Welcome to Social Research & Evaluation
News and Events
Here I will, from time-to-time, provide information on current initiatives in which the consultancy is involved, and issues of particular interest that I (David McDonald, the consultancy's Director) believe the on-line community will find of interest.
06.Feb.10
Further evidence supporting prison needle syringe programs The two main arguments proffered in support of prison NSPs (needle syringe programs) are that (1) such programs have been demonstrated to reduce the incidence of blood-borne virus transmission - especially hepatitis C and HIV/AIDS - among people who inject illegal drugs and (2) that prison inmates are entitled to health care services (including health promotion services) at least as good as those provided to the community at large.
New research has quantified the incidence of transmission of hepatitis C among inmates who inject drugs in NSW prisons. It has shown that the incidence is 34 per 100 person years, that is, one-third of injecting prisoner who enter prison free of hepatitis C become infected, in prison, within a year:
Abstract. To determine hepatitis C incidence and the demographic and behavioural predictors in seronegative drug injecting prisoners. Prisoners in New South Wales, Australia who: were aged 18 years and over; reported IDU; had been continuously imprisoned; had a documented negative HCV antibody test result in prison in the last 12 months; provided written informed consent. Subjects were interviewed about their demographic characteristics and detailed risk factors for transmission prior to, and since, imprisonment. A blood sample was collected to screen for HCV antibodies by ELISA and RNA by PCR. Of 253 inmates recruited, 120 were continuously imprisoned and included in this analysis. Sixteen acquired HCV infection indicating an incidence of 34.2 per 100 person years (CI: 19.6-55.6). Risk factors for transmission included prior imprisonment, methadone treatment and greater than 10 years of education. Although the frequency of injecting was reduced in prison, 33.6% continued to inject drugs, most commonly methamphetamine, and 90% of these reported sharing injecting equipment. Prison inmates were at high risk of HCV infection, despite some reduction in high-risk behaviours and access to prevention services. To prevent HCV transmission in prisons, better prevention strategies are required.
The authors argue for a trial, in an Australian prison, of the provision of sterile injecting equipment to inmates as a strategy for reducing the transmission of blood-borne viral disease, owing to the failure of existing interventions to achieve this important public health goal.
Dolan, K, Teutsch, S, Scheuer, N, Levy, M, Rawlinson, W, Kaldor, J, Lloyd, A & Haber, P 2010, 'Incidence and risk for acute hepatitis C infection during imprisonment in Australia', European Journal of Epidemiology, published online 19 January 2010.
Today the first Annual ACT Alcohol & other Drug Sector (AOD) Awards were presented at the Legislative Assembly for the ACT by Ms Mary Porter AM, MLA.
The Inaugural Award for Excellence in Alcohol and other Drug Work was presented to Ms Clare Purcell from ACT Health's Alcohol and Drug Program.
The Inaugural Lifetime Achievement Award was presented to Ms Dawn Bainbridge from the Alcohol and Drug Foundation of the ACT.
The Inaugural Outstanding Contributions Award was presented to me, David McDonald. The citation reads, in part:
This award recognises the contributions of an individual who has worked to prevent or reduce the psychological, physical, social and/or economic harms caused by alcohol and other drugs in the ACT. The individual need not have worked in direct service delivery or specifically in the AOD sector, but will have over a considerable period of time worked to improve the health and well-being of people affected alcohol and other drug issues. David McDonald is a social scientist who has worked tirelessly to improve the health and wellbeing of people affected by alcohol and other drug issues. He has particularly achieved this by contributing to the evidence base upon which ACT public policy is formed; and by supporting the ACT alcohol and other drug sector to engage with the evidence base… Through his various roles, David has had a significant impact on the sector, with the ACT sector particularly benefiting from his work. For example his work on the extent and nature of drug use and harms in the ACT; profiling the workforce; conducting evaluations; monthly reviews of the evidence to support workers to bridge the gap between evidence, policy and service delivery; and active participation in over six ACT groups and committees concurrently. David is dedicated to ensuring that the sector's public health initiatives and policy are carefully designed, rigorously implemented, and appropriately evaluated. For example, he has contributed to high level endeavours such as the National Drug Strategy and the ACT Alcohol, Tobacco and Other Drug Strategy. David is a well-respected, valued member of the ACT and national sectors; and he has demonstrated his commitment to reducing the harm caused by alcohol and other drugs over many decades. David's colleagues therefore wanted acknowledge his achievements by awarding him the inaugural Outstanding Contributions Award.
Publication of the report of the evaluation of Australia's National Drug Strategy 2004-2009 Over the last couple of years a team of which I was a member, led by Dr Mel Miller of Siggins Miller Consultants, has been monitoring and evaluating the 2004-2009 phase of Australia's National Drug Strategy. This project has been conducted under contract to the Australian Government Department of Health and Ageing.
The final evaluation report was considered by the Ministerial Council on Drug Strategy in May this year and was published, online, last week. There it is described in the following terms: 'This report evaluates the National Drug Strategy (NDS) as a policy framework, the outcomes of programs under the NDS, and the roles and workings of the advisory structures that inform development and implementation of the NDS. It also monitors performance of the NDS during the period 2006-2009'. The report has three components: Volume 1: findings and recommendations; Volume 2: case studies, literature reviews, and headline indicators; and Appendices.
Concurrently with releasing the evaluation report, the managers of the National Drug Strategy have released a consultation paper for the next phase of the NDS which apparently will cover the six-year period 2010 to 2015. They state:
Australia's National Drug Strategy 2004–2009 is in its final year of implementation. The Strategy has been evaluated by independent experts under the auspices of the Ministerial Council on Drug Strategy (MCDS).
