Who gets diverted into treatment? a study of defendants with psychosis.

The current study aimed to advance our understanding of the factors that influence mental health diversion in Local Courts in New South Wales, Australia. Logistic regression was used to systematically identify the factors that are correlated with diversion in a cohort of individuals (N = 7283) diagnosed with psychosis. Those with a substance-induced psychotic disorder were less likely to be diverted than those with an affective psychosis or schizophrenia, after adjusting for age, gender, Indigenous status, offence seriousness, violence and criminal history. Unexpectedly, those with psychotic disorders committing violent or serious offences were more likely to be diverted than those committing non-violent, less serious offences. Legal representation should be provided to all individuals with serious mental illnesses facing criminal charges. The State-wide Community and Court Liaison Service should be expanded to more Local Courts. Further research is required into why Aboriginal defendants with a psychotic illness are less likely to be diverted.

Offending, custody and opioid substitution therapy treatment utilisation among opioid-dependent people in contact with the criminal justice system: comparison of Indigenous and non-Indigenous Australians.

BACKGROUND: Although Indigenous Australians are over-represented among heroin users, there has been no study examining offending, time in custody, and opioid substitution therapy (OST) treatment utilisation among Indigenous opioid-dependent (including heroin) people at the population level, nor comparing these to non-Indigenous opioid-dependent people. The aims of this study were to compare the nature and types of charges, time in custody and OST treatment utilisation between opioid-dependent Indigenous and non-Indigenous Australians in contact with the criminal justice system. METHODS: This was a population-based, retrospective data linkage study using records of OST entrants in New South Wales, Australia (1985-2010), court appearances (1993-2011) and custody episodes (2000-2012). Charge rates per 100 person-years were compared between Indigenous and non-Indigenous Australians by sex, age and calendar year. Statistical comparisons were made for variables describing the cumulative time and percentage of follow-up time spent in custody, as well as characteristics of OST initiation and overall OST treatment utilisation. RESULTS: Of the 34,962 people in the cohort, 6,830 (19.5%) were Indigenous and 28,132 (80.5%) non-Indigenous. Among the 6,830 Indigenous people, 4,615 (67.6%) were male and 2,215 (32.4%) female. The median number of charges per person against Indigenous people (25, IQR 31) was significantly greater than non-Indigenous people (9, IQR 16) (p < 0.001). Overall, Indigenous people were charged with 33.2% of the total number of charges against the cohort and 44.0% of all violent offences. The median percentage of follow-up time that Indigenous males and females spent in custody was twice that of non-Indigenous males (21.7% vs. 10.1%, p < 0.001) and females (6.0% vs. 2.9%, p < 0.001). The percentage of Indigenous people who first commenced OST in prison (30.2%) was three times that of non-Indigenous people (11.2%) (p < 0.001). Indigenous males spent less time in OST compared to non-Indigenous males (median percentage of follow-up time in treatment: 40.5% vs. 43.1%, p < 0.001). CONCLUSIONS: Compared to non-Indigenous opioid-dependent people, Indigenous opioid-dependent people in contact with the criminal justice system are charged with a greater number of offences, spend longer in custody and commonly initiate OST in prison. Hence, contact with the criminal justice system provides an important opportunity to engage Indigenous people in OST.

The savings associated with decriminalization of drug use in New South Wales, Australia: A comparison of four drug policies.

INTRODUCTION: Most Australian states and territories have established some form of scheme to divert minor drug offenders from court. However, the number charged with drug possession continues to rise. We examine the costs of four alternatives to existing policy in relation to people apprehended by police using or in possession of a prohibited drug. METHODS: We construct a Markov micro-simulation model to examine four policies: (1) current policy; (2) expanding the existing cannabis cautioning scheme to all drug use/possession offences; (3) issuing an infringement notice to all those found using or in possession of a prohibited drug; (4) prosecuting all drug use/possession offences in the courts. The cycle length is one month. Since our aim is to examine the cost to the government, all costs are taken from the Government perspective and are in 2020 Australian dollars. RESULTS: The current estimated annual cost per offence is $977 (SD: $293). Policy 2 costs $507 per offence per year (SD: $106). Policy 3 turns into a net revenue gain of $225 (SD: $68) per offence per annum. Policy 4 lifts the current cost of processing from $977 to $1282 per offence per year (SD: $321). CONCLUSIONS: Extending the cannabis cautioning scheme to all drugs would reduce the cost of current policy by more than 50 %. A policy of issuing infringement notices or cautions for drug use/possession would save costs and generate income for the government.

