Preparing interdisciplinary leadership for a sustainable future.

Urgent sustainability challenges require effective leadership for inter- and trans-disciplinary (ITD) institutions. Based on the diverse experiences of 20 ITD institutional leaders and specific case studies, this article distills key lessons learned from multiple pathways to building successful programs. The lessons reflect both the successes and failures our group has experienced, to suggest how to cultivate appropriate and effective leadership, and generate the resources necessary for leading ITD programs. We present two contrasting pathways toward ITD organizations: one is to establish a new organization and the other is to merge existing organizations. We illustrate how both benefit from a real-world focus, with multiple examples of trajectories of ITD organizations. Our diverse international experiences demonstrate ways to cultivate appropriate leadership qualities and skills, especially the ability to create and foster vision beyond the status quo; collaborative leadership and partnerships; shared culture; communications to multiple audiences; appropriate monitoring and evaluation; and perseverance. We identified five kinds of resources for success: (1) intellectual resources; (2) institutional policies; (3) financial resources; (4) physical infrastructure; and (5) governing boards. We provide illustrations based on our extensive experience in supporting success and learning from failure, and provide a framework that articulates the major facets of leadership in inter- and trans-disciplinary organizations: learning, supporting, sharing, and training.

Fast-tracking implementation through trial design: the case of buprenorphine treatment in Victoria.

OBJECTIVES: We investigated how a randomised controlled trial (RCT) could be designed to incorporate features known or thought likely to enhance the uptake of the new treatment into clinical practice post-trial. METHOD AND RESULTS: Between 1999 and 2001, we trialled buprenorphine treatment for heroin dependence in community settings throughout Victoria, using 28 experienced methadone prescribers and 34 pharmacists across 19 sites. In this case study, we describe how we incorporated seven features considered important in treatment uptake: skilled and experienced practitioners, government and policy support, incentives to prescribe the new treatment, specialist support services, clinical guidelines, training programs and patient involvement and information. We also present information showing that uptake of buprenorphine treatment was substantially boosted in Victoria compared with other Australian jurisdictions immediately after the trial in 2001 and that this increase was sustained until at least 2006. CONCLUSION: While we cannot prove that our trial design was responsible for the increased uptake of buprenorphine treatment in Victoria, we do show that design has been a neglected aspect of clinical trials in terms of enhancing post-trial uptake of the treatment being tested. IMPLICATIONS: Those interested in closing the 'know-do' gap between research and practice may wish to further explore this very promising lead. Imaginative linking of features known to enhance treatment uptake to pressing research questions may lead to new information on efficacy, as well as getting valuable drugs into the treatment system more rapidly.

Improving nurses' therapeutic attitude to patients who use illicit drugs: workplace drug and alcohol education is not enough.

This study examines the impact of workplace drug and alcohol education on nurses' therapeutic attitude to patients who use illicit drugs. It builds on a study of the generalist nursing workforce in the Australian Capital Territory in 2003, which showed that the interaction of role support with workplace drug and alcohol education facilitated nurses' therapeutic attitude. This paper explores this interaction in detail, showing that workplace education has no independent association with therapeutic attitude and that an effect from education only occurs when nurses have at least a moderate level of role support. Nursing workforce development needs to focus on strategies that provide role support for nurses as they work with this clinically challenging patient group. Without the ready availability of someone in the nurse's clinical field to advise and assist them, efforts to increase nurses' knowledge and skills are wasted.

A research routine to assess bias introduced by low response rates in postal surveys.

Low response rates to postal surveys potentially bias study results. We used three approaches to determine why 46 per cent of a sample were non-responders, and to analyse any potential bias. Labour force data, telephone interviews with a number of non-responders and trend examination showed that our study sample was no different to the known nursing population, that there were few differences between responders and non-responders and that there were no trends in differences between early and late responders respectively. Results suggest 'intenders', or potential responders who do not complete and return the survey, are a key factor in non-response in surveys of nurses. Analysis for response bias increases confidence in the interpretations and conclusions of any study and should therefore become standard survey practice.