The evaluation found that the Strategy and its three pillars of supply, demand and harm reduction are fundamentally sound and have been vital to the success of the Strategy in reducing the prevalence of, and harms from, drug use in Australia over a long period.
Nonetheless, significant harms from drug use continue to occur inAustralia and new trends are emerging. This Consultation Paper aims to identify emerging issues and seek input from expert stakeholders and the broader community on directions for the next phase of the Strategy 2010–2015.
The Paper has been prepared on behalf of the MCDS by the Intergovernmental Committee on Drugs National Drug Strategy Development Working Group. The MCDS invites feedback on the paper...
The MCDS will consider your feedback in response to this paper in developing a draft of the National Drug Strategy 2010-2015, which will be released for further consultation in the first half of 2010.
This approach to evaluation of the NDS, and widespread consultation as inputs to developing the next phase, has characterised the NDS' development since it commenced in 1985.
Launches of our new book: Research Integration Using Dialogue Methods
The new book Research Integration Using Dialogue Methods that I have co-authored with Professor Gabriele Bammer and Peter Deane (see 5 Sep 2009, below) was launched this month. The first launch occurred on 20 November at the Institute of Geography, University of Berne, Switzerland, where Gabriele gave a keynote address at the ‘Integration in Inter- and Transdisciplinary Research’ conference. The launch was conducted by Julie Thompson Klein, Professor of Humanities in the Interdisciplinary Studies Program at the College of Lifelong Learning, Wayne State University, Detroit USA.
The second launch was held on 26 November at the Co-op Bookshop at The Australian National University. It was conducted by Professor Ted Lefroy, Director of the Centre for Environment at the University of Tasmania, and a member of the Board of Land & Water Australia. Dr Michael Robinson, CEO of Land & Water Australia, chaired the launch.
The book is published by ANU E Press, and is available as a free download in pdf, html and mobile device formats. It can be read on the screen or downloaded as a whole, or in chapters. Printed copies can also be ordered from the publisher.
APSAD conference presentation on the unintended consequences of drug policy
Today I gave a presentation to the APSAD National Conference which was held in Darwin, NT. The title was 'Understanding the adverse unintended consequences of policies and interventions addressing drug availability and drug use'. Here is the abstract:
Background Despite some fine achievements in developing and implementing policies addressing psychoactive substances, too many interventions have produced unintended adverse consequences. Furthermore, too many of these were predictable. Two taxonomies of adverse unintended consequences in this field have recently been published, one by a senior United Nations official (Costa) and another by a leading international academic (Reuter). I suggest that this type of taxonomy can be useful in substance abuse policy analysis and in designing evaluations of drug policy and interventions.
The study The two taxonomies have been developed deductively. I will report on the findings of a study which assessed them using published case material: a grounded, inductive approach to taxonomy development. This will help clarify their validity and utility in substance abuse policy development, implementation and evaluation.
Results The study has clarified the validity of the two overlapping taxonomies. It has shown their strengths and weaknesses as tools for contributing to substance abuse policy development, implementation and evaluation.
Implications Policy analysis guidelines direct analysts to consider both the predictable and unpredictable unintended adverse consequences of competing policy options. This study builds on Costa’s and Reuter’s suggestions for ways of thinking about the unintended consequences of drug policy. It does so by providing new insights for drug policy analysts and evaluators, enabling them to address, in a more systematic and explicit manner, the adverse unintended consequences of drug policies.
Citation: McDonald, D 2009, 'Understanding the adverse unintended consequences of policies and interventions addressing drug availability and drug use', Drug and Alcohol Review, vol. 28, no. Supp. 1, p. A43.
Publication of a new book: Research Integration Using Dialogue Methods Gabriele Bammer, Peter Deane and I have prepared this book. It was published online today by ANU E Press, and is available as a free download in both pdf or html forms. The book can be read on the screen or downloaded as a whole, or in chapters. Printed copies can also be ordered from the publisher.
Book description:
Research on real-world problems—like restoration of wetlands, the
needs of the elderly, effective disaster response and the future of the
airline industry—requires expert knowledge from a range of disciplines,
as well as from stakeholders affected by the problem and those in a
position to do something about it. This book charts new territory in
taking a systematic approach to research integration using dialogue
methods to bring together multiple perspectives. It links specific
dialogue methods to particular research integration tasks. Fourteen dialogue methods for research integration are classified into two groups: 1. Dialogue methods for understanding a problem broadly: integrating judgements 2. Dialogue methods for understanding particular aspects of a problem: integrating visions, world views, interests and values. The
methods are illustrated by case studies from four research areas: the
environment, public health, security and technological innovation.
Recommended citation: McDonald, D, Bammer, G & Deane, P 2009, Research integration using dialogue methods, ANU E Press, Canberra.
Conference paper presented: 'Applying theories of policy processes to evaluation: the example of evaluating Australia’s National Drug Strategy' Today, on behalf of the team that conducted the 2009 evaluation of Australia's National Drug Strategy, I presented a paper at the Australasian Evaluation Society International Conference which was held in Canberra: McDonald, D, Cleary, G, Miller, M-E, Lai, SH-C, Siggins, I & Bush, R 2009, 'Applying theories of policy processes to evaluation: the example of evaluating Australia’s National Drug Strategy'.