Longer-term impacts of trading restrictions on alcohol-related violence: insights from New South Wales, Australia.

BACKGROUND AND AIMS: In February 2014, the government of New South Wales (NSW), Australia, introduced new restrictions (known as the 'lockout laws') on the sale of alcohol in licensed premises in two of Sydney's most prominent entertainment districts, Kings Cross (KX) and the central business district (CBD). This study aimed to determine: (i) whether the introduction of the lockout laws was the point at which the time pattern of the assault series in the KX and CBD entertainment precincts changed; (ii) whether the apparent reduction in assault in these precincts persists when we control for common variations in assault across the entire state of NSW; (iii) whether the reduction in assault in the KX and CBD entertainment precincts resulted in a displacement of the assault problem into other areas; and (iv) whether there is a net reduction in assault after taking any spill-over or displacement effects into account. DESIGN: Structural break analysis was used to determine the date at which the time pattern of assaults changed. Interrupted time series analysis with a rest-of-NSW comparator was used to assess the change in assault. SETTING, CASES AND MEASUREMENTS: The monthly totals of incidents of non-domestic assaults reported to the NSW Police between January 2009 and March 2019 (n = 123). FINDINGS: The structural break in assaults occurred in January 2014 rather than in February 2014, when the lockout laws were introduced. The reduction in assault persists even when we control for common influences across NSW as a whole. In particular, from January 2014 onwards, assaults fell immediately by 22% (a downward step) in KX (90% confidence interval [CI] = 15-28) and by 33% in the CBD (90% CI = 19-47). Assaults continued declining in KX (trend-break coefficient = -0.094, 90% CI = -0.192 to 0.005). The reduction in assault in the KX and CBD precincts is associated with a rise in assault in areas surrounding these precincts. The net effect, nonetheless, remains a lower level of assault. In particular, we estimate that the net reduction over the three areas combined was 1670 assaults (i.e. 27 per month). CONCLUSION: Some of the initial reduction in assault in KX and the CBD of Sydney, Australia, previously attributed to the February 2014 introduction of lockout laws may have been a response to publicity surrounding recent deaths connected with alcohol-related violence.

Changes in and correlates of Australian public attitudes toward illicit drug use.

INTRODUCTION: The present study explores Australian public support for more lenient treatment of persons found in possession of small amounts of illegal drugs for personal use. METHODS: Data for the study are drawn from the 2013, 2016 and 2019 National Drug Strategy Household Surveys. Bivariate associations were tested using χ2 tests corrected for survey design. Multivariate analyses of public support for legalisation and imprisonment involved logistic regression. Multivariate analyses of public preferences for various responses to those found in possession of illicit drugs involved the use of multinomial regression. RESULTS: Support for legalising personal use of three drugs (cannabis, ecstasy and cocaine) has risen significantly since 2013 but remained stable (and low) for two (heroin and methamphetamine). Support for no action, a caution or a warning has grown for those found in possession of cannabis, ecstasy and heroin for personal use but not for those found in possession of methamphetamine. There is, however, more support for responding to this group with treatment, education or a small fine than there is for imprisonment. DISCUSSION AND CONCLUSION: There is strong support for legalising use of cannabis. There is little support for legalising use of ecstasy and cocaine but growing public support for a less punitive approach to those who use these drugs. There is little public support for a change in the current approach to heroin and methamphetamine.

Does correctional supervision of amphetamine users reduce the risk of re-offending?

