Substance use among vocational trainees in Australia: differences between medical specialties.

BACKGROUND: There have been few large-scale nationally representative studies on the prevalence of substance use among doctors. In addition, the association of different medical specialties with the use of different substances requires further research. AIMS: To investigate how the use of alcohol, tobacco and illicit drugs varied between junior doctors enrolled in different specialty training programmes. METHODS: A secondary analysis was conducted on a national survey of 12 252 Australian doctors. The population of interest was junior doctors currently enrolled in a specialty training programme, termed vocational trainees (VT; n = 1890; 15.4% of the overall sample). Self-report prevalence of current alcohol, tobacco and illicit drug use were assessed and hazardous alcohol use was assessed using the Alcohol Use Disorders Identification Test. Logistic regression was used to examine the association between specialty and substance use, adjusting for demographic characteristics when required. RESULTS: One in six VT reported hazardous levels of alcohol use (n = 268; 17.3%). After adjusting for confounders, the association between the prevalence of alcohol use and the specialties of emergency medicine/intensive care unit (odds ratio (OR) 2.15; 95% confidence interval (CI) 1.40-3.32; P < 0.001), anaesthetics (OR 2.53; 95% CI 1.35-4.76; P = 0.004) and obstetrics/gynaecology (OR 1.89; 95% CI 1.19-3.02; P = 0.007) remained significant. No significant associations were found between tobacco use/illicit drug use/hazardous alcohol use and medical specialty. CONCLUSIONS: While rates of substance use and hazardous alcohol use in VT are similar, if not lower, than the general population, it poses a concern that there are higher rates of alcohol use in certain medical specialties.

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

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

The efficacy of behavioural activation treatment for co-occurring depression and substance use disorder (the activate study): a randomized controlled trial.

BACKGROUND: Epidemiological studies suggest that compared with the general population, mood disorders are up to 4.7 times more prevalent in substance dependent samples. Comorbid substance use disorder (SUD) and depression has been associated with a more severe and protracted illness course and poorer treatment outcomes. Despite this, the development and assessment of behavioural interventions for treating depression among individuals with SUDs have received little empirical attention. Behavioural Activation Treatment for Depression (BATD-R) is an empirically supported treatment for depression that has shown some efficacy among substance users. This paper describes the study protocol of a parallel, single blind, randomised controlled trial to determine the efficacy and feasibility of a modified version of the BATD-R (Activate) in reducing symptoms of depression and substance dependence among individuals in residential rehabilitation (RR) and opioid substitution therapy (OST). METHODS/DESIGN: A sample of approximately 200 individuals with depressive symptomatology in treatment for SUD will be recruited from RR and OST services in New South Wales, Australia. Dynamic random allocation following minimisation methodology will be used to assign participants to one of two groups. The control group will receive treatment as usual (TAU), which will be the model of care provided in accordance with standard practice at participating RR and OST services. The intervention group will receive Activate, comprising 10 individual 60-min therapy sessions with a psychologist employed on the research team, in addition to TAU. Data collection will occur at baseline (pre-intervention), and 3-months and 12-months post baseline. DISCUSSION: The association between depression and substance dependence has been well documented, yet practical and effective treatments are scarce. The findings of the present study will contribute significantly to understanding the types of programs that are effective in treating this comorbidity. TRIAL REGISTRATION: This trial is registered with the Australian and New Zealand Clinical Trials registry, ACTRN12613000876796 . Registered on 7 August, 2013.

Alcohol use in hazardous situations: implications for DSM-IV and DSM-5 alcohol use disorders.

