Changes in mental health and help-seeking among young Australian adults during the COVID-19 pandemic: a prospective cohort study.

BACKGROUND: Young people may have elevated risk for poorer mental health during the coronavirus disease 2019 (COVID-19) pandemic, yet longitudinal studies documenting this impact are lacking. This study assessed changes in mental health and help-seeking since COVID-19 restrictions in young Australians, including gender differences. METHODS: Data were drawn from a recent subsample (n = 443; 60% female; Mage = 22.0) of a prospective cohort originally recruited in secondary school to complete annual surveys. The subsample completed an additional COVID-19 survey during COVID-19 restrictions (May-June 2020), which was compared to responses from their latest annual survey (August 2019-March 2020). Mixed effect models with time and gender as the primary predictors were conducted for: (i) scores on the Patient Health Questionnaire Depression 9-item (PHQ-9) and Generalised Anxiety Disorder 7-item (GAD-7) modules assessed before and during COVID-19 restrictions, and (ii) self-reported help-seeking from a health professional in February 2020, and the month preceding May-June 2020. RESULTS: Mean symptom scores increased from before to during COVID-19 restrictions on the PHQ-9 (coefficient: 1.29; 95% CI 0.72-1.86) and GAD-7 (0.78; 95% CI 0.26-1.31), but there was no increase in help-seeking over time (odds ratio 0.50; 95% CI 0.19-1.32). There was no evidence of differential changes by gender. CONCLUSIONS: This study found increases in depression and anxiety symptoms but not greater help-seeking among young Australian adults during the first wave of the pandemic. Increasing availability and awareness of accessible treatment options and psychoeducation is critical, as well as further research into risk and protective factors to help target treatment to this vulnerable age group.

The experience of physiological and psychosocial alcohol-related harms across adolescence and its association with alcohol use disorder in early adulthood: A prospective cohort study.

BACKGROUND: Different forms of alcohol-related harm (e.g., hangovers, fighting) may confer differential risk of clinically relevant alcohol problems. We examine: (i) patterns of transition in experiencing alcohol-related harms across adolescence; (ii) whether factors in early adolescence predict transition patterns; and (iii) whether transition patterns predict later alcohol use disorder (AUD) symptoms. METHODS: We used a longitudinal Australian cohort (n = 1828) to model latent class transition patterns of alcohol-related harms across three timepoints (Mage  = 13.9, 16.8, 18.8 years). Regression models assessed whether child, peer, and parent factors in early adolescence (Mage  = 12.9) predicted harms transition patterns and whether these patterns predicted AUD symptoms in early adulthood (Mage  = 19.8). RESULTS: Five transition patterns characterized most of the cohort (n ≈ 1609, 88.0%): (i) minimal harms (n ≈ 381, 20.8%); (ii) late physiological harms (n ≈ 702, 38.4%); (iii) early physiological harms (n ≈ 226, 12.4%); (iv) late all harms (n ≈ 131, 7.2%); and (v) gradual all harms (n ≈ 169, 9.2%). With late physiological harms as the reference, females had increased risk of experiencing early physiological harms (relative risk [RR]: 2.15; 99.5% CI: 1.19, 3.90). Late all harms (RR: 1.71; CI: 1.19, 2.47) and gradual all harms (RR: 1.84; CI: 1.37, 2.47) were each associated with increased odds of meeting criteria for AUD, even when patterns of alcohol consumption are considered. CONCLUSIONS: Adolescents display heterogeneous transition patterns across physiological and psychosocial alcohol-related harms. Females are at greater risk of experiencing early physiological harms. Experience of both physiological and psychosocial harms in late adolescence is an important and potentially modifiable precursor to clinically relevant alcohol problems in early adulthood.

Gender differences in the supply of alcohol to adolescent daughters and sons.