AIM: To examine the specific deterrent effect of offender supervision on the risk of a further offence by persons convicted of amphetamine use and/or possession. DESIGN: Observational study of two groups matched on a wide range of factors using augmented inverse probability of treatment weighting. SETTING: New South Wales (NSW), Australia. PARTICIPANTS: A total of 2099 persons convicted of amphetamine use and/or possession and placed on either a supervised good behaviour bond (1004) or a bond without supervision (1096). MEASUREMENTS: Conviction for another amphetamine use/possession offence, any drug offence, assault or theft within 48 months free time after the index court appearance. FINDINGS: Only two of the treatment estimates were consistent with a deterrent effect. Where the outcome was an assault offence, the estimated reduction in risk of re-offending was 1%. Where the outcome was a theft offence, the estimated reduction in the risk of reoffending was 0.07%. Neither result was statistically significant. The coefficients measuring the effect of supervision on the remaining two outcomes (use/possess amphetamine and use/possess any drug) were both positive and not statistically significant. CONCLUSION: Correctional supervision does not appear to have been effective in New South Wales, Australia, in reducing the risk of reoffending among people convicted of amphetamine use/possession.

A trial of Criminal Infringement Notices as an alternative to criminal penalties for illicit drug offences in New South Wales, Australia: Estimated savings.

INTRODUCTION AND AIMS: In 2019, legislation was introduced allowing New South Wales police to issue Criminal Infringement Notices (CIN) instead of criminal charges for prohibited drug possession offences, excluding cannabis leaf. This initiative was trialled across NSW music festivals from 25 January to 1 August 2019. This paper aims to examine the number of CINs administered and to estimate the associated (actual and potential) savings. DESIGN AND METHODS: Data were obtained from the NSW Bureau of Crime Statistics and Research (Recorded Crime Statistics, Reoffending Database). To estimate the monetary savings associated with administering CINs for drug possession offences, as opposed to processing them through the criminal justice system, data were obtained from the 2020 Report on Government Services. RESULTS: From January to June 2019, 300 CINs were issued for illicit drug possession (mostly for ecstasy possession; n = 256), resulting in an estimated saving to the criminal justice system of 194 400 AUD (or 314 400, if generated revenue included). We estimate that issuing CINs for all illicit drug possession offences would have provided savings of over 5 million AUD in that same six-month period, or approximately 1.7 million AUD if CINs were only issued to people with no prior convictions. DISCUSSION AND CONCLUSION: Issuing CINs for illicit drug possession has the potential to yield substantial monetary savings. However, to avoid unintended consequences (e.g. disproportionate impact on disadvantaged populations), we would argue that police also be given the discretion to issue cautions for illicit drug possession offences.

The contribution of methamphetamine use to crime: Evidence from Australian longitudinal data.

BACKGROUND: To quantify the extent to which methamphetamine use is associated with increases in crime net of any premorbid risk of criminality among people who use the drug. METHODS: Four one-month data panels from 469 participants dependent on methamphetamine were drawn from the MATES cohort (N = 501). Odds ratios for within-person effects were extracted from a random intercept logistic regression model for crime during periods of methamphetamine use compared to no use. Effects were adjusted for time-varying measures of age, other substance use, and socio-economic disadvantage (income, unemployment and unstable accommodation). Involvement in crime (property crime, drug dealing, fraud, violent crime) and days of methamphetamine in the past month were assessed using the Opiate Treatment Index. RESULTS: Crime was more likely during months when participants used methamphetamine compared to when they did not (OR 13.2 95% CI 8.5-20.6; AOR 4.7 95% CI 2.8-8.0), this reflecting more property crime (OR 10.6 95% CI 6.3-18.0; AOR 5.5 95% CI 2.8-10.8), violent crime (OR 8.2 95% CI 4.2-15.9; AOR 3.4 95% CI 1.5-8.0), fraud (OR 3.4, 95% CI 2.0-5.8; AOR 1.7 95% CI 0.8-3.3) and dealing drugs (OR 18.2 95% CI 10.2-32.5; AOR 5.9 95% CI 3.0-11.9), although the adjusted relationship for fraud was not significant. Effects were dose related. CONCLUSIONS: The use of methamphetamine was associated with significant increases in crime beyond premorbid risk for criminality. Crime is a likely social consequence of methamphetamine use and efforts are needed to reduce this impact.

The effect of entry and retention in opioid agonist treatment on contact with the criminal justice system among opioid-dependent people: a retrospective cohort study.