BACKGROUND: The use in hazardous situations criterion (hazard) is 1 of 4 criteria related to alcohol abuse in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and 1 of the 11 criteria related to the new alcohol use disorder (AUD) proposed for DSM-5. The current study aims to evaluate the hazard criterion in the context of both DSM-IV alcohol abuse and DSM-5 AUD. METHODS: Data came from the 2007 Australian National Survey of Mental Health and Well-Being (n = 8,841) as a stratified, multistage area probability sample of persons aged 16 to 85 years. Logistic regressions were used to: (i) compare the clinical characteristics of those with alcohol abuse including hazard and those with alcohol abuse because of other criteria; (ii) investigate the relationship between the hazard criterion and indices of socioeconomic status (SES); and (iii) investigate the effect of eliminating the hazard criterion on the epidemiology and correlates of the proposed DSM-5 AUD diagnosis. RESULTS: When compared with the other abuse subgroup, those with abuse including hazard (irrespective of other abuse criteria endorsed) were more likely to report another drug use disorder. The 2 abuse subgroups could not be differentiated by any other clinical characteristics. There were no systematic relationships between the hazard criterion and indices of SES. The elimination of the hazard criterion would lead to a considerable decrease in the prevalence of AUD, with those no longer receiving a diagnosis more likely to be young males with drug use disorders and suicidal behaviors. CONCLUSIONS: The current study failed to replicate previous analyses that indicated problems with the hazard criterion when assessed in the U.S. population. Many of the problems identified in the hazard criterion appear to be due to operationalizations of this criterion that includes items specifically related to drink-driving. The current results indicate that the elimination of the hazard criterion would lead to a considerable decline in the prevalence of DSM-5 AUD and risk excluding a potentially clinically significant subtype of AUD from future diagnosis.

Do young adults interpret the DSM diagnostic criteria for alcohol use disorders as intended? a cognitive interviewing study.

BACKGROUND: Estimates of the prevalence of DSM-IV alcohol use disorders (AUD; i.e., abuse and dependence) are consistently higher for younger adults compared with their older counterparts. However, questions remain as to whether this "youthful epidemic" of AUD is real or a methodological artifact of the prevailing classification criteria. The aim of the current study was to explore potential shortcomings in the AUD criteria when applied to young adults. METHODS: Experts in the field of substance use disorder classification carried out standardized appraisal of 4 DSM-IV diagnostic criteria for alcohol abuse/dependence (hazard, tolerance, larger/longer, quit/cut down). Cross-sectional surveys of 100 young adult drinkers aged 18 to 24 were carried out. All participants were administered a structured diagnostic interview as well as a structured cognitive interview. The cognitive interviews were comprised of a set of predetermined and standardized probe questions designed to shed light on young adults' understanding of interview questions designed to tap the AUD diagnostic criteria. Answers to the cognitive interview probe questions were summarized across the total sample and, where appropriate, comparisons were made between those who endorsed the diagnostic criterion and those who did not. RESULTS: Results showed that there were substantial inconsistencies in young adults' interpretations of survey questions reflecting impaired control over alcohol. Interpretations of questions designed to measure tolerance to the effects of alcohol and use of alcohol in hazardous situations were largely understood as intended by the architects of DSM. CONCLUSIONS: Survey questions designed to tap compulsive patterns of alcohol use require close attention to ensure they reflect the intentions of the DSM diagnostic criteria for AUD.

Prevalence, correlates and comorbidity of DSM-IV Cannabis Use and Cannabis Use Disorders in Australia.

OBJECTIVE: To report nationally representative findings on the prevalence, correlates, psychiatric comorbidity and treatment of DSM-IV Cannabis Use and Cannabis Use Disorders in Australia. METHOD: The 2007 National Survey of Mental Health and Wellbeing was a nationally representative household survey of 8841 Australians (16-85 years) that assessed symptoms of the most prevalent DSM-IV mental disorders. RESULTS: Prevalence of lifetime and 12-month cannabis use was 18% and 6%; prevalence of lifetime and 12-month cannabis use disorder was 6% and 1%. The conditional prevalence (proportion of ever users who met criteria for a disorder) of lifetime and 12-month cannabis use disorder was 32.2% and 14.3%. Current cannabis use disorders were more common in males (OR 2.0) and younger users (OR 4.6). Strong associations were observed between current cannabis use disorders and alcohol use disorders (OR 3.6) and current affective disorders (OR 3.0). Only 36.2% of those with current cannabis use disorders sought any treatment. CONCLUSIONS: The prevalence of cannabis use disorders in the Australian population is comparable with that in the USA. Current cannabis use disorders are highly concentrated in young Australians who have high levels of comorbidity. The low rates of treatment seeking warrant attention in treatment and prevention strategies.