Background: Parents are the main supplier of alcohol to children but it is not known whether mothers and fathers equally contribute to the supply of alcohol to their female and male children as these children transition to adulthood.Objectives: i) to determine whether the gender of the parent is associated with the gender of the adolescent offspring when alcohol is supplied and ii) whether the gender of the parent supplying is associated with gender differences in adolescent binge drinking and alcohol related harms.Methods: Longitudinal cohort of 1,927 (males = 1052) Australian adolescents (mean age 12.9 years), recruited in 2010/11 from schools in Australia and surveyed annually for six years. We assessed the association between adolescent and parent gender related to subsequent adolescent drinking, binge drinking (>4 standard drinks), and alcohol-related harms.Results: At mean age of 12.9 years about one in ten children report parental supply of alcohol which increases to about four in ten children by 17.8 years. Mothers consistently more often supply their daughters with alcohol than their sons, [Wave 5 OR 1.77 (1.53,2.05)], while mothers less often supply sons than their daughters, [Wave 5 OR 0.82 (0.71,0.95)]. Mothers' supply of alcohol to daughters predicts substantially increased odds of daughters binge drinking, [OR 1.67 (1.10,2.53)] and experiencing alcohol related harms, [OR 1.65 (1.10,2.48)].Conclusion: There is a need to involve both mothers and fathers and to equally target female and male children in programs to reduce the harmful consequences of parental supply of alcohol to their children.

Effect of Cytisine vs Varenicline on Smoking Cessation: A Randomized Clinical Trial.

Importance: Cytisine is more effective than placebo and nicotine replacement therapy for smoking cessation. However, cytisine has not been tested against the most effective smoking cessation medication, varenicline, which is associated with adverse events known to lead to discontinuation of therapy. Objective: To examine whether standard cytisine treatment (25 days) was at least as effective as standard varenicline treatment (84 days) for smoking cessation. Design, Setting, and Participants: This noninferiority, open-label randomized clinical trial with allocation concealment and blinded outcome assessment was undertaken in Australia from November 2017 through May 2019; follow-up was completed in January 2020. A total of 1452 Australian adult daily smokers willing to make a quit attempt were included. Data collection was conducted primarily by computer-assisted telephone interview, but there was an in-person visit to validate the primary outcome. Interventions: Treatments were provided in accordance with the manufacturers' recommended dosage: cytisine (n = 725), 1.5-mg capsules taken 6 times daily initially then gradually reduced over the 25-day course; varenicline (n = 727), 0.5-mg tablets titrated to 1 mg twice daily for 84 days (12 weeks). All participants were offered referral to standard telephone behavioral support. Main Outcomes and Measures: The primary outcome was 6-month continuous abstinence verified using a carbon monoxide breath test at 7-month follow-up. The noninferiority margin was set at 5% and the 1-sided significance threshold was set at .025. Results: Among 1452 participants who were randomized (mean [SD] age, 42.9 [12.7] years; 742 [51.1%] women), 1108 (76.3%) completed the trial. Verified 6-month continuous abstinence rates were 11.7% for the cytisine group and 13.3% for the varenicline group (risk difference, -1.62% [1-sided 97.5% CI, -5.02% to ∞]; P = .03 for noninferiority). Self-reported adverse events occurred less frequently in the cytisine group (997 events among 482 participants) compared with the varenicline group (1206 events among 510 participants) and the incident rate ratio was 0.88 (95% CI, 0.81 to 0.95; P = .002). Conclusions and Relevance: Among daily smokers willing to quit, cytisine treatment for 25 days, compared with varenicline treatment for 84 days, failed to demonstrate noninferiority regarding smoking cessation. Trial Registration: anzctr.org.au Identifier: ACTRN12616001654448.

Early Life Parechovirus Infection Neurodevelopmental Outcomes at 3 Years: A Cohort Study.