BACKGROUND: Evidence on the effectiveness of opioid agonist treatment (OAT) in reducing crime is mixed. We aimed to assess the effect of OAT on crime in terms of delaying time to first charge and reducing overall charge rates, as well as the relationship between OAT retention and overall charge rates. METHODS: We did a retrospective cohort study of opioid-dependent people who entered OAT for the first time between Jan 1, 2004, and Dec 30, 2010, in New South Wales (NSW), Australia. We used three linked NSW and national administrative datasets. Data on OAT were obtained from the Pharmaceutical Drugs of Addiction System, data on charges were obtained from the Reoffending Database, and data on mortality were obtained from the National Death Index. The cohort was followed up until Dec 31, 2011. Time-dependent OAT exposure was modelled using Cox proportional hazards models (time to first charge) and Andersen-Gill intensity models (total charge-days). Retention in OAT was modelled using two features of treatment engagement, number of OAT episodes and proportion of follow-up time in OAT (presented in quartile groupings: lowest, low-mid, low-high, highest) using zero-inflated negative binomial regression (total charges). All models were adjusted for sociodemographic, criminographic, and treatment-related variables. FINDINGS: 10 744 new OAT entrants were included in the study. 5751 (53·5%) people were charged with an offence. In adjusted analyses, OAT was associated with an initial benefit in delaying the time to first charge (hazard ratio 0·43, 95% CI 0·33-0·55) and reducing total charge-days (0·39, 95% CI 0·30-0·52); however, these protective effects reduced over time. Total charge rates were higher as the number of OAT episodes increased (incident rate ratio [IRR] 1·13, 95% CI 1·11-1·15), and when relatively lower proportions of time were spent in OAT (IRR among the lowest three quartiles ranged from 1·11 [95% CI 1·02-1·21] to 1·22 [95% CI 1·12-1·33]). INTERPRETATION: OAT was associated with a reduction in overall charge rates and was more protective as treatment engagement increased. Maximising treatment retention is crucial to achieving long-term health and social benefits of OAT. FUNDING: Australian National Health and Medical Research Council, Australian Institute of Criminology, National Institute on Drug Abuse, Australian Government Department of Health, UNSW Sydney.

Correlates of driving under the influence of cannabis.

BACKGROUND: Identifying cannabis users who are most at risk of driving under the influence of cannabis (DUIC) has important implications for drug treatment and prevention efforts. This paper examined correlates of DUIC among a purposive sample of recent cannabis users. METHODS: Interviews were carried out among a cross-sectional sample of 320 Australian cannabis users. Past-year prevalence of DUIC (without using alcohol or other drugs) was regressed against a range of potential predictor variables. RESULTS: Use of multiple drugs, believing that DUIC does not increase accident risk and cannabis dependence all predicted likelihood of DUIC. There was an interaction between age of first cannabis use and gender, whereby earlier onset cannabis use predicted DUIC but only among women. CONCLUSIONS: The correlates of drug driving reflected cannabis users' beliefs about the dangers of cannabis use as well as their patterns of drug consumption. The emergence of cannabis dependence and age of onset as predictors of DUIC suggests a clearly defined role for treatment and prevention efforts in reducing the potential harms associated with DUIC.

The effect of liquor licensing restrictions on assault: a quasi-experimental study in Sydney, Australia.

AIMS: To determine whether restrictions on the availability of alcohol in two inner-city entertainment areas in Sydney, Australia (1) reduced the incidence of assault in those areas, (2) increased the incidence of assault in nearby areas (where the restrictions did not apply), (3) resulted in a net reduction in overall levels of assault (4) and/or whether the reductions in assault were most pronounced during the daily time-periods when liquor trading restrictions were in operation. DESIGN: Structural time-series modelling was used to estimate and compare trends in assault in areas/times affected by the new restrictions on alcohol availability with trends in assault in areas unaffected by the new restrictions. SETTING: Sydney, Australia. PARTICIPANTS/MEASUREMENTS: The primary outcome measure was the police-recorded monthly incidence of non-domestic assault in the 78 months between January 2009 and June 2015. FINDINGS: Following the reforms, we found reductions in assaults of 45% [beta = -0.599, 95% confidence interval (CI) = -1.107, -0.091] and 22% (beta =0.260, 95% CI = -0.397, -0.123), respectively, in the Kings Cross and Sydney CBD Entertainment Precincts. In the Kings Cross Entertainment Precinct, reductions in assault were observed in all three daily time-periods. In the Sydney CBD Entertainment Precinct reductions in assault were observed only in the second and third daily time-periods. Assaults did not increase in entertainment areas adjacent to or within easy reach of the target areas. CONCLUSION: Restrictions on the availability of alcohol appear to reduce the incidence of assault.