Affective and anxiety disorders and their relationship with chronic physical conditions in Australia: findings of the 2007 National Survey of Mental Health and Wellbeing.

OBJECTIVE: The aim of this study was to report nationally representative data on the prevalence and patterns of 12 month comorbidity of chronic physical conditions (diabetes, asthma, coronary heart disease, stroke, cancer, arthritis) and DSM-IV affective and anxiety disorders in Australian adults. METHOD: The 2007 National Survey of Mental Health and Wellbeing (NSMHWB) was a nationally representative household survey of 8841 Australian adults (16-85 years) assessing symptoms of ICD-10 mental disorders and the presence of chronic physical conditions. RESULTS: Prevalence of at least one National Health Priority Area chronic physical condition was 32.2% (95%CI = 30.9%-33.5%). Among those with chronic physical conditions 21.9% had an affective or anxiety disorder. Affective and anxiety disorders were more common among people with physical conditions than among people without chronic physical conditions (affective OR 1.5; anxiety OR 1.8). Of those with a 12 month affective or anxiety disorder, 45.6% had a chronic physical condition. Physical disorders were more common in those with an affective or anxiety disorder than among people without an affective or anxiety disorder (affective OR 1.6; anxiety OR 2.0). Disability was high in those with an anxiety disorder, an affective disorder and a physical condition and 43.4% were classified as high service users. CONCLUSIONS: Comorbidity between chronic physical conditions and affective and anxiety disorders is widespread and is associated with high levels of disability and service use.

Patterns and correlates of prescribed and non-prescribed pregabalin use among a sample of people who inject drugs in Australia.

INTRODUCTION AND AIMS: Pregabalin is a gamma-aminobutyric acid analogue registered and subsidised for the treatment of neuropathic pain in Australia. Despite pre-clinical evidence of low abuse potential, there are increasing reports of extramedical use and overdose deaths involving pregabalin. This study aimed to describe patterns of pregabalin use among an Australian sample of people who inject drugs (PWID) and identify sociodemographic, substance use and mental/physical health correlates of prescribed and non-prescribed use. DESIGN AND METHODS: Data were obtained from the 2018 Illicit Drug Reporting System, comprising a cross-sectional sample of 905 PWID recruited from Australian capital cities. Multinomial logistic regression was used to identify correlates of past 6-month prescribed and non-prescribed pregabalin use. RESULTS: One-quarter (25%) of participants reported any past 6-month pregabalin use, with 10% reporting prescribed use and 15% non-prescribed use. Past 6-month use of prescribed benzodiazepines and non-prescribed pharmaceutical opioids were associated with both prescribed and non-prescribed pregabalin use compared to no recent pregabalin use. Pain/discomfort on the day of interview was significantly associated with prescribed pregabalin use. Recent use of non-prescribed benzodiazepines and illicit stimulants and past year non-fatal overdose were significantly associated with non-prescribed pregabalin use (compared to no recent pregabalin use). DISCUSSION AND CONCLUSIONS: Pregabalin use was relatively common among an Australian sample of PWID. Benzodiazepine and pharmaceutical opioid use were positively correlated with both prescribed and non-prescribed pregabalin use, suggesting that education campaigns regarding the risks of harm associated with concomitant use of these substances are warranted (targeting both health professionals and consumers).

Opioid use and harms associated with a sustained-release tapentadol formulation: A post-marketing surveillance study.