OBJECTIVE: To investigate the long-term developmental and behavioral outcomes in an established cohort of children hospitalized as infants with human parechovirus (HPeV) infection and sepsis-like illness. STUDY DESIGN: The HPeV cohort was composed of children 3 years of age after HPeV infection and hospitalization in early infancy that occurred during a well-documented HPeV genotype 3 outbreak in Australia. We assessed neurodevelopmental and behavioral outcomes using the Bayley Scales of Infant and Toddler Development-III and the Child Behavior Checklist. We compared their outcomes with a subsample of healthy control infants drawn from the independently sampled Triple B Pregnancy Cohort Study. RESULTS: Fifty children, with a mean age of 41 months, were followed for 3 years after hospital admission with HPeV infection. There were 47 children whose original illness was fever without source or sepsis-like illness and 3 who had encephalitis. All children in the HPeV cohort showed age-specific development within the population normal range on the Bayley Scales of Infant and Toddler Development-III. There was no difference in developmental attainment compared with 107 healthy control infants after adjusting for measured confounders. The HPeV cohort showed higher average scores on the Child Behavior Checklist and a higher frequency of clinical range scores compared with healthy controls. CONCLUSIONS: Although HPeV sepsis-like illness did not result in neurodevelopmental delay at 3 years of age, it was associated with increased behavioral problems compared with healthy controls. The behavioral problems reached a clinical threshold in a minority of children. Results inform clinical management and planning for children after severe HPeV infection in infancy.

A Global Meta-analysis of the Prevalence of HIV, Hepatitis C Virus, and Hepatitis B Virus Among People Who Inject Drugs-Do Gender-Based Differences Vary by Country-Level Indicators?

BACKGROUND: Women-specific factors exist that increases vulnerability to drug-related harms from injection drug use, including blood-borne viruses (BBVs), but gender-based differences in BBV prevalence have not been systematically examined. METHODS: We conducted meta-analyses to estimate country, regional, and global prevalence of serologically confirmed human immunodeficiency virus (HIV), hepatitis C virus (HCV; based on detection of anti-HCV antibody), and hepatitis B virus (HBV; based on detection of HBV surface antigen) in people who inject drugs (PWID), by gender. Gender-based differences in the BBV prevalence (calculated as the risk among women relative to the risk among men) were regressed on country-level prevalence and inequality measures (Gender inequality index, Human development index, Gini coefficient, and high, low or middle income of the country). RESULTS: Gender-based differences varied by countries and regions. HIV prevalence was higher among women than men in sub-Saharan Africa (relative risk [RR], 2.8; 95% confidence interval [CI], 1.8-4.4) and South Asia (RR, 1.7; 95% CI, 1.1-2.7); anti-HCV was lower among women in the Middle East and North Africa (RR, 0.6; 95% CI, .5-.7) and East and Southeast Asia (RR, 0.8; 95% CI, .7-.9). Gender-based differences varied with country-levels of the BBV prevalence in the general population, human development, and income distribution. CONCLUSION: HIV was more prevalent in women who inject drugs as compared to their male counterparts in some countries, but there is variation between and within regions. In countries where women are at higher risks, there is a need to develop gender-sensitive harm-reduction services for the particularly marginalized population of women who inject drugs.

Concerns and Help-Seeking Among Patients Using Opioids for Management of Chronic Noncancer Pain.

BACKGROUND: The safety and efficacy of long-term opioid treatment for chronic noncancer pain (CNCP) remains controversial. This study examined whether patients who report problematic opioid use sought help and/or perceived barriers to help-seeking. METHODS: Data were collected from 1,086 people prescribed opioids for CNCP via a large prospective cohort called the Pain and Opioids IN Treatment (POINT) study. Patients' characteristics and help-seeking were examined according to scores on the Prescribed Opioids Difficulties Scale (PODS). RESULTS: Participants scoring "intermediate" (17%) or "high" (30%) on the PODS were younger and reported more complex pain presentations, higher opioid doses, poorer physical health, moderate to severe anxiety and depression, aberrant behavior, past month opioid use disorder and help-seeking (compared with the "low" PODS group, 53%). One-quarter (26%) had sought help, most commonly from a primary care physician, specialist pain clinic, family member/partner, counselor/psychologist, and the Internet. Participants in the "high" PODS group were more likely to have sought help from an alcohol or other drug service, addiction specialist, or drug information helpline. Common barriers to help-seeking were desire for self-management and concern that their opioid treatment may be discontinued. Although 35% met criteria for likely opioid use disorder, only 4.8% reported lifetime treatment with methadone or buprenorphine; participants' ratings indicated significant perceived stigma associated with these medications. CONCLUSIONS: The PODS is effective in identifying patients who are concerned about their opioid use. Strategies to address stigma related to drug treatment, including better integration of primary health, specialist pain, and addiction services, are important in reducing opioid-related harm.

