Randomised Controlled Trial (RCT) of cannabinoid replacement therapy (Nabiximols) for the management of treatment-resistant cannabis dependent patients: a study protocol.

BACKGROUND: The cannabis extract nabiximols (Sativex®) effectively supresses withdrawal symptoms and cravings in treatment resistant cannabis dependent individuals, who have high relapse rates following conventional withdrawal treatments. This study examines the efficacy, safety and cost-effectiveness of longer-term nabiximols treatment for outpatient cannabis dependent patients who have not responded to previous conventional treatment approaches. METHODS/DESIGN: A phase III multi-site outpatient, randomised, double-blinded, placebo controlled parallel design, comparing a 12-week course of nabiximols to placebo, with follow up at 24 weeks after enrolment. Four specialist drug and alcohol outpatient clinics in New South Wales, Australia. One hundred forty-two treatment seeking cannabis dependent adults, with no significant medical, psychiatric or other substance use disorders. Nabiximols is an oromucosal spray prescribed on a flexible dose regimen to a maximum daily dose of 32 sprays; 8 sprays (total 21.6 mg tetrahydrocannabinol (THC) and 20 mg cannabidiol (CBD)) four times a day, or matching placebo, dispensed weekly. All participants will receive six-sessions of individual cognitive behavioural therapy (CBT) and weekly clinical reviews. Primary endpoints are use of non-prescribed cannabis (self-reported cannabis use days, urine toxicology), safety measures (adverse events and abuse liability), and cost effectiveness (incremental cost effectiveness in achieving additional Quality Adjusted Life Years). Secondary outcomes include, improvement in physical and mental health parameters, substance use other than cannabis, cognitive functioning and patient satisfaction measures. DISCUSSION: This is the first outpatient community-based randomised controlled study of nabiximols as an agonist replacement medication for treating cannabis dependence, targeting individuals who have not previously responded to conventional treatment approaches. The study and treatment design is modelled upon an earlier study with this population and more generally on other agonist replacement treatments (e.g. nicotine, opioids). TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry: ACTRN12616000103460 (Registered 1st February 2016).

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.

The political and scientific challenges in evaluating compulsory drug treatment centers in Southeast Asia.

BACKGROUND: In Vietnam, like many countries in Southeast Asia, the commonly used approach of center-based compulsory drug treatment (CCT) has been criticized on human rights ground. Meanwhile, community-based voluntary methadone maintenance treatment (MMT) has been implemented for nearly a decade with promising results. Reform-minded leaders have been seeking empirical evidence of the costs and effectiveness associated with these two main treatment modalities. Conducting evaluations of these treatments, especially where randomization is not ethical, presents challenges. The aim of this paper is to discuss political challenges and methodological issues when conducting cost-effectiveness studies within the context of a non-democratic Southeast Asian country. METHODS: A retrospective analysis of the political and scientific challenges that were experienced in the study design, sample size determination, government approval and ethics approvals, participant recruitment, data collection, and determination of sources, and quantification of cost and effectiveness data was undertaken. As a consequence of the non-randomized design, analysis of patient characteristics for both treatment types was undertaken to identify the magnitude of baseline group differences. Concordance between self-reported heroin use and urine drug testing was undertaken to determine the reliability of self-report data in a politically challenging environment. RESULTS: We demonstrate that conducting research around compulsory treatment in a non-democratic society is feasible, yet it is politically challenging and requires navigation between science and politics. We also demonstrate that engagement with the government decision makers in the research conception, implementation, and dissemination of the results increases the likelihood of research evidence being considered for change in a contentious drug policy area. CONCLUSIONS: Local empirical evidence on the comparative cost-effectiveness of CCT and MMT in a Southeast Asian setting is critical to consideration of more holistic, humane, and effective drug-dependence treatment approaches, but the garnering of such evidence is very challenging.

A systematic review of modelling approaches in economic evaluations of health interventions for drug and alcohol problems.