AIMS: A sustained-release formulation (SRF) of tapentadol has been marketed in Australia since February 2013. This study examined tapentadol SRF extra-medical use, attractiveness for extra-medical use, and associated harms in Australia. METHODS: This post-marketing study comprises analyses of Australian community sales data (2011-2017) for eleven pharmaceutical opioids (prescription and over-the-counter codeine disaggregated); calls to three poisons information centres (covering five of the eight jurisdictions in Australia) related to pharmaceutical opioids and coded by the centres as 'misuse' or 'abuse' (2011-2017); and interviews with people who inject drugs (n = 888) recruited as part of the Illicit Drug Reporting System (IDRS) from all Australian capital cities (2017). RESULTS: Population-level availability of tapentadol SRF increased from market launch, comprising the sixth largest market share of all opioid unit sales, and third greatest share in oral morphine equivalent milligrams sold, in December 2017. Lifetime tapentadol SRF use among the IDRS sample (n = 888) was low (1.5%; 95%CI 0.9-2.5), with few reporting past-6 month non-prescribed use or injection. Non-fatal overdose following tapentadol use was self-reported by less than 1% (95%CI 0.1-0.8). Between 2013-2017, 1.1% (n = 25) of pharmaceutical opioid 'misuse/abuse' calls were related to tapentadol, and predominantly the SRF. CONCLUSIONS: Increasing utilisation of tapentadol sustained-release formulation was observed, along with indications of extra-medical use and harms associated with use, although on a smaller scale relative to other opioids. These findings need to be interpreted in the context of the low level of exposure to tapentadol sustained-release formulation among the sentinel population of people who inject drugs.

Injecting risk behaviours amongst people who inject drugs: A global multi-stage systematic review and meta-analysis.

BACKGROUND: Injecting risk behaviour, such as receptive sharing of injecting equipment and/or re-using one's equipment, is associated with bloodborne virus transmission and infections in people who inject drugs (PWID). We aimed to estimate prevalence and correlates of injecting risk behaviours amongst PWID. METHODS: We conducted a systematic review and meta-analyses to estimate country, regional, and global prevalences of injecting risk behaviours (including sharing or re-using needle/syringe and sharing other injecting equipment). Using meta-regression analyses, we determined associations between study- and country-level characteristics and receptive needle/syringe sharing. RESULTS: From 61,077 identified papers and reports and 61 studies from expert consutation, evidence on injecting risk behaviours was available for 464 studies from 88 countries. Globally, it is estimated that 17.9% (95%CI: 16.2-19.6%) of PWID engaged in receptive needle/syringe sharing at last injection, 23.9% (95%CI: 21.2-26.5%) in the past month, and 32.8% (95%CI: 28.6-37.0%) in the past 6-12 months. Receptive sharing of other injecting equipment was common. Higher prevalence of receptive needle/syringe sharing in the previous month was associated with samples of PWID with a lower proportion of females, shorter average injecting duration, a higher proportion with ≥daily injecting, and older studies. Countries with lower development index, higher gender inequality and lower NSP coverage had higher proportions reporting receptive needle/syringe sharing. CONCLUSIONS: High levels of injecting risk behaviours were observed amongst PWID globally, although estimates were only available for half of the countries with evidence of injecting drug use. There is a need for better capturing of injecting risk behaviours in these countries to inform implementation of harm reduction services and evaluate potential impacts of interventions to reduce risk.

Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia.