The deterrent effects of Australian street-level drug law enforcement on illicit drug offending at outdoor music festivals.

BACKGROUND: Australian and international street-level drug law enforcement deploy many strategies in efforts to prevent or deter illicit drug offending. Limited evidence of deterrence exists. This study assessed the likely impacts of four Australian policing strategies on the incidence and nature of drug use and supply at a common policing target: outdoor music festivals. METHODS: A purpose-built national online survey (the Drug Policing Survey) was constructed using five hypothetical experimental vignettes that took into account four policing strategies (High Visibility Policing, Riot Policing, Collaborative Policing, and policing with Drug Detection Dogs) and a counter-factual (no police presence). The survey was administered in late 2015 to 2115 people who regularly attend festivals. Participants were block-randomised to receive two vignettes and asked under each whether they would use, possess, purchase, give or sell illicit drugs. RESULTS: Compared to 'no police presence', any police presence led to a 4.6% point reduction in engagement in overall illicit drug offending: reducing in particular willingness to possess or carry drugs into a festival. However, it had minimal or counterproductive impacts on purchasing and supply. For example, given police presence, purchasing of drugs increased significantly within festival grounds. Offending impacts varied between the four policing strategies: Drug Detection Dogs most reduced drug possession but High Visibility Policing most reduced overall drug offending including supply. Multivariate logistic regression showed police presence was not the most significant predictor of offending decisions at festivals. CONCLUSIONCONCLUSION: The findings suggest that street-level policing may deter some forms of drug offending at music festivals, but that most impacts will be small. Moreover, it may encourage some perverse impacts such as drug consumers opting to buy drugs within festival grounds rather than carry in their own. We use our findings to highlight trade-offs between the goals of public health promotion and crime control in street-level enforcement.

Preventing cannabis users from driving under the influence of cannabis.

Face-to-face, structured interviews were conducted with 320 recent cannabis users in New South Wales, Australia to assess the likely deterrent effects of (a) increasing the certainty of apprehension for driving under the influence of cannabis (DUIC) and (b) doubling the severity of penalties for DUIC. Participants were presented with a drug-driving scenario and asked to indicate their likelihood of driving given that scenario. The perceived risk of apprehension and severity of punishment were manipulated in each scenario to create four different certainty/severity conditions and participants were randomly allocated to one of these four groups. A subsidiary aim was to assess the likely impact of providing factual information about the accident risk associated with DUIC. Recent drug drivers who felt at low risk of accident when DUIC were asked to rate their willingness to drive if convinced that it was dangerous. The results suggested that increasing the certainty but not severity of punishment would produce reductions in cannabis-intoxicated driving among recent cannabis users. Providing factual information about the risks associated with DUIC would appear to have little impact on drug-driving rates among this population.

Do drug seizures predict drug-related emergency department presentations or arrests for drug use and possession?

BACKGROUND: Direct evidence of the effect of drug seizures on drug use and drug-related harm is fairly sparse. The aim of this study was to see whether seizures of heroin, cocaine and ATS predict the number of people arrested for use and possession of these drugs and the number overdosing on them. METHOD: We examined the effect of seizure frequency and seizure weight on arrests for drug use and possession and on the frequency of drug overdose with autoregressive distributed lag (ARDL) models. Granger causality tests were used to test for simultaneity. RESULTS: Over the short term (i.e. up to 4 months), increases in the intensity of high-level drug law enforcement (as measured by seizure weight and frequency) directed at ATS, cocaine and heroin did not appear to have any suppression effect on emergency department (ED) presentations relating to ATS, cocaine and heroin, or on arrests for use and/or possession of these drugs. A significant negative contemporaneous relationship was found between the heroin seizure weight and arrests for use and/or possession of heroin. However no evidence emerged of a contemporaneous or lagged relationship between heroin seizures and heroin ED presentations. CONCLUSION: The balance of evidence suggests that, in the Australian context, increases in the monthly seizure frequency and quantity of ATS, cocaine and heroin are signals of increased rather than reduced supply.