BACKGROUND: The overarching goal of health policies is to maximize health and societal benefits. Economic evaluations can play a vital role in assessing whether or not such benefits occur. This paper reviews the application of modelling techniques in economic evaluations of drug and alcohol interventions with regard to (i) modelling paradigms themselves; (ii) perspectives of costs and benefits and (iii) time frame. METHODS: Papers that use modelling approaches for economic evaluations of drug and alcohol interventions were identified by carrying out searches of major databases. RESULTS: Thirty eight papers met the inclusion criteria. Overall, the cohort Markov models remain the most popular approach, followed by decision trees, Individual based model and System dynamics model (SD). Most of the papers adopted a long term time frame to reflect the long term costs and benefits of health interventions. However, it was fairly common among the reviewed papers to adopt a narrow perspective that only takes into account costs and benefits borne by the health care sector. CONCLUSIONS: This review paper informs policy makers about the availability of modelling techniques that can be used to enhance the quality of economic evaluations for drug and alcohol treatment interventions.

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

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

Duration of stay and rate of subsequent criminal conviction and hospitalisation for substance use among young people admitted to a short-term residential program.

INTRODUCTION: This study examined the association between program duration and rate of criminal conviction and hospitalisation for substance use up to 15 years later among young people admitted to a short-term residential program for drug and alcohol use. METHODS: Data were derived from linked administrative records of all clients referred to a modified therapeutic community for young people from January 2001 to December 2016 in New South Wales, Australia (n = 3059). Cox proportional hazards regression analyses examined the rate of conviction (separately for any offence, violent offence, non-violent offence and administrative offence) and hospitalisation for substance use, up to 15 years post-program among young people who attended treatment for 1-29 days, 30-59 days, 60-89 days and 90-120 days. RESULTS: Thirty days or more in treatment was independently associated with a lower rate of conviction for any offence and a non-violent offence, as well as hospitalisation for substance use, while 60 days or more was associated with a lower rate of conviction for a violent and administrative offence, relative to those who spent 1-29 days in the program. Additional months in the program were also associated with reduced rates of conviction and hospitalisation, although 90-120 days appeared to confer no additional benefits than 60-89 days. DISCUSSION AND CONCLUSIONS: At least 60 days may be the minimum duration needed for short-term, therapeutic community programs to reduce the risk of conviction across all crime types and hospitalisation for substance use.

Cannabis policies in Canada: How will we know which is best?

BACKGROUND: The recent legalisation of cannabis in Canada by the Federal Government, along with the accompanying laws and regulations of provincial and territorial governments provides an opportunity to assess the expected benefits and harms of legalisation. While the legislative changes have been initiated by the federal government, much of the responsibility for the implementation falls onto the provinces and territories. These jurisdictions are responsible for regulating the wholesale distribution, retail structures, cannabis consumption, as well as a host of other regulations. METHODS: Key characteristics of policies outlined are categorised according to a framework previously developed by the authors (2018). The categories are: (1) government regulation or control, (2) social costs that accompany its use, and (3) legal sanctions that accompany its production and use. Towards that end, we develop a framework for a cost benefit analysis (CBA) outlining in some detail the data that is needed to undertake a credible economic evaluation of cannabis policies. RESULTS: Key data issues discussed include consumer surplus, government receipts including legal and regulatory costs, impact on substitutes, change in profits to firms (growers, wholesalers, and retailers), incomes earned in the industry, health and other costs incurred by cannabis users. DISCUSSION: This paper presents a summary of the expected categories of costs and benefits given the various provincial cannabis policies. Additionally, it provides a framework for subsequent cost benefit analyses which can quantify said harms and benefits.

Societal preferences for the treatment of impulsive-violent offenders: a discrete choice experiment.

OBJECTIVES: The aim of this study is to quantify societal preferences for, and assess trade-offs between characteristics of treatment programmes for impulsive-violent offenders. SETTING: The study was conducted in New South Wales, Australia's largest state. PARTICIPANTS: The study participants were income tax payers, aged over 18 and who were able to provide informed consent. METHODS: A discrete choice experiment was used to assess the preferences for treatment programmes for impulsive violent offenders. The survey presented participants with six choice sets in which they chose between two unlabelled treatment scenarios and a 'no treatment' choice. A random parameters logistic (RPL) model and a latent class (LC) model were used to analyse the societal preferences for treatment and estimate willingness to pay values based on marginal rates of substitution. Respondents were asked to self-identify if they ever had experiences with violence and subgroup analysis was done. RESULTS: The survey was completed by 1021 highly engaged participants. The RPL model showed that society had a preference for more effective programmes, programmes that provided full as opposed to partial treatment of all co-occurring health conditions, compulsory over voluntary programmes, those with flexibility in appointments and programmes that are provided with continuity of care postprison. Respondents were willing to pay an additional annual tax contribution for all significant attributes, particularly compulsory programmes, continuity of treatment and effectiveness.The LC model identified two classes of respondents with some differences in preferences which could be largely identified by whether they had experiences with violence or not. CONCLUSION: The results are important for future programme design and implementation. Programmes for impulsive violent offenders that are designed to encompass societal preferences are likely to be supported by public and tax payers.