Abstract This paper explores the utility of theories, frameworks and models of policy processes for understanding the nature of the evaluation/policy nexus, and for maximising the likelihood that evaluation processes and products will actually contribute to the development of sound social policy. We argue that people evaluating policies and their implementation—especially large, complex social interventions—will benefit from applying a policy lens to their work. Doing so can provide an entry point to the evaluation, help set boundaries, and contribute to evaluation design. The policy theories that are available include the systems model, the stages heuristic, the rational/comprehensive model, the bounded rationality model, institutional rational choice frameworks, the incrementalism model, the multiple streams model and the advocacy coalitions model. Each can contribute to understanding Australia’s National Drug Strategy and potentially contribute to its evaluation. We conclude that policy theory provides to evaluators insights into the policies that they are evaluating that would otherwise remain hidden. Furthermore, it potentially contributes to focusing the evaluation, interpreting the findings and enhancing evaluation utilisation.
Further evidence for the effectiveness of heroin maintenance for opioid dependent people who fail to respond to standard treatment Carefully controlled trials in a number of European countries have demonstrated that opioid-dependent people who fail to benefit from methadone maintenance treatment do well when maintained on injectable diacetylmorphine (pharmaceutical-grade heroin). This finding has now been confirmed in the North American Opiate Medication Initiative (NAOMI) trial conducted in Canada by a group of Canadian and US researchers. The participants were people who engaged in long-term, treatment-refractory opioid use and had previously relapsed from methadone maintenance treatment. They were randomly assigned to receive oral methadone or injectable opioids, with most of the latter group receiving diacetylmorphine but a small number receiving hydromorphone. The provision of the injectable opioids was implemented on a double-blind basis, i.e., neither the participants nor the staff knew whether diacetylmorphine or hydromorphone was being as dispensed to them. The primary outcomes, assessed at 12 months, were retention in treatment or drug-free status and a reduction in illicit drug use or other illegal activity.
The results were clear. The retention rate in treatment in the diacetylmorphine group was 88% compared with 54% in the oral methadone group. The reduction in rates of illicit drug use or other illegal activity was 67% in the diacetylmorphine group and 48% in the methadone group. The most common serious adverse events among those who received diacetylmorphine injections were overdoses (in 10 participants) and seizures (in 6). Since the diacetylmorphine and hydromorphone were self-administered at the treatment service, these adverse events were dealt with promptly and all participants recovered satisfactorily.
Interestingly, the participants who received injectable opioids were not able to differentiate between diacetylmorphine and hydromorphone. (One implication of this is that further research is required to determine if maintenance on injectable hydromorphone produces outcomes as positive as those from maintenance on diacetylmorphine, among opioid dependent people who have not benefited from standard therapies.)
The researchers concluded that 'Injectable diacetylmorphine was more effective than oral methadone. Because of a risk of overdoses and seizures, diacetylmorphine maintenance therapy should be delivered in settings where prompt medical intervention is available'.
Oviedo-Joekes, E, Brissette, S, Marsh, DC, Lauzon, P, Guh, D, Anis, A & Schechter, MT 2009, 'Diacetylmorphine versus methadone for the treatment of opioid addiction', New England Journal of Medicine, vol. 361, no. 8, pp. 777-86.
Can the
secondary exchange of sterile injecting equipment provide an opportunity for
health promotion?
Secondary
exchange of needles and syringes ‘refers to the giving or receiving of new
sterile needles and syringes to/from another individual that were originally
obtained from formal or “safe” sources. It can include trading, purchasing or
selling of needles and syringes for money, drugs or other commodities or
services; or it can simply involve the giving or receiving outright of needles
and syringes’. Researchers from the National Centre for HIV Social Research,
University of NSW, studied the extent, patterns and contexts of secondary
exchange in south east Sydney, and examined whether secondary exchange is
independently associated with blood borne viruses risk practices.
They
found that secondary exchange ‘is a common activity in south east Sydney but
does not appear to be highly organised, usually taking place in small networks
of friends and/or partners for altruistic reasons’. They conclude that
secondary exchange ‘is a practice that could be exploited to expand the reach
of current needle distribution programs’ to reach people who inject illicit
drugs who do not use formal distribution services.
Bryant,
J & Hopwood, M 2008, ‘Secondary exchange of sterile injecting equipment in
a high distribution environment: a mixed method analysis in south east Sydney,
Australia’, International Journal of Drug
Policy, vol. 20, no. 4, pp. 324-28.
Canberra's syringe vending machines trial evaluation published Some time ago I completed the evaluation of the trial of syringe vending machines in Canberra. A paper on the topic has now been published: McDonald, D 2009, 'The evaluation of a trial of syringe vending machines in Canberra, Australia', Int J Drug Policy, vol. 20, no. 4, pp. 336-9.
Abstract: BACKGROUND: Syringe vending machines (SVMs) have been trialled in Canberra, Australian Capital Territory, Australia, as an intervention aiming to increase the availability of sterile injecting equipment for use by IDUs. This study evaluated the 12-month trial. METHODS: A utilisation-focused evaluation model, with both formative and summative components, was employed. Four SVMs were installed, each dispensing packs containing four 1mL syringes and associated injecting paraphernalia. The trial participants were the clients of the SVMs and other key informants. The core measurements used were the number of syringes dispensed in Canberra by SVMs and other outlets, SVM clients' demographics and experiences of and attitudes towards SVMs, perceived impacts of SVMs on needle sharing, unsafe disposal of used syringes in the vicinity of SVMs, and community and stakeholder attitudes. RESULTS: The trial was implemented successfully, with no adverse consequences identified. The SVMs appear to be serving both the usual clients of the other outlets for sterile injecting equipment (community pharmacies and the Needle Syringe Program outlets) and others who are reluctant to use such outlets or find them inconvenient. The out-of-business-hours provision of syringes through the SVMs was particularly welcomed by both SVM clients and other stakeholders. The continuing operation of the initial four SVMs is widely supported, and additional machines are requested by clients and others. CONCLUSIONS: Owing to the success of the trial in terms of feasibility and outcomes for both IDUs and for the broader community, it is desirable that providing sterile injecting equipment through SVMs continues and be expanded as an integral component of harm reduction strategies.
Drug driving article published The issue of drug driving (so-called 'random drug testing' of drivers) continues to be of interest, with various Police Services expanding their endeavours in this area. As I have argued previously in this news blog, it appears that the intervention has been implemented without a sound evidence base as to its likely impacts on road safety. Furthermore, there is no sign of any evaluation of its impacts on road safety in Australia.
This month has seen the publication of an article I wrote - an opinion piece or commentary: McDonald, D 2009, 'The policy context of roadside drug testing', Journal of the Australasian College of Road Safety, vol. 20, no. 1, pp. 37-43.
Abstract Roadside testing of oral fluids for a suite of illegal drugs has been taking place in Victoria since late 2004, is now operating in some form in all of Australia’s States and the Northern Territory. I suggest that the current roadside drug testing regimes have been introduced with insufficient rigour in the underlying policy analysis. The authorities state that it is a road safety initiative and not about punishing drivers for using illegal drugs, but this assertion can be challenged. The research evidence linking particular levels of drugs in the body and driving impairment is limited, no convincing evidence exists demonstrating that roadside drug testing improves traffic safety at the population level, the initiative fails to target some of the drugs the use of which has been demonstrated to be a traffic safety risk, the opportunity costs seem to have been ignored, and it may well fail the human rights test of proportionality.
Conference presentations on roadside drug testing and Australia's National Drug Strategy
At the National Conference of the Australian Professional Society on Alcohol and other Drugs in Sydney I made two presentations. The first was a poster, co-authored with Dr Sally Hsueh-Chih Lai, titled Evaluating the 2004-2009 phase of Australia’s National Drug Strategy. A copy is here.
The second was a conference paper with the title Roadside drug testing: an example of a flawed policy analysis?. A copy of the Powerpoint presentation is here.
My theme was that roadside drug testing (also - incorrectly - called random drug testing) as implemented in most of Australia's states and territories is based on a flawed policy analysis:
Unclear goal specification: roadside drug testing purports to have as its aim improving road safety, i.e. reducing crash incidence & severity.
A program logic analysis suggests that we are unlikely to attain this goal from this intervention.
The research evidence also suggests that we are unlikely to attain this goal from this intervention.
We have no evidence of careful consideration of the opportunity costs or the relative cost-effectiveness of other interventions aiming to improve road safety.
The human rights considerations appear to have been ignored.
Prevention is finally on the agenda! In October the National Preventative Health Taskforce, which was appointed by the Commonwealth Government, released its first three discussion papers. The first, Australia: the healthiest country by 2020, deals with preventive health generally plus obesity, tobacco and alcohol. It was accompanied by three technical reports, separately covering obesity, alcohol (Preventing alcohol-related harm in Australia: a window of opportunity) and tobacco (Tobacco control in Australia: making smoking history).
These reports highlight our failure to come to term with prevention, and to implement what we already know works.
The discussion paper and technical reports are online at http://www.preventativehealth.org.au/ .
Does tobacco health promotion increase social inequalities?
A long-standing criticism of health promotion as it is usually implemented is that it maintains and, indeed, increases health inequalities. This is because its benefits are more likely to be attained by people in higher socio-economic classes as they have the resources to engage in health-promoting activities. Pleasingly, a new study has demonstrated that population-level tobacco control interventions do not adversely impact on social inequalities in smoking. Specifically:
'No strong evidence of differential effects was found for smoking restrictions in workplaces and public places, although those in higher occupational groups may be more likely to change their attitudes or behaviour. Smoking restrictions in schools may be more effective in girls. Restrictions on sales to minors may be more effective in girls and younger children. Increasing the price of tobacco products may be more effective in reducing smoking among lower-income adults and those in manual occupations, although there was also some evidence to suggest that adults with higher levels of education may be more price-sensitive. Young people aged under 25 are also affected by price increases, with some evidence that boys and non-white young people may be more sensitive to price.'
Thomas, S, Fayter, D, Misso, K, Ogilvie, D, Petticrew, M, Sowden, A, Whitehead, M & Worthy, G 2008, 'Population tobacco control interventions and their effects on social inequalities in smoking: systematic review', Tobacco Control, vol. 17, no. 4, pp. 230-7.
Today I gave a presentation on the topic 'Alcohol Policy in the ACT' (ACT = Australian Capital Territory) at the First Annual ACT Alcohol & Other Drug Sector Conference which was conducted as part of Drug Action Week by the ACT Alcohol & Other Drug Sector Project, of which I am a team members. It was held at the National Library of Australia, and featured prominent national authorities and Canberra-based experts discussing various aspects of alcohol policy and interventions.
The Conference was very well-attended - a full house - and was judged by both organisers and participants to be a great success.
I noted the history of alcohol policy in Canberra, commencing with the period of prohibition, through to the present situation where the relatively free availability of alcohol, and the adverse consequences flowing from it, have led the ACT Government to undertake a review of the Liquor Act. (I have contributed to that Review.)
My presentation to the Conference is available online.
Today I participated in a Public Forum at the University of Canberra on the topic of drugs and driving or drug driving. Its focus was RDT: roadside drug testing or random drug testing. It was organised by the ACT Department of Territory and Municipal Services (TAMS) and hosted by the Head of Pharmacy at the University of Canberra, Professor Gabrielle Cooper. In its promotion of the event, TAMS described the Forum as follows.
The Forum will provide an opportunity for the public to hear from
experts on the impact of drugs on driving, learn about random roadside
drug testing practice in other parts of Australia, and gain insight
into current research into drug driving.
The Forum will include presentations and general discussion by a
panel comprising University of Canberra researchers, a NSW Police
forensic pharmacologist, a member of the Victorian Police Traffic Drug
and Alcohol Unit, the ACT Human Rights Commissioner, ACT Government
Analytical Laboratory and a health-focussed social researcher.
I was the health-focussed social researcher referred to. My presentation was titled 'The Policy Context of Drug Driving Countermeasures' and sought to assess the degree to which the policy analysis underlying the proposed introduction of roadside drug testing in Canberra (and elsewhere) is based on a sound policy analysis, including the research evidence base and a program logic analysis. I conclude that it is not. My PowerPoint presentation is available here.
Uncertainty and risk in the alcohol and other drugs sector
The alcohol and other drugs sector is full of uncertainty: we have gaps in knowledge about the extent of drug use and harms, and what to do about them. We don’t know what is the right balance between prevention, treatment and law enforcement or between demand reduction, supply reduction and harm reduction. We are uncertain about matching client to treatment, and about the impacts of social marketing.
In the past, the main approach to uncertainty has been to attempt the impossible, namely to eliminate it. However, new ways of thinking about and addressing uncertainty and risk are being developed. An important new book edited by Australian National university scholars with whom I am associated through our work on Research Integration describes and discusses these: Bammer, G & Smithson, M (eds) 2008, Uncertainty and risk: multidisciplinary perspectives, Earthscan, London. A strength of the book is how it considers the issues from diverse disciplinary and practice stances, including from the alcohol and other drugs sector in a chapter by Drug policy Modelling Program Director Associate Professor Alison Ritter intriguingly titled ‘Heroin : injected with uncertainty’. Details are available from the publisher’s web site.
The effectiveness of peer education among people who inject illegal drugs
Australian readers might be be aware of the national hand-washing education campaign being conducted under the auspices of AIVL (the Australian Injecting & Illicit Drug Users League) using (among other things) ultra-violet light to demonstrate the extent and nature of contamination of the hands and injecting environments of people who inject illegal drugs. A USA study has investigated the effectiveness of this approach to peer education among people with hepatitis C, in a randomised controlled trial. They found that ‘Compared with the control group, intervention-group participants were less likely to report distributive risk behaviors at 3 months…and 6 months…a 26% relative risk reduction, but were no more likely to cite their HCV-positive status as a reason for refraining from syringe lending…Peer mentoring and self-efficacy were significantly increased among intervention-group participants, and intervention effects were mediated through improved self-efficacy’. This provides further evidence of the effectiveness of peer education among people who use the currently-illegal drugs. Latka, MH, Hagan, H, Kapadia, F, Golub, ET, Bonner, S, Campbell, JV, Coady, MH, Garfein, RS, Pu, M, Thomas, DL, Thiel, TK & Strathdee, SA 2008, ‘A randomized intervention trial to reduce the lending of used injection equipment among injection drug users infected with hepatitis C’, American Journal of Public Health, vol. 98, no. 5, pp. 853-61.
Are needlestick injuries an important OH&S issue for the staff of correctional services?
With the imminent opening of the Alexander Maconochie Centre, Canberra’s new prison, it is timely that Australian researchers have published an assessment of the extent of needlestick injuries among correctional officers.
The study was conducted in two Australian states in 2006 using a self report questionnaire. Two-thirds of the 246 prison officers who completed the survey reported that they had found needles and syringes in their prison workplaces and 10% of them (7% of the total sample) had experienced at least one needlestick injury during their prison officer career. Most of these injuries occurred during searches.
Fortunately, serological testing for blood-borne viral infections following injury was common, but less than half the injured officers accessed support services.
The authors point out that ‘There have been no published reports of prison officers acquiring [blood-borne viral infections] via accidental needlestick injuries’ (p. 165) and that ‘A pragmatic, inexpensive intervention for reducing the risk of needlestick injuries is the introduction of needle and syringe programs (NSP) in prisons. Prisons in at least six countries, including Spain, Switzerland and Germany, offer sterile equipment to drug injecting inmates. Needles and syringes held by the inmate must be stored in a rigid container in a designated area of the inmate’s cell, reducing the risk that an officer may receive a needlestick injury’ (p. 167).
They concluded that ‘Needlestick injuries appear to be a relatively rare occurrence, but may be further reduced by improving search techniques and equipment and regulating needles and syringes in prisons’.
Larney, S & Dolan, K 2008, 'An exploratory study of needlestick injuries among Australian prison officers', Int J Prison Health, vol. 4, no. 3, pp. 164-8.
Today I was the guest speaker at a packed Public Forum held at the Legislative Assembly for the Australian Capital Territory on the topic 'How Fear and Stigma Inhibit Good Health Policy'. It was organised by the Community Coalition on Corrections and hosted by Mr Simon Corbell MLA, ACT Attorney-General.
This is the first of a series of Public Forums organised to discuss issues concerning the Alexander Maconochie Centre, Canberra’s new prison that will open later in the year. As requested, my focus was on how stigma and discrimination are linked to the spread of blood-borne viral diseases,especially hepatitis C, hepatitis B and HIV/AIDS, particularly within prisons.
My PowerPoint slides and the audio of the presentation are here.
Withdrawing from nicotine and other drugs, and the cannabis withdrawal syndrome Clinicians have accepted for some years that a cannabis withdrawal syndrome exists, though the authorities who determine the disease taxonomies (such as the DSM and ICD systems) have been slower to acknowledge its reality. Researchers from the Johns Hopkins University School of Medicine in the USA have conducted a small study comparing the nature of withdrawal from cannabis and nicotine, both separately and concurrently, among heavy users of both drugs.
They concluded that ‘Overall withdrawal severity associated with cannabis alone and tobacco alone was of a similar magnitude. Withdrawal during simultaneous cessation of both substances was more severe than for each substance alone, but these differences were of short duration and substantial individual differences were noted’ (p. 48).
Also noteworthy is their reminder of how little we know about withdrawing from more than one drug at a time: ‘Interestingly, we could not locate another prospective study comparing withdrawal severity during cessation from one versus more than one drug simultaneously’ (p. 53).
Vandrey, RG, Budney, AJ, Hughes, JR & Liguori, A 2008, 'A within-subject comparison of withdrawal symptoms during abstinence from cannabis, tobacco, and both substances', Drug and Alcohol Dependence, vol. 92, no. 1-3, pp. 48-54.
Illicit drug policy: scoping the interventions and taxonomies For some years I have been involved with the Australian national Drug Policy Modelling Project (DPMP). The Director of the DPMP, Assoc. Professor Alison Ritter and I have recently published an article in which we review the many taxonomies of (national) drug policies, and explore how the diverse interventions dealing with drug issues map to the taxonomies.
Ritter, A & McDonald, D 2008, 'Illicit drug policy: scoping the interventions and taxonomies', Drugs: education, prevention and policy, vol. 5, no. 1, pp. 15-35.
Illicit drug policy interventions cover treatment, law enforcement, prevention and harm reduction. This paper provides a comprehensive list across these sectors, of known drug policy interventions. One hundred and eight interventions were identified. With such a long and undifferentiated list of drug policy interventions, the ways in which these interventions are then coded and classified is also addressed. Ten different classification schemes are reviewed including summary information on the original sources and backgrounds to the schemes. The authors rated each of the policy interventions against the schemes. Those which proved useful in summarising illicit drug policy interventions included the four pillars approach, the UNODC classification, the demand, supply and harm reduction paradigm, the public health model and the policy instruments model. The list of 108 policy interventions will be of use to policy makers, researchers and practitioners in appreciating the array of drug policy options, and could be used in reviews of policy or practice. The classification schemes reveal the different ways in which drug policy interventions can be clustered and described to different audiences.
How effective is drug treatment? Controversy still exists about the effectiveness of standard treatments of opioid (including heroin) dependence. These important Australia treatment outcomes findings have just been published demonstrating the high levels of successful treatment outcomes seen in Australia: Teesson, M, Mills, K, Ross, J, Darke, S, Williamson, A & Havard, A 2008, 'The impact of treatment on 3 years' outcome for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS)', Addiction, vol. 103, no. 1, pp. 80-8.
Aim: To examine the impact of treatment for heroin dependence on drug use, injection-related risk-taking, health problems, criminality and general physical and mental health over 3 years among heroin-dependent Australians. Design: Longitudinal prospective cohort study. Participants: A total of 615 heroin users enrolled in the Australian Treatment Outcome Study; 94.5% of the sample completed at least one follow-up interview over 36-month follow-up. Findings: The proportion who reported using heroin in the preceding month continued to decrease significantly from baseline to 24-month follow-up (99% versus 35%), with this rate remaining stable to 36-month follow-up. The reduction in heroin use was accompanied by reductions in other drug use. There were also substantial reductions in risk-taking, crime, injection-related health problems and improvements in general physical and mental health. Positive outcomes were associated with more time in maintenance therapies and residential rehabilitation and fewer treatment episodes. Time spent in detoxification was not associated with positive outcomes. Major depression was also associated consistently with poorer outcome. Conclusions: At 3 years, there were impressive reductions in drug use, criminality, psychopathology and injection-related health problems following treatment exposure.
Is childhood socio-economic status associated with adult alcohol use? An important policy issue in this era of increasing acknowledgement of the social determinants of problematic drug use is the link between childhood socio-economic status and patterns of alcohol use in later life. A systematic review of evidence on this link was recently conducted by British researchers. A core finding is that we do not have sufficient quality data upon which to draw definitive, or even strongly indicative, findings:
'Nineteen relevant articles were identified…There was little consistent evidence to support an association between lower childhood SES and later (mis)use of alcohol….We found little robust evidence to support the assumption that childhood disadvantage is associated with later alcohol use/abuse. Given the importance of this issue in terms of policy, the lack of evidence is surprising and emphasizes the need for further research in order to inform future policies and public health messages.'
Wiles, NJ, Lingford-Hughes, A, Daniel, J, Hickman, M, Farrell, M, Macleod, J, Haynes, JC, Skapinakis, P, Araya, R & Lewis, G 2007, 'Socio-economic status in childhood and later alcohol use: a systematic review', Addiction, vol. 102, no. 10, pp. 1546-63.
Tobacco harm reduction: isn’t it time we got serious about this? An irony of Australia’s National Drug Strategy, since its inception, has been the embracing of harm reduction with regard to alcohol and the illegal drugs, but not with regard to the greatest killer of all, tobacco. This was the subject of an editorial in a recent issue of the International Journal of Drug Policy. The editorialists canvassed the issues, discussed what they see as the public health profession’s denial of the positive roles of tobacco harm reduction, and concluded:
‘We can reduce tobacco related death and disease far more rapidly than we can reasonably expect to reduce nicotine use by focusing on the fact that people smoke for the nicotine but die from the smoke. Applying harm reduction principles to public health policies on tobacco/nicotine is more than simply a rational and humane policy. It is more than a pragmatic response to a market that is, anyway, already in the process of undergoing significant changes. It has the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century’ (p. 74).
Source: Sweanor, D, Alcabes, P & Drucker, E 2007, 'Tobacco harm reduction: how rational public policy could transform a pandemic', International Journal of Drug Policy, vol. 18, no. 2, pp. 70-4.
Evaluation of the National Drug Strategy: the process
I am a member of a team of researchers undertaking the evaluation of Australia's National Drug Strategy (NDS). The evaluation has been commissioned by the Commonwealth Department of Health and Ageing with the endorsement of the Ministerial Council on Drug Strategy.
On 7 August Dr Sally Lai and i, on behalf of the evaluation team, gave a presentation to the Australasian Evaluation Society International Conference, describing and discussing the processes involved. The central challenges are defining the evaluand (the scope of the National Drug Strategy and developing an evaluation strategy that deals explicitly with the NDS as a complex intervention. Our paper is available online: McDonald, D, Lai, SH-C, Miller, M-E, Hall, W, Cleary, G, Bush, R, Fowler, G, O’Connor, P, Sumner-Armstrong, C, Siggins, I, Bolton, M, Siggins, E & Price, K 2007, ‘Evaluating major national strategies in human services: challenges and possibilities - the case of Australia’s National Drug Strategy 2004-2009’, paper presented to Australasian Evaluation Society International Conference 2007, Melbourne 5-7 August 2007 .
Cannabis in Papua New Guinea Some years ago I undertook a Rapid Situation Assessment of drugs, drug use, drug abuse and responses to these in PNG. This review paper is an off-shoot of that study. Although the issue of the journal is dated 2004, it was only published this year.
McDonald, D 2004, 'Cannabis in Papua New Guinea', Pacific Health Dialog, vol. 11, no. 1, pp. 96-101.
This review covers published information on psychoactive drugs, particularly cannabis, in Papua New Guinea. Legal drugs are mentioned to place the illegal drugs into a broader public health context. Although a number of psychoactive drugs were used traditionally (and are used now), cannabis is the only illicit drug for which prevalence of use is currently not negligible. Very little epidemiology research on cannabis use and its individual and public health sequelae has been conducted, although a fuller criminology literature on the topic exists. The published cannabis use prevalence studies are limited in scope, and the most-cited one is of questionable accuracy. The complex interactions between the health of individuals and their social environments are highlighted by the destructive impacts that cannabis cultivation, trafficking and use are having in contemporary PNG.
Does alcohol consumption confer health benefits? Whether or not consuming alcohol in small quantities has a protective effect for coronary heart disease, and perhaps other health conditions, has long been of interest to epidemiologists and clinicians, with most studies supporting a protective effect for coronary heart disease. This has been confirmed in a new meta-analysis published this month. The study also concludes that 'Low levels of alcohol intake (1-2 drinks per day for women and 2-4 drinks per day for men) are inversely associated with total mortality in both men and women': Di Castelnuovo, A, Costanzo, S, Bagnardi, V, Donati, MB, Iacoviello, L & de Gaetano, G 2006, 'Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies', Archives of Internal Medicine, vol. 166, no. 22, pp. 2437-45, here. This review has already had an impact with clinicians.
In contrast, however, is the study published in April 2006 which presents reasonably convincing evidence that many of the studies that show the protective effects of alcohol consumption suffer from a systematic bias in the way they classify drinkers and abstainers: Fillmore, KM, Kerr, WC, Stockwell, T, Chikritzhs, T & Bostrom, A 2006, 'Moderate alcohol use and reduced mortality risk: systematic error in prospective studies, Addiction Research and Theory, vol. 14, no. 2, pp. 101-32, here.
It will be interesting to see how this body of evidence evolves.
I presented a paper Drugs, money and government: estimating ACT Government expenditures on preventing and responding to drug abuse at the ACT Biennial Public Health Forum 2006. The presentation was also based on the published paper listed below at 22.Mar.06.
I presented a paper 'Estimating ACT Government expenditure on preventing and responding to drug abuse at the APSAD National Conference: Drugs: Meeting New Challenges, in Cairns, Qld. The presentation was based on the published paper listed below at 22.Mar.06.
Canberra NGOs' roles in addressing alcohol and other drugs in correctional settings The NGOs working in the substance abuse and related fields in Canberra are concerned that the programs covering this area to be introduced to Canberra's new prison, the Alexander Maconochie Centre (currently under construction), are being developed without their involvement.
Accordingly, through Directions ACT, they commissioned me to prepare a background paper to assist them in scoping and focusing on the issues, and to prepare for consultations with the ACT Government and ACT Corrective Services.
I presented a paper at the International Evaluation Conference in Darwin, NT, on the topic Linking policy analysis and program evaluation: the Canberra syringe vending machines trial. It is available online.
Launch of Drug Policy Modelling Program Stage 2: Seminar 'Strategic approaches to illicit drug policy: Findings from the first stage of the Drug Policy Modelling Program' This was an important occasion for illicit drugs policy both nationally and globally. Members of the Drug Policy Modelling Program (DPMP) research team, Program Reference Group members and Technical Advisors, along with a large crowd of other AOD people, participated in the Launch at the University of NSW, Sydney. It was chaired by Professor Margaret Hamilton who established the program - she now describes herself as the Ambassador for the DPMP.
I gave a presentation on a DPMP study that I conducted with Assoc Prof Alison Ritter, the DPMP Director, titled 'Scoping drug policy interventions and taxonomies', based on DPMP Monograph no. 2: Drug policy interventions: a comprehensive list and a review of classification schemes.
Mr Andrew Brookes, Executive Officer of the Colonial Foundation Trust, who are funding the DPMP, formally launched Stage 2. Professor Hamilton and Associate Professor Ritter expressed the research team's thanks to Colonial Foundation Trust for its generosity and congratulated it on its far-sightedness in supporting what we believe will further develop into a body of research that will make an important contribution to improving illicit drug policy and policy responses.
Syringe Vending Machine Trial: preliminary findings The third progress report on Canberra's trial of syringe vending machines, along with the preliminary findings of the 12 month trial, have now been publicly released.
Overall, the trial has gone well. Here are some highlights: * The mean monthly number of Fitpacks sold in the first five months was 736 and in the following six months 1,082 * The syringe vending machines’ sales composed approximately 8.5% of all syringes sold or otherwise distributed over the 11 months through the various types of Canberra outlets * Some 575 kg of waste has been placed in the sharps disposal bins adjacent to the machines over the trial period to date * The trial commenced and has operated over its first 11 months with virtually no adverse comments from members of the public or from opinion leaders. The syringe vending machines seem to have been accepted by the Canberra community as a normal part of the ACT’s community health services.
Innovative drug policies in the Scottish criminal justice system While in Scotland this month I was able to make some observations about the criminal justice system’s responses to drugs. The Scots are innovative in this area, and are commended for their down-to-earth, realistic harm reduction approaches.
Apparently many Scottish police agencies, and at least one prison, offer sterile injecting equipment to detainees upon release from custody, acknowledging that some of them will inject illegal drugs soon after release, and that the risks in doing so will be reduced if they have sterile equipment. A description of the Lothian and Borders Police activities in this area is online. This is a press release that begins: ‘Lothian and Borders Police are piloting a needle exchange scheme for prisoners in a bid to reduce health risks to police staff and reduce harm to drug users’.
The Scottish Prison Service is investigating policy options for improved services for its drug-using prisoners, and is substantially increasing the treatment and rehabilitation services for them.
Congratulations are due to the Scottish police and corrections agencies for developing and implementing realistic, evidence-based policies on drugs.
Profiling the alcohol and other drug workforce With excellent co-operation from the Australian Capital Territory alcohol and other drugs agencies, I conducted an online survey of the ACT AOD workforce. The report of the study, ‘A profile of the Australian Capital Territory Alcohol and Other Drug Workforce, April 2006’, is online. All 12 ACT agencies participated; the estimated response rate was 66%, a high enough figure to obtain valid results.
Peer education resources and presentation The Melbourne-based Alcohol and Drug Foundation, through its Centre for Youth Drug Studies, has this year focussed on peer education as an intervention concerning both licit and illicit drugs. It has produced an excellent set of resource materials on the topic; these are available online. I provided a guest editorial ‘Peer education: “popular but not proven?”’ for their publication DrugInfo: Newsletter of the Australian Drug Foundation’s Prevention Clearinghouse, vol. 4, no. 3, available online at the same site.
On 11 April they ran a one-day DrugInfo Seminar: 'Peer Education as a Drug Prevention Strategy: What Works?.' I made an presentation with the title 'Evaluating peer education: whose values and which “gold standard”?' and a summary of this, along with the other presentations, is also available online.
In 2005 I was commissioned to prepare a literature review on school-based peer education: Alcohol and other drug peer education in schools: A review for the ACT Alcohol, Tobacco and Other Drug Strategy Evaluation Group. It is available online.
How much do governments spend on drug abuse? A particularly interesting consultancy assignment addressing this question was also completed this month for ACT Health. Its report, Australian Capital Territory Government Expenditure on Preventing and Responding to Drug Abuse, 2004-05, reveals that the Government spent at least AU$85 million that year in this area, which is some 3.2% of the total ACT Government budget for the year.
Approximately 77% of this went was expended on the criminal justice system with most of the balance being hospital expenditures on drug abuse and the costs of operating the government and non-government AOD agencies. The largest single expenditure area was ACT Policing, composing some 48% of the total.
Alcohol advertising An important study has recently been published on the impacts of alcohol advertising on consumption by young people. Its significance is that it is the first longitudinal study on the topic and provides powerful evidence of the relationship between alcohol advertising and drinking. It parallels the evidence for the relationship between tobacco advertising and smoking among youth.
The study is Snyder, LB, Milici, FF, Slater, M, Sun, H & Strizhakova, Y 2006, 'Effects of alcohol advertising exposure on drinking among youth', Archives of Pediatrics and Adolescent Medicine, vol. 160, no. 1, pp. 18-24.
The authors state: 'The results of the present large-scale national longitudinal study provide evidence that the amount of advertising expenditures in 15- to 26-year-olds’ media environment and the amount of advertising recalled related to greater youth drinking' (p. 22).
Australian Parliamentary Group for Drug Law Reform National Meeting presentation Today I participated in a National Meeting of the Australian Parliamentary Group for Drug Law Reform, held at Parliament House, Canberra. The National Convenor of the Parliamentary Group, Hon. Duncan Kerr SC, MP, chaired the meeting. The presenters were # Rev Harry Herbert: ‘Medically Supervised Injecting Centre’ # Hon Dr Mal Washer MP: ‘Zero tolerance: a practitioner’s point of view’ # Dr Andrew Byrne # David McDonald: ‘At the frontier of drug harm reduction: prisoners' rights to health & safety’
In my presentation I discussed the rights of prisoners to health and safety, emphasising how the United Nations General Assembly’s 1990 resolution on the Basic Principles for the Treatment of Prisoners and the Australian Corrective Services Ministers' