music festivals in Australia and elsewhere, despite concern about iatrogenic effects and recommendations for their overhaul. While drug amnesty bins are a commonly implemented strategy purported to mitigate risk associated with policing, the efficacy of this intervention is debated. This paper investigates two of the most concerning iatrogenic effects of drug policing practices at Australian festivals - internal concealment and panic consumption - and explores the potential efficacy of drug amnesty bins. METHODS: A stepped, mixed methods study (qual→QUANT→qual) comprised qualitative interviews with key informants and festivalgoers, and a quantitative online survey completed by almost 2000 Australian festivalgoers (52% male; median age 20 years old). Descriptive statistics were performed alongside bivariable and multivariable logistic regressions predicting internal concealment and panic consumption. Inductive thematic analysis was used to examine the qualitative data. RESULTS: Among respondents who had ever used illicit drugs at festivals (n=1065), 23% reported hiding drugs internally to evade police detection and 17% reported panic consumption. Female respondents and respondents expecting dogs were at greater odds of reporting internal concealment. The qualitative data provided greater insight into the risky nature of internal concealment practices and panic incited by police at the gates. When asked if they would have considered discarding their drugs into a drug amnesty bin had they been concerned about detection, less than a quarter (24%) said they definitely or probably would have. CONCLUSION: This paper adds to the evidence regarding iatrogenic effects of punitive drug policing practices at festivals. The findings have implications for shifting away from punitive policies to ones focused on public health. Additionally, the findings suggest drug amnesty bins should not be viewed as an adequate response for averting harms from drug policing.

The cost and impact of distributing naloxone to people who are prescribed opioids to prevent opioid-related deaths: findings from a modelling study.

BACKGROUND AND AIMS: Although most opioid-related mortality in Australia involves prescription opioids, most research to understand the impact of naloxone supply on opioid-related mortality has focused upon people who inject heroin. We aimed to examine the cost and probable impact of up-scaling naloxone supply to people who are prescribed opioids. DESIGN: Decision-tree model. Four scenarios were compared with a baseline scenario (the current status quo): naloxone scale-up between 2020 and 2030 to reach 30 or 90% coverage by 2030, among the subgroups of people prescribed either ≥ 50 or ≥ 100 mg of oral morphine equivalents (OME). SETTING: Australia. PARTICIPANTS: People who are prescribed opioids. MEASUREMENTS: Possible deaths averted, costs (ambulance and naloxone distribution) and cost per life saved for different scenarios of naloxone scale-up. FINDINGS: Maintaining the status quo, there would be an estimated 7478 [uncertainty interval (UI) = 6868-8275] prescription opioid overdose deaths between 2020 and 2030, resulting in Australian dollars (A$)51.9 million (49.4, 56.0) in ambulance costs. If naloxone were scaled-up to 90% of people prescribed > 50 mg OME, an estimated 657 (UI = 245, 1489) deaths could be averted between 2020 and 2030 (a 20% reduction in the final year of the model compared with the no naloxone scenario), with a cost of A$43 600 (20 800-110 500) per life saved. If naloxone were scaled-up to 30% of people prescribed > 50 mg OME an estimated 219 (82-496) deaths could be averted with the same cost per live saved. If naloxone were restricted to those prescribed > 100 mg OME, an estimated 130 (UI = 44-289) deaths would be averted if scaled-up to 30% or 390 (UI = 131-866) deaths averted if scaled-up to 90%, with the cost per life saved for both scenarios A$38 200 (UI = 12 400-97 400). CONCLUSION: In Australia, scaling-up take-home naloxone by 2030 to reach 90% of people prescribed daily doses of ≥ 50 mg of oral morphine equivalents would be cost-effective and save more than 650 lives.

Assessing options for cannabis law reform: A Multi-Criteria Decision Analysis (MCDA) with stakeholders in New Zealand.

BACKGROUND: A number of jurisdictions are considering or implementing different options for cannabis law reform, including New Zealand. Multi-Criteria Decision Analysis (MCDA) helps facilitate the resolution of complex policy decisions by breaking them down into key criteria and drawing on the combined knowledge of experts from various backgrounds. AIMS: To rank cannabis law reform options by facilitating expert stakeholders to express preferences for projected reform outcomes using MCDA. METHODS: A group of cannabis policy experts projected the outcomes of eight cannabis policy options (i.e., prohibition, decriminalization, social clubs, government monopoly, not-for-profit trusts, strict regulation, light regulation, and unrestricted market) based on five criteria (i.e., health and social harm, illegal market size, arrests, tax income, treatment services). A facilitated workshop of 42 key national stakeholders expressed preferences for different reform outcomes and doing so generated relative weights for each criterion and level. The resulting weights were then used to rank the eight policy options. RESULTS: The relative weighting of the criteria were: "reducing health and social harm" (46%), "reducing arrests" (31%), "reducing the illegal market" (13%), "expanding treatment" (8%) and "earning tax" (2%). The top ranked reform options were: "government monopoly" (81%), "not-for-profit" (73%) and "strict market regulation" (65%). These three received higher scores due to their projected lower impact on health and social harm, medium reduction in arrests, and medium reduction in the illegal market. The "lightly regulated market" option scored lower largely due its projected greater increase in health and social harm. "Prohibition" ranked lowest due to its lack of impact on reducing the number of arrests or size of the illegal market. CONCLUSION: Strictly regulated legal market options were ranked higher than both the current prohibition, and alternatively, more lightly regulated legal market options, as they were projected to minimize health and social harms while substantially reducing arrests and the illegal market.

The Overdose Response with Take Home Naloxone (ORTHN) project: Evaluation of health worker training, attitudes and perceptions.

INTRODUCTION: Naloxone is a life-saving medication that reverses opioid overdose; naloxone can be provided on a 'take-home' basis so naloxone can be administered outside of the health-care setting. The Overdose Response and Take Home Naloxone (ORTHN) project established a model of care for take-home naloxone (THN) interventions across alcohol and other drug and harm reduction services in NSW, Australia. This paper evaluates the staff training and credentialing program, and examines staff attitudes and perspectives regarding the provision of THN interventions in these settings. METHODS: Staff across seven services were trained through a 'train-the-trainer' credentialing model to deliver ORTHN, including naloxone supply. Staff were surveyed regarding their experience, attitudes and knowledge on THN prior to and after training, and after 6 months. At the 6 months follow up, staff were asked about the interventions they provided, barriers and enablers to uptake, and opinions regarding future rollout. RESULTS: A total of 204 staff were trained and credentialed to provide the ORTHN intervention. Most (60%) were nurses, followed by needle syringe program workers and allied health/counsellors (32%). Linear and logistic regression analyses indicated that the training program was associated with significant improvements in staff knowledge and attitudes towards overdose and THN; however, only attitudinal improvements were maintained over time. There were high rates of staff satisfaction with the ORTHN intervention and training. DISCUSSION/CONCLUSIONS: The ORTHN program is 'fit for purpose' for broad implementation in these settings. A number of potential barriers (e.g. time, medication and staffing costs) and enablers (e.g. peer engagement, regulatory framework for naloxone supply) in implementing THN interventions were identified.

Changes in illicit drug use and markets with the COVID-19 pandemic and associated restrictions: findings from the Ecstasy and Related Drugs Reporting System, 2016-20.

AIMS: To describe (i) self-reported changes in drug use and (ii) trends in price, perceived availability, and perceived purity of illicit drugs, among people who regularly use ecstasy/ 3,4-methylenedioxymethamphetamine (MDMA) and other illicit stimulants in Australia following COVID-19 and associated restrictions. DESIGN: Annual interviews with cross-sectional sentinel samples conducted face-to-face in 2016-19 and via video conferencing or telephone in 2020. Data were collected via an interviewer-administered structured questionnaire. SETTING: Australian capital cities. PARTICIPANTS: Australians aged 16 years or older who used ecstasy/MDMA and other illicit stimulants on a monthly or more frequent basis and resided in a capital city, recruited via social media and word-of-mouth (n ~ 800 each year). MEASUREMENTS: Key outcome measures were self-reported illicit drug market indicators (price, purity and availability) and, in 2020 only, perceived change in drug use (including alcohol and tobacco) since March 2020 and reasons for this change. FINDINGS: For most drugs, participants reported either no change or a reduction in their use since COVID-19 restrictions were introduced. Ecstasy/MDMA was the drug most frequently cited as reduced in use (n = 552, 70% of those reporting recent use), mainly due to reduced opportunities for socialization. While market indicators were largely stable across most drugs, the odds of perceiving MDMA capsules as 'high' in purity decreased compared with 2016-19 [adjusted odds ratio (aOR) = 0.72, 95% confidence interval (CI) = 0.53-0.99], as did perceiving them as 'easy' to obtain (aOR = 0.42, CI = 0.26-0.67). The odds of perceiving cocaine and methamphetamine crystal as 'easy' to obtain also decreased (aOR = 0.67, CI = 0.46-0.96 and aOR = 0.12, CI = 0.04-0.41, respectively). CONCLUSIONS: After COVID-19-related restrictions were introduced in Australia, use of ecstasy/MDMA, related stimulants and other licit and illicit drugs mainly appeared to remain stable or decrease, primarily due to impediments to socialization.