Quality of life as a predictor of time to heroin relapse among male residents following release from compulsory rehabilitation centres in Vietnam.

INTRODUCTION AND AIMS: Quality of life (QOL) is a relevant and quantifiable outcome of drug dependence treatment. We assessed health-related QOL for people released from three centre-based compulsory treatment (CCT) centres in Vietnam, using the EQ-5D. The study aimed to examine the prognostic value of health-related QOL in relation to time to relapse to heroin use among the participants. DESIGN AND METHODS: Two hundred and eight CCT participants with heroin dependence were interviewed at release, and at 3, 6 and 12 months post-release. Health-related QOL was measured with the EQ-5D. Kaplan-Meier survival models were fitted using Cox modelling to examine the rate, timing and prediction of the number of days to heroin relapse and to examine the predictability of the health-related QOL measures for days to relapse. Relapse was defined as first time of heroin use. RESULTS: The study found a substantial relapse rate (85.6%) among participants within 12 months following release from CCT centres; the mean number of days to relapse was 57.7 (SD = 31.6). There was no statistically significant change over time in the mean values of health-related QOL (P = 0.11). While the total index score (across the five pre-specified EQ-5D domains) did not have a significant effect in predicting cumulative relapse, lower scores on the Visual Analogue Scale of the EQ-5D were significantly (P < 0.05) predictive of cumulative relapse, with adjusted hazard ratios for relapse of 0.987 (P = 0.013). DISCUSSION AND CONCLUSIONS: EQ-5D Visual Analogue Scale score is a useful predictor of cumulative heroin relapse among participants released from CCT centres.

Is in vitro fertilisation more effective than stimulated intrauterine insemination as a first-line therapy for subfertility? A cohort analysis.

OBJECTIVE: To compare a strategy of two cycles of intrauterine insemination with controlled ovarian hyperstimulation (IUI/COH) vs one in vitro fertilisation (IVF) treatment programme (one fresh plus associated frozen embryo cycles) in couples presenting with unexplained, mild male or mild female subfertility. METHODS: A retrospective cohort design was used and analysed according to intention-to-treat principles. A total of 272 couples underwent an intended course of two cycles of IUI/COH and 176 couples underwent one IVF treatment programme. RESULTS: The cumulative live birth rate (CLBR) per couple for the IUI/COH group was 27.6% compared to 39.2% for the IVF group (P = 0.01). The mean time to pregnancy was 69 days in the IUI/COH group compared to 44 days in the IVF group (P = 0.02). The IVF programme was costlier, with an incremental cost-effectiveness ratio for an additional live birth in the range of $39,637-$46,325. The multiple delivery rate was 13.3% in the IUI/COH group compared to 10.1% in the IVF group (P = 0.55). One set of triplets and one set of quadruplets followed IUI/COH treatment. CONCLUSIONS: One IVF treatment programme was more effective, but costlier than an intended course of two cycles of IUI/COH. With consistently higher success rates, shorter times to pregnancy and a trend to less higher order multiple pregnancies, this study supports the view that IVF is now potentially safer and more clinically effective than IUI/COH as a first-line therapy for subfertility.

Valuing families' preferences for drug treatment: a discrete choice experiment.