The determinants of nurses' therapeutic attitude to patients who use illicit drugs and implications for workforce development.

AIM: To examine the determinants of generalist nurses' therapeutic attitude to patients who use illicit drugs, and to model workforce development initiatives. BACKGROUND: Individuals who use illicit drugs rely heavily on healthcare in emergency departments and inpatient hospital wards. Little is known about the determinants of generalist nurses' therapeutic attitude to provide care, therefore limiting our understanding of the important issues for workforce development. DESIGN: The study was a cross-sectional survey of registrants on the Australian Capital Territory Nurses Registration Roll 2002 (N = 3241, 50% response rate). The associations between variables and nurses' therapeutic attitude were examined by multi-variable linear regression analysis. METHOD: Nurses' therapeutic attitude was assessed using a modified version of the Alcohol and Alcohol Problems Perception Questionnaire. Personal characteristics, attitudes to illicit drugs and professional practice variables such as drug and alcohol education, experience with the patient group and role support were examined using a mix of standardised and new questions. RESULTS: Professional practice variables explained 53% of the variation of nurses' therapeutic attitude, the most important being role support. Although a negative attitude to illicit drugs had a statistically significant association with therapeutic attitude, it added less than 1% to the variation explained. Personal characteristics showed no association. CONCLUSIONS: Generalist nurses struggle to provide care to this patient group. Role support was found to be the strongest driver of nurses' therapeutic attitude, and workplace illicit drug education was only useful in combination with high role support. RELEVANCE TO CLINICAL PRACTICE: Nurses' caring role with patients who use illicit drugs is complex and demanding. Nursing workforce development must focus on increasing nurses' role support, in terms of appropriately skilled staff readily available for consultation and advice. Support for nurses, in the form of evidence-based practice standards and appropriate time allocation, is also important.

Effective drug policy: a new approach demonstrated in the Drug Policy Modelling Program.

The aim of this paper is to describe a new comprehensive approach to studying illicit drug policy - one that integrates evidence, disciplinary approaches, drug use behaviours and policy making processes. The methods described here include systematic reviews of the evidence, studies of the ways in which policy decision-making actually occurs, and the use of modelling approaches that can explicate the multi-dimensional nature of drug policy responses and their dynamic interactions. The approach described has the potential to facilitate new drug policy that would not have been possible or apparent through the sole study of one aspect of drug policy, such as the evidence-base or the political context or the economics of drug markets. We believe this approach may be more likely to produce strategic drug policy because it reflects the richness and complexity of the real world of drug use, and drug policy. The purpose of employing an integrative methodology is to create the potential for new drug policy insights, ideas and interventions - not restricted to one body of evidence, nor to accidental or fortuitous policy-making processes.

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

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

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

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

The effect of timing when seeking permission to access personal health services utilization records.

PURPOSE: To determine if the timing for requesting signed permission to access personal health services utilization records affects authorization or survey response rates. METHODS: A screening question about in-principle willingness to permit access to personal health services utilization records was included in a mail-based survey of two Australian female samples (n = 292). Half of the surveys for each sample also included a separate form to be signed to approve access. For the other half the form was not included, but an authorization form was sent subsequently. RESULTS: Around 30% of participants signed the authorization form and there was no significant difference between the randomized groups [ relative risk (RR) = 0.95, 95% confidence interval (CI) = 0.72-1.25). However, the response rate to the postal survey was significantly higher for the group who received the form after returning the questionnaire (60% compared to 46%; RR = 1.31, 95% CI = 1.06-1.62). CONCLUSIONS: A two-staged approach, with a time lag between seeking in principle permission to access personal health services utilization records and requesting signed authorization, does not affect authorization rates. In addition, it results in a significantly higher survey response rate than if an authorization form is included with the survey.