The impact of the Sydney Medically Supervised Injecting Centre (MSIC) on crime.

The current study aimed to model the effect of Australia's first Medically Supervised Injecting Centre (MSIC) on acquisitive crime and loitering by drug users and dealers. The effect of the MSIC on drug-related property and violent crime was examined by conducting time series analysis of police-recorded trends in theft and robbery incidents, respectively. The effect of the MSIC on drug use and dealing was examined by (a) time series analysis of a special proxy measure of drug-related loitering; (b) interviewing key informants; and (c) examining trends in the proportion of Sydney drug offences that were recorded in Kings Cross. There was no evidence that the MSIC trial led to either an increase or decrease in theft or robbery incidents. There was also no evidence that the MSIC led to an increase in 'drug-related' loitering at the front of the MSIC after it opened, although there was a small increase in 'total' loitering (by 1.2 persons per occasion of observation). Trends in both 'drug-related' and 'total' loitering at the front of the MSIC steadily declined to baseline levels, or below, after it opened. There was a very small but sustained increase in 'drug-related' (0.09 persons per count) and 'total' loitering (0.37 persons per count) at the back of the MSIC after it opened. Key informant interviews noted an increase in loitering across the road from the MSIC but this was not attributed to an influx of new users and dealers to the area. There was no increase in the proportion of drug use or drug supply offences committed in Kings Cross that could be attributed to the opening of the MSIC. These results suggest that setting up an MSIC does not necessarily lead to an increase in drug-related problems of crime and public loitering.

The effects of liquor licensing restriction on alcohol-related violence in NSW, 2008-13.

AIM: To estimate the effect on assault of a series of legislative reforms that restricted the trading hours and trading conditions of licensed premises in New South Wales (NSW), Australia. METHODS: We examine the effects of the legislative reforms introduced between July 2008 and January 2012 using time series structural models. These models are used to estimate the underlying long-term dynamics of the time series of police recorded domestic and non-domestic assaults occasioning actual bodily harm (ABH) and assaults occasioning grievous bodily harm (GBH) in NSW between January 1996 and December 2013. The effect of the legislative changes is captured by including terms in the models which reflect a smooth step change in the number of assaults. RESULTS: The reforms introduced between July 2008 and January 2012 were associated with a fall in levels of ABH and GBH assaults. The joint effect of all the interventions on ABH lasted until July 2013, accounting for a reduction of -31.27% over that period [parameter estimate -0.38 with 95% confidence interval (CI) = -0.65, -0.10)]. The same set of interventions had a greater effect on GBH assaults; achieving a -39.70% reduction over a shorter period of time July 2008 and July 2012 (parameter estimate -0.51 with 95% CI = -0.69, -0.33). CONCLUSION: Legislative reforms introduced in New South Wales, Australia between July 2008 and January 2012 to restrict trading hours and trading conditions of licensed alcohol premises appear to have reduced the number of police-recorded assaults of ABH and GBH by 31.27% and 39.70% respectively.

A cost-effectiveness analysis of opioid substitution therapy upon prison release in reducing mortality among people with a history of opioid dependence.

AIM: Although opioid substitution therapy (OST) immediately after prison release reduces mortality, the cost-effectiveness of treatment has not been examined. Therefore, we undertook a cost-effectiveness analysis of OST treatment upon prison release and the prevention of death in the first 6 months post-release. DESIGN: Population-based, retrospective data linkage study using records of OST entrants (1985-2010), charges and court appearances (1993-2011), prison episodes (2000-11) and death notifications (1985-2011). SETTING: New South Wales, Australia. PARTICIPANTS: A cohort of 16,073 people with a history of opioid dependence released from prison for the first time between 1 January 2000 and 30 June 2011. INTERVENTION: OST treatment compared to no OST treatment at prison release. MEASUREMENTS: Mortality and costs (treatment, criminal justice system-court, penalties, prison-and the social costs of crime) were evaluated at 6 months post-release. Analyses included propensity score matching, bootstrapping and regression. FINDINGS: A total of 13,468 individuals were matched (6734 in each group). Twenty (0.3%) people released onto OST died, compared with 46 people (0.7%) not released onto OST. The final average costs were lower for the group that received OST post-release ($7206 versus $14,356). The incremental cost-effectiveness ratio showed that OST post-release was dominant, incurring lower costs and saving more lives. The probability that OST post-release is cost-effective per life-year saved is 96.7% at a willingness to pay of $500. CONCLUSION: Opioid substitution treatment (compared with no such treatment), given on release from prison to people with a history of opioid dependence, is cost-effective in reducing mortality in the first 6 months of release.