BACKGROUND AND AIMS: The burden on family members of those who are dependent on illicit drugs is largely unidentified, despite the presence of significant negative financial, health and social impacts. This makes it difficult to provide appropriate services and support. This study aimed to assess the preferences for treatment attributes for heroin dependence among family members affected by the drug use of a relative and to obtain a measure of the intangible economic benefit. DESIGN: Discrete choice experiment. Data were analysed using mixed logit which accounted for repeated responses. SETTING: Australia. PARTICIPANTS: Eligible participants were Australian residents aged 18+ years with a relative with problematic drug use. Complete data on 237 respondents were analysed; 21 invalid responses were deleted. MEASUREMENTS: Participant preference for likelihood of staying in treatment, family conflict, own health status, contact with police and monetary contribution to a charitable organization providing treatment. FINDINGS: All attributes were significant, and the results suggest that there was a preference for longer time in treatment, less family discord, better own health status, less likelihood of their relative encountering police and, while they were willing to contribute to a charity for treatment to be available, they prefer to pay less, not more. In order of relative importance, participants were willing to pay an additional A$4.46 [95% confidence interval (CI) = 3.33-5.60] for treatment which resulted in an additional 1% of heroin users staying in treatment for longer than 3 months, A$42.00 (95% CI = 28.30-55.69) to avoid 5 days per week of family discord, A$87.94 (95% CI = 64.41-111.48) for treatment options that led to an improvement in their own health status and A$129.66 (95% CI = 53.50-205.87) for each 1% decline in the chance of police contact. CONCLUSIONS: Drug treatment in Australia appears to have intangible benefits for affected family members. Families are willing to pay for treatment which reduces family discord, improves their own health, increases time in treatment and reduces contact with police.

Open-label, multicentre, single-arm trial of monthly injections of depot buprenorphine in people with opioid dependence: protocol for the CoLAB study.

INTRODUCTION: Opioid agonist treatment is effective for opioid dependence and newer extended-release buprenorphine (BUP-XR) injections represent a significant development. The Community Long-Acting Buprenorphine (CoLAB) study aims to evaluate client outcomes among people with opioid dependence receiving 48 weeks of BUP-XR treatment, and examines the implementation of BUP-XR in diverse community healthcare settings in Australia. METHODS AND ANALYSIS: The CoLAB study is a prospective single-arm, multicentre, open-label trial of monthly BUP-XR injections in people with opioid dependence. Participants are being recruited from a network of general practitioner and specialist drug treatment services located in the states of New South Wales, Victoria and South Australia in Australia. Following a minimum 7 days on 8-32 mg of sublingual buprenorphine (±naloxone), participants will receive monthly subcutaneous BUP-XR injections administered by a healthcare practitioner at intervals of 28 days (-2/+14 days). The primary endpoint is participant retention in treatment at 48 weeks after treatment initiation. Secondary endpoints will evaluate dosing schedule variations, craving, withdrawal, substance use, health and well-being, and client-reported treatment experience. Qualitative and costing substudies will examine implementation barriers and facilitators at the client and provider level. ETHICS AND DISSEMINATION: The study has received ethics approval from the St Vincent's Hospital Sydney Human Research Ethics Committee (Ref. HREC/18/SVH/221). The findings will be disseminated via publication in peer-reviewed journals, presentations at national and international scientific conferences, and in relevant community organisation publications and forums. TRIAL REGISTRATION NUMBER: NCT03809143 PROTOCOL IDENTIFIER: CoLAB1801, V.4.0 dated 01 August 2019.

Evaluation of an Assertive Management and Integrated Care Service for Frequent Emergency Department Attenders with Substance Use Disorders: The Impact Project: Evaluating an assertive management service for frequent ED attenders with substance use disorders.

INTRODUCTION: Frequent attenders to Emergency Departments (ED) often have contributing substance use disorders (SUD), but there are few evaluations of relevant interventions. We examine one such pilot assertive management service set in Sydney, Australia (IMPACT), aimed at reducing hospital presentations and costs, and improving client outcomes. METHODS: IMPACT eligibility criteria included moderate-to-severe SUD and ED attendance on ≥5 occasions in the previous year. A pre-post intervention design examined clients' presentations and outcomes 6 months before and after participation to a comparison group of eligible clients who did not engage. RESULTS: Between 2014 and 2015, 34 clients engaged in IMPACT, with 12 in the comparison group. Clients demonstrated significant reductions in preventable (p < 0.05) and non-preventable (p < 0.01) ED presentations and costs, and in hospital admissions and costs (p < 0.01). IMPACT clients also reported a significant reduction in use days for primary substance (p < 0.01). The comparison group had a significant reduction (p < 0.05) in non-preventable visits only. CONCLUSIONS: Assertive management services can be effective in preventing hospital presentations and costs for frequent ED attenders with SUDs and improving client outcomes, representing an effective integrated health approach. The IMPACT service has since been refined and integrated into routine care across a number of hospitals in Sydney, Australia.