Parent hazardous drinking and their children's alcohol use in early and mid-adolescence: prospective cohort study.

BACKGROUND: Why adolescents' drinking is associated with their parents' drinking remains unclear. We examined associations in a prospective cohort study, adjusting for socio-demographic characteristics and family factors. METHODS: We recruited 1927 children from grade 7 classes (mean age 13 years), and one of their parents, in three Australian states, contacted participants annually from 2010 to 2014, and analysed data from assessments at ages 13, 14, 15 and 16 years. We used the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) subscale to identify hazardous drinking in parents (score ≥5) and children (score ≥3) and constructed mixed-effect logistic regression models, accounting for clustering within school and adjusting for likely confounders. We evaluated the sensitivity of estimates by imputing missing values assuming the data were missing at random vs. missing not at random. RESULTS: Parent hazardous drinking predicted mid-adolescent hazardous drinking, e.g. 15 years olds whose parents [adjusted odds ratio (aOR) 2.00; 95% confidence interval 1.51-2.64] or parents' partners (aOR 1.94; 1.48-2.55) were hazardous drinkers had higher odds of being hazardous drinkers at age 16. The magnitude of univariate associations changed little after adjusting for covariates, and sensitivity analyses confirmed the robustness of the association, across a wide range of assumptions about the missing data. CONCLUSIONS: The associations between parents' and their adolescent children's hazardous drinking are unlikely to be due to confounding by socio-demographic and family factors. Parents should be encouraged, and supported by public policy, to reduce their own alcohol consumption in order to reduce their children's risk of becoming hazardous drinkers.

Prenatal alcohol exposure and infant gross motor development: a prospective cohort study.

BACKGROUND: Maternal alcohol consumption in pregnancy may have adverse effects on child gross motor (GM) development. There have been few human studies on this topic, particularly ones examining low exposure. This study examined the association between prenatal alcohol exposure (PAE) and infant GM development at 12-months of age. METHODS: Participants were 1324 women recruited from antenatal clinics in Sydney and Perth, Australia. Maternal and paternal alcohol use was assessed in pregnancy via interview; offspring GM development was measured at 12-months with the Bayley Scales of Infant Development (BSID-III). RESULTS: Any alcohol use in pregnancy was common: 56.1%, of pregnant women drank early in Trimester one (0-6 weeks), however this reduced to 27.9% on average thereafter and at predominantly low levels. However, infant BSID GM scale scores were not found to differ significantly as a function of PAE in the first 6-weeks (low, moderate, binge or heavy PAE), nor with low PAE across pregnancy. CONCLUSIONS: We found no evidence to suggest that low PAE is associated with measurable impairment in infant GM development at 12-months. Further research is needed to examine potential PAE impacts on GM development in heavier exposure groups and through the childhood years when subtle GM deficits may be more detectable.

Correction to: Prenatal alcohol exposure and infant gross motor development: a prospective cohort study.

Following publication of the original article [1], the authors opted to revise the first paragraph of the section "Characteristics associated with maternal drinking in pregnancy". Below is the updated version.

Mother-Infant Bonding and Emotional Availability at 12-Months of Age: The Role of Early Postnatal Bonding, Maternal Substance Use and Mental Health.

INTRODUCTION: The quality of the mother-child relationship in the first year of life has far reaching implications across the life course (Bornstein in Annu Rev Psychol 65:121-158, 2014). Yet little is known about predictors of maternal bonding and emotional availability in early infancy. In this study we examined the extent to which postnatal bonding, maternal mental health, and substance use at 8-weeks postpartum predicted mother-infant bonding (self-report) and mother emotional availability (observational) at 12-months of age. METHODS: Data were obtained from an Australian longitudinal cohort study of pregnancy (n = 308). Data were collected during pregnancy, at birth, and postnatally at 8-weeks and 12-months. RESULTS: The results show strong continuity between postnatal bonding at 8-weeks and 12-months. Early postpartum stress and depression were associated with bonding at 12-months; however, the effect did not persist after adjustment for bonding at 8-weeks. Tobacco use at 8-weeks, but no other indicators of mental health, predicted lower emotional availability scores at 12-months. DISCUSSION: Results suggest that the mother's felt bond to her child is stable across the first year of life and that early bonding is a more robust indicator of bonding at 12-months than a mother's mental health or substance use. These findings point to the importance of clinical and public health investments in establishing a strong bond between mother and child in the early postpartum period.