AIMS: To examine perceptions of extended-release (XR) buprenorphine injections among people who regularly use opioids in Australia. DESIGN: Cross-sectional survey prior to implementation. XR-buprenorphine was registered in Australia in November 2018. SETTING: Sydney, Melbourne and Hobart. Participants A total of 402 people who regularly use opioids interviewed December 2017 to March 2018. MEASUREMENTS: Primary outcome concerned the proportion of participants who believed XR-buprenorphine would be a good treatment option for them, preferred weekly versus monthly injections and perceived advantages/disadvantages of XR-buprenorphine. Independent variables concerned the demographic characteristics and features of current opioid agonist treatment (OAT; medication-type, dose, prescriber/dosing setting, unsupervised doses, out-of-pocket expenses and travel distance). FINDINGS: Sixty-eight per cent [95% confidence interval (CI) = 63-73%] believed XR-buprenorphine was a good treatment option for them. They were more likely to report being younger [26-35 versus > 55 years; odds ratio (OR) = 3.16, 95% CI = 1.12-8.89; P = 0.029], being female (OR = 1.67, 95% CI = 1.04-2.69; P = 0.034), < 10 years school education (OR = 1.87, 95% CI = 1.12-3.12; P = 0.016) and past-month heroin (OR = 1.81, 95% CI = 1.15-2.85; P = 0.006) and methamphetamine use (OR = 1.90, 95% CI = 1.20-3.01; P = 0.006). Fifty-four per cent reported no preference for weekly versus monthly injections, 7% preferred weekly and 39% preferred monthly. Among OAT recipients (n = 255), believing XR-buprenorphine was a good treatment option was associated with shorter treatment episodes (1-2 versus ≥ 2 years; OR = 3.93, 95% CI = 1.26-12.22; P = 0.018), fewer unsupervised doses (≤ 8 doses past-month versus no take-aways; OR = 0.50; 95% CI = 0.27-0.93; P = 0.028) and longer travel distance (≥ 5 versus < 5 km; OR = 2.10, 95% CI = 1.20-3.65; P = 0.009). Sixty-nine per cent reported 'no problems or concerns' with potential differences in availability, flexibility and location of XR-buprenorphine. CONCLUSIONS: Among regular opioid users in Australia, perceptions of extended-release buprenorphine as a good treatment option are associated with being female, recent illicit drug use and factors relating to the (in)convenience of current opioid agonist treatment.

Rumination and problematic substance use among individuals with a long-term history of illicit drug use.

BACKGROUND: Rumination is a cognitive process that is implicated in the development and maintenance of various forms of psychopathology, including problematic substance use. Most studies on the role of rumination in substance use have been conducted among community samples or individuals with alcohol use disorders and have predominately focused on overall rumination rather than differentiating between its subtypes, ruminative brooding and ruminative reflection. The current study therefore aimed to investigate i) whether rumination subtypes are associated with problematic substance use among people with a long-term history of illicit drug use independently of related psychological disorders (depression and post-traumatic stress disorder [PTSD]), and ii) whether gender moderates these relationships. METHODS: This cross-sectional study used data from the Australian Treatment Outcome Study (ATOS); a naturalistic prospective cohort study of people with heroin dependence. At the 11-year follow-up of ATOS, a total of 380 participants completed measures of rumination, depression, PTSD, and indices of problematic substance use. RESULTS: Hierarchical logistic regression analyses indicated that higher brooding scores were associated with current heroin dependence (OR = 1.11, CI: 1.01-1.22), polydrug use (OR = 1.16, CI: 1.06-1.28) and experience of injection related health problems (OR = 1.08, CI: 1.00-1.17), independently of depression, PTSD, and other covariates. Reflection was not related to any of the substance use measures. These results were not moderated by gender. CONCLUSIONS: Findings indicate that ruminative brooding is related to a poorer substance use profile among people with long-term illicit drug use and highlight the potential benefits of targeting brooding during substance use treatment.

Intravenous fentanyl use among people who inject drugs in Australia.

INTRODUCTION AND AIMS: There is a current epidemic of pharmaceutical opioid (PO) misuse, particularly fentanyl and fentanyl analogues, globally. Fentanyl is a highly potent synthetic opioid with rapid onset and significantly higher risk of overdose compared with other opioids. Contexts and correlates of fentanyl use among people who inject drugs (PWID) in Australia are under-researched. DESIGN AND METHODS: The Australian Needle Syringe Program Survey is conducted annually. Consenting PWID complete a self-administered questionnaire and provide a capillary dried blood spot for human immunodeficiency virus and hepatitis C virus antibody testing. Bivariate and multivariate logistic regressions determined correlates of recent (last 6 months) fentanyl injection in 2014. RESULTS: Recent fentanyl injection was reported by 8% (n = 193) of the total sample. Among the 848 PWID who recently injected POs, 23% injected fentanyl. Compared with PO injectors who had not injected fentanyl, those who had injected fentanyl were significantly more likely to identify as Indigenous Australian [adjusted odds ratio (AOR) 1.61; 95% confidence interval (CI) 1.04, 2.51; P = 0.034], inject daily or more frequently (AOR 1.92; 95% CI 1.30, 2.83; P = 0.005), inject in public (AOR 1.43; 95% CI 1.01, 2.02; P = 0.042) and to have overdosed in the past year (AOR 2.16; 95% CI 1.48, 3.13; P < 0.001), but were significantly less likely to receptively share syringes (AOR 0.56; 95% CI 0.36, 0.87; P = 0.010). DISCUSSION AND CONCLUSIONS: Fentanyl injectors in Australia are significantly more likely to identify as Indigenous, report frequent injection, inject in public and experience overdose. Increased access to harm reduction interventions, including naloxone distribution, wheel filters and supervised injection facilities, are likely to benefit this population.

Health risk and health seeking behaviours among people who inject performance and image enhancing drugs who access needle syringe programs in Australia.

INTRODUCTION AND AIMS: People who use performance and image enhancing drugs (PIED) are a growing population in needle syringe programs (NSP) in Australia. Previous international research has identified heterogeneity among the PIED-using population. This study investigated health behaviours among NSP attendees who had recently (last 12 months) injected PIEDs and examined differences among this group according to recent psychoactive drug use. DESIGN AND METHODS: The Australian Needle and Syringe Program Survey is an annually repeated cross-sectional survey conducted at approximately 50 NSPs nationally. In 2015, respondents provided information on their demographic characteristics, health risk and health monitoring behaviours, and provided a capillary dried blood spot for HIV and hepatitis C virus antibody testing. Univariable and multivariable logistic regressions assessed factors associated with recent (last 12 months) use (all routes of administration) of psychoactive drugs. RESULTS: Among recent PIED injectors (n = 156), 59% had recently used psychoactive substances. Those who had recently used psychoactive drugs were significantly younger, less educated and more likely to have experienced redness at an injection site in the previous 12 months but were more likely to report recent HIV/hepatitis C virus testing. DISCUSSION AND CONCLUSIONS: This study identified significant differences in demographic characteristics, risk and health seeking behaviour among PIED users who did and did not also use psychoactive substances. There is a need to enhance and tailor harm reduction efforts and to build the capacity of NSP staff to better meet the needs of this diverse group.

Trajectories of heroin use: 10-11-year findings from the Australian Treatment Outcome Study.

AIMS: To identify trajectories of heroin use in Australia, predictors of trajectory group membership and subsequent outcomes among people with heroin dependence over 10-11 years. DESIGN: Longitudinal cohort study. SETTING: Sydney, Australia. PARTICIPANTS: A total of 615 participants were recruited between 2001 and 2002 as part of the Australian Treatment Outcome Study (66.2% male; mean age 29 years). The predominance of the cohort (87.0%) was recruited upon entry to treatment (maintenance therapies, detoxification and residential rehabilitation), and the remainder from non-treatment settings (e.g. needle and syringe programmes). This analysis focused upon 428 participants for whom data on heroin use were available over 10-11 years following study entry. MEASUREMENTS: Structured interviews assessed demographics, treatment history, heroin and other drug use, overdose, criminal involvement, physical health and psychopathology. Group-based trajectory modelling was used to: (i) identify trajectory groups based on use of heroin in each year, (ii) examine predictors of group membership and (iii) examine associations between trajectory group membership and 10-11-year outcomes. FINDINGS: Six trajectory groups were identified [Bayesian Information Criterion (BIC) = -1927.44 (n = 4708); -1901.07 (n = 428)]. One in five (22.1%) were classified as having 'no decrease' in heroin use, with the probability of using remaining high during the 10-11 years (> 0.98 probability of use in each year). One in six (16.1%) were classified as demonstrating a 'rapid decrease to maintained abstinence'. The probability of heroin use among this group declined steeply in the first 2-3 years and continued to be low (< 0.01). The remaining trajectories represented other fluctuating patterns of use. Few baseline variables were found to predict trajectory group membership, but group membership was predictive of demographic, substance use and physical and mental health outcomes at 10-11 years. CONCLUSIONS: Long-term trajectories of heroin use in Australia appear to show considerable heterogeneity during a decade of follow-up, with few risk factors predicting group membership. Just more than a fifth continued to use at high levels, while fewer than a fifth become abstinent early on and remained abstinent. The remainder showed fluctuating patterns.