Supply control and harm reduction: lessons from the Australian heroin 'drought'.

AIMS: To examine the effects of supply-side drug law enforcement on the dynamics of the Australian heroin market and the harms associated with heroin. SETTING: Around Christmas 2000, heroin users in Sydney and other large capital cities in Australia began reporting sudden and significant reductions in the availability of heroin. The changes, which appear to have been caused at least in part by drug law enforcement, provided a rare opportunity to examine the potential impact of such enforcement on the harm associated with heroin. DESIGN: Data were drawn from a survey of 165 heroin users in South-Western Sydney, Australia; from the Drug Use Monitoring in Australia (DUMA) project; from NSW Health records of heroin overdoses; and from the Computerized Operational Policing System (COPS) database. FINDINGS: Heroin price increased, while purity, consumption and expenditure on the drug decreased as a result of the shortage. The fall in overall heroin use was accompanied by a significant reduction in the rate of overdose in NSW. However, the health benefits associated with the fall in overdose may have been offset by an increase in the use of other drugs (mainly cocaine) since the onset of the heroin shortage. There does not appear to have been any enduring impact on crime rates as a result of the heroin 'drought'. CONCLUSION: Supply control has an important part to play in harm reduction; however, proponents of supply-side drug law enforcement need to be mindful of the unintended adverse consequences that might flow from successfully disrupting the market for a particular illegal drug.

Cost-effectiveness analysis of the New South Wales adult drug court program.

In New South Wales, Australia, a cost-effectiveness evaluation was conducted of an adult drug court (ADC) program as an alternative to jail for criminal offenders addicted to illicit drugs. This article describes the program, the cost-effectiveness analysis, and the results. The results of this study reveal that, for the 23-month period of the evaluation, the ADC was as cost-effective as were conventional sanctions in delaying the time to the first offense and more cost-effective in reducing the frequency of offending for those outcome measures selected. Although the evaluation was conducted using the traditional steps of a cost-effectiveness analysis, because of the complexity of the program and data limitations it was not always possible to adhere to textbook procedures. As such, each step involved in undertaking the cost-effectiveness analysis is discussed, highlighting the key issues faced in the evaluation.

The impact of opioid substitution therapy on mortality post-release from prison: retrospective data linkage study.

AIMS: Release from prison is a high-risk period for mortality. We examined the impact of opioid substitution therapy (OST), for opioid dependence during and after incarceration, upon mortality post-release. DESIGN: A cohort was formed of all opioid-dependent people who entered OST between 1985 and 2010 and who, following first OST entry, were released from prison at least once between 2000 and 2012. We linked data on OST history, court and prison records and deaths. SETTING: New South Wales (NSW), Australia. PARTICIPANTS: A total of 16,453 people released from prison 60,161 times. MEASUREMENTS: Crude mortality rates (CMRs) were calculated according to OST retention; multivariable Cox regressions for post-release periods were undertaken to examine the association between OST exposure (a time-dependent variable) and mortality post-release, for which covariates were updated per-release. FINDINGS: There were 100,978 person-years (PY) post-release; 1050 deaths occurred. Most received OST while incarcerated (76.5%); individuals were receiving OST in 51% of releases. Lowest post-release mortality was among those continuously retained in OST post-release CMR 4 weeks post-release = 6.4 per 1000 PY; 95% confidence interval (CI) = 5.2, 7.8, highest among those with no OST (CMR = 36.7 per 1000 PY; 95% CI = 28.8, 45.9). Multi-factorial models showed OST exposure in the 4 weeks post-release reduced hazard of death by 75% (adjusted hazard ratio 0.25; 95% CI = 0.12, 0.53); OST receipt in prison had a short-term protective effect that decayed quickly across time. CONCLUSION: In New South Wales, Australia, opioid substitution therapy in prison and post-release appears to reduce mortality risk in the immediate post-release period.