A randomized controlled trial of buprenorphine in the management of short-term ambulatory heroin withdrawal.

AIM: To determine whether buprenorphine is more effective than clonidine and other symptomatic medications in managing ambulatory heroin withdrawal. DESIGN: Open label, prospective randomized controlled trial examining withdrawal and 4-week postwithdrawal outcomes on intention-to-treat. SETTING: Two specialist, out-patient drug treatment centres in inner city Melbourne and Sydney, Australia. PARTICIPANTS: One hundred and fourteen dependent heroin users were recruited. Participants were 18 years or over, and with no significant other drug dependence, medical or psychiatric conditions or recent methadone treatment. One hundred and one (89%) participants completed a day 8 research interview examining withdrawal outcomes, and 92 (81%) completed day 35 research interview examining postwithdrawal outcomes. INTERVENTIONS: Participants randomized to control (n = 56) (up to 8 days of clonidine and other symptomatic medications) or experimental (n = 58) (up to 5 days of buprenorphine) withdrawal groups. Following the 8-day withdrawal episode, participants could self-select from range of postwithdrawal options (naltrexone, substitution maintenance, or counselling). MEASUREMENTS: Retention in withdrawal; heroin use during withdrawal; and retention in drug treatment 4 weeks after withdrawal. SECONDARY OUTCOMES: Withdrawal severity; adverse events, and heroin use in the postwithdrawal period. FINDINGS: The experimental group had better treatment retention at day 8 (86% versus 57%, P = 0.001, 95% CI for numbers needed to treat (NNT) = 3-8) and day 35 (62% versus 39%, P = 0.02, 95% CI for NNT = 4-18); used heroin on fewer days during the withdrawal programme (2.6 +/- 2.5 versus 4.5 +/- 2.3, P < 0.001, 95% CI = 1-2.5 days) and in the postwithdrawal period (9.0 +/- 8.2 versus 14.6 +/- 10, P < 0.01, 95% CI = 1.8-9.4); and reported less withdrawal severity. No severe adverse events reported. CONCLUSIONS: Buprenorphine is effective for short-term ambulatory heroin withdrawal, with greater retention, less heroin use and less withdrawal discomfort during withdrawal; and increased postwithdrawal treatment retention than symptomatic medications.

A randomized trial comparing levo-alpha acetylmethadol with methadone maintenance for patients in primary care settings in Australia.

AIMS: The present study aimed to compare the efficacy of levo-alpha-acetylmethadol (LAAM) and methadone, as measured by retention in treatment and heroin use, in a randomized trial conducted under naturalistic conditions. SETTING: This study is the first randomized trial comparing LAAM with methadone in the primary care setting. Participants were recruited through 29 medical practitioners working in specialist and generalist settings in Australia. PARTICIPANTS: Existing methadone maintenance patients, aged 18 years and over and able to give informed consent, were randomized to receive either LAAM or methadone. A total of 93 patients participated. INTERVENTION: After being trained in the use of LAAM, existing methadone prescribers were then able to determine an individually tailored treatment regimen for each patient. The trial was an open-label study. Methadone and LAAM dosing was supervised through local community pharmacies. Participation in ancillary services (e.g. counselling) was optional for all patients. The treatment period for the trial was 12 months. MEASUREMENTS: Baseline, 3-, 6- and 12-month interviews were conducted. Outcome measures were retention in treatment, self-reported heroin use and serious adverse events. FINDINGS: There were no significant differences between LAAM and methadone on retention in treatment, nor heroin use. There was a trend for LAAM patients to have lower heroin use than methadone patients. Of the seven serious adverse events in the LAAM group, three were not drug-related. There were two dosing errors. CONCLUSIONS: This study demonstrates (a) the efficacy of LAAM as a treatment for heroin dependence, and (b) the capacity for LAAM to be effectively delivered in primary care settings by trained general practitioners and pharmacists. The next challenge is to resolve outstanding safety concerns with LAAM.