Long-term mortality, remission, criminality and psychiatric comorbidity of heroin dependence: 11-year findings from the Australian Treatment Outcome Study.

AIMS: To determine the long-term mortality, remission, criminality and psychiatric comorbidity during 11 years among heroin-dependent Australians. DESIGN: Longitudinal cohort study. SETTING: Sydney, Australia. PARTICIPANTS: A total of 615 participants were recruited and completed baseline interviews between 2001 and 2002. Participants completed follow-up interviews at 3, 12, 24 and 36 months post-baseline, and again at 11 years post-baseline; 431 (70.1%) of the original 615 participants completed the 11-year follow-up. MEASUREMENTS: Participants were administered the Australian Treatment Outcome Study (ATOS) structured interview, addressing demographics, treatment history, drug use, heroin overdose, criminality, health and mental health at all interviews. Overall, 96.1% of the cohort completed at least one follow-up interview. FINDINGS: At 11 years, 63 participants (10.2%) were deceased. The proportion of participants who reported using heroin in the preceding month decreased significantly from baseline (98.7%) to 36-month follow-up (34.0%; odds ratio = 0.01; 95% confidence interval = 0.00, 0.01) with further reductions evident between 36 months and 11 years (24.8%). However, one in four continued to use heroin at 11 years, and close to one-half (46.6%) were in current treatment. The reduction in current heroin use was accompanied by reductions in risk-taking, crime and injection-related health problems, and improvements in general physical and mental health. The relationship with treatment exposure was varied. Major depression was associated consistently with poorer outcome. CONCLUSIONS: In an 11-year follow-up of patients undergoing treatment for heroin dependence, 10.2% had died and almost half were still in treatment; the proportion still using heroin fell to a quarter, with major depression being a significant predictor of continued use.

Improving the diagnostic criteria for alcohol use disorders through survey methodology and cognitive interviewing.

This study aims to identify problems in the structure and wording of questions designed to operationalize four DSM-IV diagnostic criteria for alcohol use disorders (AUDs): (1) use of alcohol in hazardous situations (hazard); (2) tolerance; (3) use of alcohol in larger amounts/longer periods than intended (larger/longer); (4) unsuccessful attempts to cut down or control alcohol use (quit/cut down). Ten experts appraised the questions related to these criteria in the WMH-CIDI according to a standardized checklist. These experts identified three main problems: (1) the double-barrelled nature of some of the questions; (2) definitional issues; and (3) unclear thresholds for criterion endorsement. Cognitive interviews of 100 young adult drinkers aged 18-24 were then conducted. The double-barrelled nature of the DSM-IV criteria led to their subsequent over- or under-endorsement. Key terms in the questions under investigation were defined inconsistently. There was also a large amount of variability in the thresholds at which larger/longer and quit/cut down were endorsed. Many of these problems could be linked back to the DSM-IV text. The findings raise questions as to the validity of AUD diagnoses when established via structured diagnostic interview. Further research should focus on testing alternative structure and wording of key AUD criteria to ensure accurate operationalizations of these criteria in structured diagnostic interviews.