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.

Designing, implementing and evaluating the overdose response with take-home naloxone model of care: An evaluation of client outcomes and perspectives.

INTRODUCTION AND DESIGNS: Take-home naloxone (THN) interventions are an effective response to preventing overdose deaths, however uptake across Australia remains limited. This project designed, implemented and evaluated a model of care targeting opioid users attending alcohol and other drug (AOD) treatment, needle and syringe programs (NSP) and related health services targeting people who inject drugs. DESIGN AND METHODS: Service providers, consumers and regulators collaboratively designed a THN brief intervention (ORTHN, Overdose Response with Take-Home Naloxone) involving client education and supply of naloxone in pre-filled syringes, delivered by nursing, allied health and NSP workers. ORTHN interventions were implemented in over 15 services across New South Wales, Australia. The evaluation included client knowledge, attitudes, substance use and overdose experiences immediately before and 3 months after ORTHN intervention in a subsample of participants. RESULTS: Six hundred and sixteen interventions were delivered, with 145 participants recruited to the research subsample, of whom 95 completed the three-month follow up. Overdose-related attitudes amongst participants improved following ORTHN, with no evidence of increased substance use or failure to implement other 'first responses' (e.g. calling an ambulance). Nine participants (10%) reversed an overdose using THN in the follow-up period. Participants identified a willingness to access THN from a range of services. While a minority (16%) indicated they were unwilling to pay for THN, the median price that participants were willing to pay was $AUD20 (IQR $10.40). DISCUSSION AND CONCLUSIONS: The ORTHN model of care for THN appears an effective way to disseminate THN to people who use opioids attending AOD, NSP and related health-care settings.

Health-related quality of life among people who use methamphetamine.

INTRODUCTION AND AIMS: We assessed health-related quality of life amongst people who use methamphetamine, examined how this related to different patterns of methamphetamine use and what other factors were associated with decrements in quality of life in this sample. DESIGN AND METHODS: A cross-sectional survey of 169 at least monthly methamphetamine users. Health utility scores were derived using the Assessment of Quality of Life - 4D for the past month (0 reflects death and 1 represents full health; the population mean Assessment of Quality of Life score in Australia is 0.81). Dependence on methamphetamine was a score of 4+ on the Severity of Dependence Scale. Other measures included days of methamphetamine use and other substance use in the past month, injecting methamphetamine, demographics, psychiatric symptoms (score of 4+ on the Brief Psychiatric Rating Scale items) and a lifetime DSM-IV diagnosis of schizophrenia. RESULTS: The mean utility score was 0.52 (95% confidence interval 0.48-0.56). Methamphetamine dependence was associated with lower utility (-0.10, P = 0.003) after adjustment for other univariate correlates of utility. Other factors independently associated with lower utility were being a woman (-0.14, P < 0.001), depression (-0.10, P = 0.008), self-neglect (-0.08, P = 0.035), schizophrenia (-0.17, P = 0.003) and fewer years of schooling (0.02 per year, P = 0.037). DISCUSSION AND CONCLUSIONS: We found poor quality of life in this sample of methamphetamine users relative to the general population, this being associated with both dependence on methamphetamine and other factors, particularly poor mental health. We also found poorer health amongst women.

A protocol for a discrete choice experiment: understanding patient medicine preferences for managing chronic non-cancer pain.