Does adolescent heavier alcohol use predict young adult aggression and delinquency? Parallel analyses from four Australasian cohort studies.

While the association between heavy alcohol consumption and aggression has been well documented, the causal direction of this association, particularly at a population level, is disputed. A number of causal sequences have been proposed. First, that aggression leads to heavy alcohol use. Second, that heavy alcohol use leads to aggression. Third, that the association between alcohol use and aggression is due to confounding by (a) sociodemographic variables or (b) delinquency. We report here data from four Australasian prospective longitudinal studies of adolescents, to assess the temporal sequence of heavy drinking and aggression over the period from adolescence to young adulthood. The four cohort studies provide a total sample of 6,706 persons (Australian Temperament Project, n = 1701; Christchurch Health and Development Study, n = 931; Mater-University of Queensland Study of Pregnancy, n = 2437; Victorian Adolescent Health Cohort Study, n = 1637). We use multinomial logistic regression to determine whether early adolescent aggression predicts subsequent age of onset of heavy episodic drinking (HED), after adjustment for concurrent sociodemographic factors and delinquency. We then consider whether HED predicts subsequent aggression, after adjusting for past aggression, concurrent delinquency, and a range of confounders. There are broadly consistent findings across the four cohort studies. Early aggression strongly predicts subsequent HED. HED predicts later aggression after adjustment for prior aggression and other confounders. Policies that alter population levels of alcohol consumption are likely to impact on levels of aggression in societies where HED linked to aggression is more common.

Age of Alcohol Initiation and Progression to Binge Drinking in Adolescence: A Prospective Cohort Study.

BACKGROUND: Early alcohol initiation is common and has been associated with the development of alcohol problems. Yet, past research on the association of age of initiation with later problem drinking has produced inconsistent findings. Using prospective data from the Australian Parental Supply of Alcohol Longitudinal Study cohort, this study examined age of alcohol initiation, and of first drunkenness, and associations with subsequent drinking in adolescence. METHODS: A total of 1,673 parent-child dyads recruited through Australian secondary schools completed annual surveys for 5 years (grades 7 to 11). Limiting the sample to those adolescents who had initiated alcohol use by age 17 (n = 839), multinomial logistic regression models were used to examine associations between (i) age of initiation to alcohol use (consuming at least 1 full serve) and (ii) age of first drunkenness, and 2 outcomes: (i) binge drinking (consuming >4 standard drinks on a single occasion), and (ii) the total number of alcoholic drinks consumed in the past year, adjusted for a range of potential child, parent, family, and peer covariates. RESULTS: Fifty percent of adolescents reported alcohol use and 36% reported bingeing at wave 5 (mean age 16.9 years), and the mean age of initiation to alcohol use for drinkers was 15.1 years. Age of initiation was significantly associated with binge drinking and total quantity of alcohol consumed in unadjusted and adjusted models. Age of first drunkenness was associated with total quantity of alcohol consumed in unadjusted models but not adjusted models and was not associated with subsequent bingeing. CONCLUSIONS: Initiating alcohol use earlier in adolescence is associated with an increased risk of binge drinking and higher quantity of consumption in late secondary school, supporting an argument for delaying alcohol initiation for as long as possible to reduce the risk for problematic use in later adolescence and the alcohol-related harms that may accompany this use.

The Methodological Quality and Effectiveness of Technology-Based Smoking Cessation Interventions for Disadvantaged Groups: A Systematic Review and Meta-analysis.