Buprenorphine dosing regime for inpatient heroin withdrawal: a symptom-triggered dose titration study.

The study aimed to identify the range of buprenorphine doses required to comfortably alleviate symptoms in patients undergoing inpatient heroin withdrawal using a symptom-triggered titration dosing regime, and to identify the patient characteristics that impact upon the buprenorphine dose requirements. The study was conducted in two Australian inpatient withdrawal units, recruiting 63 dependent, injecting heroin users with no recent methadone treatment, dependence on other drugs, or other active medical or psychiatric conditions. In a single (patient) blinded case series, placebo or 2 mg sublingual buprenorphine tablets was administered four times a day according to severity of withdrawal (assessed with Subjective Opiate Withdrawal Scale). Up to 16 mg buprenorphine was available over the first 4 days of the admission, up to 8 mg on day 5, and placebo continued until day 6. Thirty-two subjects completed the dosing regime, with mean (+/-S.D.) daily doses of 3.8+/-2.8 on day 1, 5.8+/-3.2 on day 2, 4.8+/-3.3 on day 3, 2.3+/-2.6 on day 4, 0.8+/-1.3 on day 5, and a total dose of 17.4+/-9.7. Higher buprenorphine doses were required by those patients with more severe psychosocial dysfunction, women, those with more frequent heroin use, and those with more severe dependence on heroin at intake. A dosing regime using sublingual buprenorphine tablets for short inpatient heroin withdrawal is proposed.

Using ambulance attendances to recruit people who have experienced non-fatal heroin overdose.

AIMS: To trial two novel methods of recruiting people who experience non-fatal heroin overdose through the ambulance service. SETTING: Melbourne and Sydney, Australia. METHODS: In Melbourne potential participants were given numbered contact cards by ambulance paramedics after revival, while in Sydney potential participants were approached after revival by a researcher who travelled with ambulance paramedics to the overdose scene. RESULTS: In Melbourne 281 cards were distributed during the period 1 June 1998-31 December 1998 and a subsequent contact rate of 24% was achieved with 14% attending a subsequent interview. In Sydney there were 170 initial contacts of which 139 (82%) answered a series of questions asked at the scene (the remainder either ineligible or incapable of answering questions) with 48 (35%) also attending for follow-up interviews. CONCLUSIONS: Recruitment through contact with ambulance services is a novel method of recruiting heroin users for research into non-fatal heroin overdose with advantages over other methods of sampling for research on non-fatal heroin overdose.

Women, work and musculoskeletal health.

Why are employed women at increased risk for upper limb musculoskeletal disorders and what can this tell us about the way work and family life shape health? Despite increases in women's labour force participation, gender differences in work-related health conditions have received little research attention. This appears be the first study to examine why employed women are much more likely than men to experience upper body musculoskeletal disorders. A mailed self-report survey gathered data from 737 Australian Public Service employees (73% women). The majority of respondents were clerical workers (73%). Eighty one per cent reported some upper body symptoms; of these, 20% reported severe and continuous upper body pain. Upper body musculoskeletal symptoms were more prevalent and more severe among women. The gender difference in symptom severity was explained by risk factors at work (repetitive work, poor ergonomic equipment), and at home (having less opportunity to relax and exercise outside of work). Parenthood exacerbated this gender difference, with mothers reporting the least time to relax or exercise. There was no suggestion that women were more vulnerable than men to pain, nor was there evidence of systematic confounding between perceptions of work conditions and reported health status. Changes in the nature of work mean that more and more employees, especially women, use computers for significant parts of their workday. The sex-segregation of women into sedentary, repetitive and routine work, and the persisting gender imbalance in domestic work are interlinking factors that explain gender differences in musculoskeletal disorders.

Aged care services for indigenous people in the Australian Capital Territory and surrounds: analysing needs and implementing change.

OBJECTIVE: To ascertain and meet current and anticipated needs for residential care and other services by older Indigenous people in the Australian Capital Territory (ACT) and region. METHODS: With advice from a reference group, qualitative and quantitative data were gathered from 98 older (45 years and over) Indigenous people in the ACT and region during 1999/2000. Indigenous and non-Indigenous researchers worked closely throughout all phases of the research. We helped participants with immediate problems identified during the interviews and worked directly with the Government funding body to implement the findings. RESULTS: No one expressed a current need for residential services. In terms of future needs, 50% of respondents favoured an arrangement where an existing mainstream provider of aged care accommodated a cluster of Indigenous people in the same facility as non-Indigenous people. Thirty-two per cent preferred an Indigenous-run organisation. Our study also revealed a broad range of health problems and needs. Assessment using the Resident Classification Scale showed that 70% required a low level of care and 4% needed a high level of care. CONCLUSION: The research identified the needs and provided a health profile of older Indigenous people in the ACT and region. This then provided policymakers with evidence on which they acted to provide appropriate aged care services. IMPLICATIONS: Collaboration between Indigenous and non-Indigenous researchers can access high-quality information, and partnership between researchers and policymakers can improve Indigenous services.

The injection of methadone syrup in New South Wales: patterns of use and increased harm after partial banning of injecting equipment.

OBJECTIVE: To describe methadone injectors and the risk practices associated with injecting methadone in New South Wales, Australia. To assess the impact on injecting drug use and risk behaviour of the withdrawal of methadone injecting equipment from government-funded needle and syringe programs. METHOD: Cross-sectional survey, conducted in 1999, of 206 people who had injected methadone at least once in the previous month. Participants were from Central Sydney, West Sydney and rural New South Wales. RESULTS: Of participants who had injected both methadone and other drugs in the previous month (n=162), significantly more reused their methadone injecting equipment compared with those who reused their other drug injecting equipment (60% vs. 28%, p<0.01). There was no significant difference in terms of sharing injecting equipment, with 19% reporting sharing methadone injecting equipment and 14% sharing other drug injecting equipment. However, women were more likely than men to share methadone injecting equipment. Over half of the participants had accessed diverted methadone and a substantial minority reported the use of public spaces for injecting methadone. CONCLUSIONS: Our results suggest that the current policy has led to increased reuse of equipment for injecting methadone. IMPLICATIONS: A range of other possible policy options, such as closer monitoring and dilution of take-home doses, increasing oral doses and implementing trials of injected methadone, may assist to reduce the prevalence of methadone syrup injection and related harms.

Disturbingly low levels of contraception among women living with hepatitis C.

OBJECTIVE: To describe the prevalence of contraception among a sample of women with hepatitis C (HCV), compare it with contraceptive use among Australian women generally, and look for associations between contraception and sample characteristics. METHOD: Women who self-identified as living with HCV were recruited through a wide range of non-clinical and clinical sites in the Australian Capital Territory (ACT) and Victoria to complete a self-administered questionnaire. RESULTS: Seventy-five per cent of distributed questionnaires were completed and returned. Of the 462 women surveyed, 34% of those aged 18-49 reported using contraceptives; a much lower prevalence than the 67% in the Australian population. Surprisingly, women who reported concerns about transmission to children were no more likely to use contraceptives. Not surprisingly, women who were lesbian or who did not have a current partner were even less likely to use contraceptives. Both employed women and those not on benefits reported significantly higher levels of contraception. Otherwise, contraception did not vary with a range of variables including age, education, injecting drug use status, self-rated health status, experience of HCV symptoms, time since diagnosis, ever having received HCV treatment, or venue at which the participants were recruited. CONCLUSIONS: The low prevalence of contraception among women with HCV is both disturbing and puzzling. IMPLICATIONS: These findings raise several important and hitherto unconsidered issues for the sexual and reproductive health and well-being of women with HCV. These require both further research and urgent attention by service providers.