INTRODUCTION: High rates of chronic non-cancer pain (CNCP), concerns about adverse effects including dependence among those prescribed potent pain medicines, the recent evidence supporting active rather than passive management strategies and a lack of funding for holistic programme have resulted in challenges around decision making for treatment among clinicians and their patients. Discrete choice experiments (DCEs) are one way of assessing and valuing treatment preferences. Here, we outline a protocol for a study that assesses patient preferences for CNCP treatment. METHODS AND ANALYSIS: A final list of attributes (and their levels) for the DCE was generated using a detailed iterative process. This included a literature review, a focus group and individual interviews with those with CNCP and clinicians who treat people with CNCP. From this process a list of attributes was obtained. Following a review by study investigators including pain and addiction specialists, pharmacists and epidemiologists, the final list of attributes was selected (number of medications, risk of addiction, side effects, pain interference, activity goals, source of information on pain, provider of pain care and out-of-pocket costs). Specialised software was used to construct an experimental design for the survey. The survey will be administered to two groups of participants, those from a longitudinal cohort of patients receiving opioids for CNCP and a convenience sample of patients recruited through Australia's leading pain advocacy body (Painaustralia) and their social media and website. The data from the two participant groups will be initially analysed separately, as their demographic and clinical characteristics may differ substantially (in terms of age, duration of pain and current treatment modality). Mixed logit and latent class analysis will be used to explore heterogeneity of responses. ETHICS AND DISSEMINATION: Ethics approval was obtained from the University of New South Wales Sydney Human Ethics committee HC16511 (for the focus group discussions, the one-on-one interviews and online survey) and HC16916 (for the cohort). A lay summary will be made available on the National Drug and Alcohol Research Centre website and Painaustralia's website. Peer review papers will be submitted, and it is expected the results will be presented at relevant pain management conferences nationally and internationally. These results will also be used to improve understanding of treatment goals between clinicians and those with CNCP.

Reliability and Validity of the Contingent Valuation Method for Estimating Willingness to Pay: A Case of In Vitro Fertilisation.

BACKGROUND: The contingent valuation (CV) method is an alternative approach to typical health economic methods for valuing interventions that have both health and non-health outcomes. Fertility treatment, such as in vitro fertilisation (IVF), fall into this category because of the significant non-health outcomes associated with having children. AIM: To estimate the general population's willingness to pay (WTP) for one cycle of IVF and one year of IVF treatment, and to test the reliability and validity of a CV instrument. METHODS: Three online CV surveys were administered to a total of 1870 participants from the Australian general population using an ex-post perspective, that is, they assumed they were infertile and needed IVF to conceive a child. Participants answered questions with starting point WTP bids of 2018 Australian dollars (AU$) 4000 or $10,000 for the cost of one IVF cycle, and treatment success rates of 10%, 20% and 50% per IVF cycle. Tests for reliability, internal construct validity, starting point bias, and external validity were performed. RESULTS: Depending on the success rate and the starting point WTP bid, the mean WTP for one IVF cycle ranged from $6135 to $13,561, while the mean WTP for one year of IVF treatment varied from $17,080 to $31,006. The CV method was reliable and satisfied internal construct and external criterion validity. However strong starting point bias was evident, rendering the mean WTP values highly imprecise. CONCLUSION: The CV method holds promise for eliciting the value of interventions, such as fertility treatment, that have significant health and non-health outcomes. Survey instruments that prevent starting point bias are essential. Comparing the results of CV methods to other value elicitation methods is needed to confirm convergent validity.

Societal preferences for fertility treatment in Australia: a stated preference discrete choice experiment.

Objective: To investigate preferences for fertility treatment from the Australian general population with the aims of calculating the willingness to pay in tax contribution for attributes (characteristics) that make up treatment and for an "ideal" fertility treatment program. We also assessed whether willingness-to-pay varies by the relationship status or sexual orientation of the patient.Methods: A stated preference discrete choice experiment was administered to a panel of 801 individuals representative of the Australian general population. Seven attributes of fertility treatment under three broad categories were included: outcome, process, and cost. Attributes were identified through published literature, focus group discussions, expert knowledge, and a pilot study. A Bayesian fractional experimental design was used, and data analysis was performed using a generalized multinomial logit model. Further analyses included interaction terms and latent class modeling.Results: Six of the seven attributes influenced the choice of a treatment program. Under process attributes, individuals preferred: continuity of care of clinic staff, where patients are seen by the same doctor but different nurses at each visit; "alternative" treatments being offered to all patients; and onsite clinic counseling and peer-support groups. Personalization and tailoring of the treatment journey were not important. Among outcome attributes, the improved success rate of having a baby per cycle and significant side-effects were considered important. Cost of treatment also influenced the choice of treatment program. Individual preferences for fertility treatment were not associated with patients' relationship status or sexual orientation. Latent class modeling revealed sub-groups with distinct fertility treatment preferences.Conclusion: This study provides important insights into the attributes that influence the preferences of fertility treatment in Australia. It also estimates socially-inclusive willingness-to-pay values in tax contributions for an "ideal" package of treatment. The results can inform economic evaluations of fertility treatment programs.