Aims: To assess the methodological quality and effectiveness of technology-based smoking cessation interventions in disadvantaged groups. Method: Four databases (EMBASE, Cochrane, Medline, and PsycInfo) were searched for studies conducted from 1980 to May 2016. Randomized controlled trials that compared a behavioral smoking cessation intervention delivered primarily through a technology-based platform (eg, mobile phone) with a no-intervention comparison group among disadvantaged smokers were included. Three reviewers assessed all relevant studies for inclusion, and one reviewer extracted study, participant and intervention-level data, with a subset crosschecked by a second reviewer. Results: Thirteen studies targeting disadvantaged smokers (n =4820) were included. Only one study scored highly in terms of methodological rigor on EPOC criteria for judging risk of bias. Of the 13 studies using a technology-based platform, most utilized websites (n = 5) or computer programs (n = 5), and seven additionally offered nicotine replacement therapy. Technology-based interventions increased the odds of smoking cessation for disadvantaged groups at 1 month (odds ratio [OR] 1.70, 95% confidence interval [CI] 1.10, 2.63), 3 months (OR 1.30, 95% CI 1.07, 1.59), 6 months (OR 1.29, 95% CI 1.03, 1.62), and 18 months post-intervention (OR 1.83, 95% CI 1.11, 3.01). Conclusion: Few methodologically rigorous studies were identified. Mobile phone text-messaging, computer- and website-delivered quit support showed promise at increasing quit rates among Indigenous, psychiatric and inpatient substance use disorder patients. Further research is needed to address the role technology-based interventions have on overcoming health inequalities to meet the needs of disadvantaged groups. Implications: This review provides the first quantitative evidence of the effectiveness of a range of technology-based smoking cessation interventions among disadvantaged smokers, with separate estimates on the basis of intervention type, and cessation outcome measure. Providing cost-effective, easily accessible and real-time smoking cessation treatment is needed, and innovative technology-based platforms will help reach this endpoint. These interventions need to be tested in larger scale randomized controlled trial designs and target broader disadvantaged groups. Data collection beyond 6 months is also needed in order to establish the efficacy of these intervention approaches on long-term cessation rates among disadvantaged population groups.

Finding the optimal treatment model: A systematic review of treatment for co-occurring alcohol misuse and depression.

OBJECTIVES: Alcohol misuse and depression are commonly co-occurring conditions. To date, no review has examined the most efficacious treatment model for psychosocial treatment of co-occurring alcohol misuse and depression. This systematic review determined the: (i) methodological quality of publications examining psychosocial treatment of co-occurring alcohol misuse and depression using a sequential, parallel or integrated treatment model; and (ii) effectiveness of each dual treatment model compared to single treatment for those with co-occurring alcohol misuse and depression. METHODS: PubMed, Medline and PsycInfo databases were searched for studies which were included if they involved treatment for alcohol misuse and depression and could be classified into one of the three treatment models. Included studies were assessed using the Cochrane's Effective Practice and Organisation of Care risk of bias criteria. Relevant study characteristics and outcomes were extracted and are presented in a narrative review format. RESULTS: Seven studies met inclusion criteria. None were categorised as low risk on the risk of bias criteria. No studies examined a sequential model of treatment, three examined a parallel model and four examined an integrated model of dual-focussed treatment. The studies examining the parallel model and two out of four studies examining the effectiveness of an integrated model demonstrated greater improvement for alcohol or depression outcomes compared to control conditions. CONCLUSION: Evidence for the psychosocial treatment of co-occurring alcohol misuse and depression is limited to a handful of studies. The evidence has several methodological limitations, which impact the interpretation of the findings. Therefore, while international guidelines recommend integrated dual-focussed treatment for co-occurring conditions, there is little evidence supporting the superiority of this treatment format for co-occurring alcohol misuse and depression. High-quality research demonstrating improvements in patient outcomes is required to ensure recommendations for clinical practice are based on strong empirical evidence.

Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study.

BACKGROUND: Despite opioid analgesics being essential for pain relief, use has been inadequate in many countries. We aim to provide up-to-date worldwide, regional, and national data for changes in opioid analgesic use, and to analyse the relation of impediments to use of these medicines. METHODS: We calculated defined daily doses for statistical purposes (S-DDD) per million inhabitants per day of opioid analgesics worldwide and for regions and countries from 2001 to 2013, and we used generalised estimating equation analysis to assess longitudinal change in use. We compared use data against the prevalence of some health disorders needing opioid use. We surveyed 214 countries or territories about impediments to availability of these medicines, and used regression analyses to establish the strength of associations between impediments and use. FINDINGS: The S-DDD of opioid analgesic use more than doubled worldwide between 2001-03 and 2011-13, from 1417 S-DDD (95% CI -732 to 3565; totalling about 3.01 billion defined daily doses per annum) to 3027 S-DDD (-1162 to 7215; totalling about 7.35 billion defined daily doses per annum). Substantial increases occurred in North America (16,046 S-DDD [95% CI 4032-28,061] to 31,453 S-DDD [8121-54,785]), western and central Europe (3079 S-DDD [1274-4883] to 9320 S-DDD [3969-14,672]), and Oceania (2275 S-DDD [763-3787] to 9136 S-DDD [2508-15,765]). Countries in other regions have shown no substantial increase in use. Impediments to use included an absence of training and awareness in medical professionals, fear of dependence, restricted financial resources, issues in sourcing, cultural attitudes, fear of diversion, international trade controls, and onerous regulation. Higher number of impediments reported was significantly associated with lower use (unadjusted incidence rate ratio 0.39 [95% CI 0.29-0.52]; p<0.0001), but not when adjusted for gross domestic product and human development index (0.91 [0.73-1.14]; p=0.4271). INTERPRETATION: Use of opioid analgesics has increased, but remains low in Africa, Asia, Central America, the Caribbean, South America, and eastern and southeastern Europe. Identified impediments to use urgently need to be addressed by governments and international agencies. FUNDING: International Narcotics Control Board, UN.

Prenatal Alcohol Consumption Between Conception and Recognition of Pregnancy.

BACKGROUND: Current estimates of the rates of alcohol-exposed pregnancies may underestimate prenatal alcohol exposure if alcohol consumption in early trimester 1, prior to awareness of pregnancy, is not considered. Extant literature describes predictors of alcohol consumption during pregnancy; however, alcohol consumption prior to awareness of pregnancy is a distinct behavior from consumption after becoming aware of pregnancy and thus may be associated with different predictors. The purpose of this study was therefore to examine prevalence and predictors of alcohol consumption by women prior to awareness of their pregnancy, and trajectories of change to alcohol use following pregnancy recognition. METHODS: Pregnant women (n = 1,403) were prospectively recruited from general antenatal clinics of 4 public hospitals in Australian metropolitan areas between 2008 and 2013. Women completed detailed interviews about alcohol use before and after recognition of pregnancy. RESULTS: Most women (n = 850, 60.6%) drank alcohol between conception and pregnancy recognition. Binge and heavy drinking were more prevalent than low-level drinking. The proportion of women who drank alcohol reduced to 18.3% (n = 257) after recognition of pregnancy. Of women who drank alcohol, 70.5% ceased drinking, 18.3% reduced consumption, and 11.1% made no reduction following awareness of pregnancy. Socioeconomic status (SES) was the strongest predictor of alcohol use, with drinkers more likely to be of high rather than low SES compared with abstainers (OR = 3.30, p < 0.001). Factors associated with different trajectories (either cessation, reduction, or continuation of drinking) included level of alcohol use prior to pregnancy recognition, age, pregnancy planning, and illicit substance use. CONCLUSIONS: In this sample of relatively high SES women, most women ceased or reduced drinking once aware of their pregnancy. However, the rate of alcohol-exposed pregnancies was higher than previous estimates when the period prior to pregnancy recognition was taken into account.

"I'm not strong enough; I'm not good enough. I can't do this, I'm failing"- A qualitative study of low-socioeconomic status smokers' experiences with accesssing cessation support and the role for alternative technology-based support.

BACKGROUND: The social gradient in smoking rates persist with an overrepresentation of smoking and its associated harms concentrated within lower socioeconomic status (SES) populations. Low-SES smokers are motivated to quit but face multiple barriers when engaging a quit attempt. An understanding of the current treatment service model from the perspectives of treatment-seeking low-SES smokers is needed to inform the design of alternative smoking cessation support services tailored to the needs of low-SES populations. This qualitative study aimed to: i) explore low-SES smokers' recent quitting experiences; ii) assess factors that impact treatment engagement; and iii) determine the acceptability and feasibility of alternative approaches to smoking cessation. METHOD: Low-SES participants (n = 24) previously enrolled in a smoking cessation RCT participated in either a semi-structured focus group or in-depth telephone interview. Data was obtained and analysed using thematic analysis from October 2015 to June 2016. Analysis was deductive from the interview guide and supplemented inductively. RESULTS: Participants expressed feelings of guilt and shame around their smoking behaviour and experienced stigmatisation for their smoking. Guilt, shame, and stigmatisation negatively impacted treatment seeking behaviours with most avoiding current quit services. Costs of pharmacotherapy and treatment adherence were commonly cited barriers to treatment success. Electronic-cigarettes were perceived to be unsafe due to uncertainty on their legal status and regulatory restrictions. Technology-based text-messaging quit support was endorsed as a more favourable alternative compared to existing behavioural treatment services. CONCLUSION: Stigmatisation was commonly endorsed and acted as an impediment to current treatment utilisation. Electronic-cigarettes may present a viable harm reduction alternative, but their likely uptake in socioeconomically disadvantaged groups in Australia is limited by smokers' uncertainty about their regulation and legality. Mobile phone based cessation support may provide an alternative to telephone counselling and overcome the stigmatisation low-SES smokers face while trying to quit.

Smoking and finances: baseline characteristics of low income daily smokers in the FISCALS cohort.

BACKGROUND: Financial stress is a barrier to successful smoking cessation and a key predictor of relapse. Little is known about the financial situation of low-income Australian daily smokers. This study aims to describe and investigate associations between the financial functioning, tobacco use and quitting behaviours of low income daily smokers. METHODS: Low-income Australian adult smokers in the 'Financial Intervention for Smoking Cessation Among Low-income Smokers (FISCALS) randomised clinical trial completed a structured telephone questionnaire. RESULTS: The median number of cigarettes typically smoked by the 1047 participants was 23 per day. The median spent on tobacco per week was AU$80. Three quarters (73.0%) reported some financial stress and 43.2% reported smoking-induced deprivation. Financial stress was significantly associated with deprivation (IRR: 1.23, 95% CI 1.21, 1.26, p < 0.001). There were no significant associations either between adjusted financial stress or deprivation and motivation to quit or certainty of quit success. CONCLUSIONS: Financial stress and smoking induced deprivation were prevalent among low-income daily smokers, but they were not associated with motivation to quit. Smoking cessation interventions need to be responsive to the role financial stress plays in reducing quit attempts and increasing relapse. TRIAL REGISTRATION: Australian and New Zealand Clinical trials Registry ACTRN12612000725864 6/07/2012.

Defined daily doses (DDD) do not accurately reflect opioid doses used in contemporary chronic pain treatment.

OBJECTIVE: To assess how well the defined daily dose (DDD) metric reflects opioid utilisation among chronic non-cancer pain patients. DESIGN: Descriptive, cross-sectional study, utilising a 7-day medication diary. SETTING: Community-based treatment settings, Australia. SUBJECTS: A sample of 1101 people prescribed opioids for chronic non-cancer pain. METHODS: Opioid dose data was collected via a self-completed 7-day medication diary capturing names, strengths and doses of each medication taken in the past week. Median daily dose was calculated for each opioid. Comparisons were made to the World Health Organization's (WHO) DDD metric. RESULTS: WHO DDDs ranged from 0.6 to 7.1 times the median opioid doses used by the sample. For transdermal fentanyl and oral hydromorphone, the median dose was comparable with the DDD. The DDD for methadone was 0.6 times lower than the median doses used by this sample of chronic pain patients. In contrast, the DDD for oxycodone and transdermal buprenorphine, the most commonly used strong opioids for chronic pain in Australia, was two to seven times higher than actual doses used. CONCLUSIONS: For many opioids, there are key differences between the actual doses used in clinical practice and the WHO's DDDs. The interpretation of opioid utilisation studies using population-level DDDs may be limited, and a recalibration of the DDD for many opioids or the reporting of opioid utilisation in oral morphine equivalent doses is recommended. Copyright © 2017 John Wiley & Sons, Ltd.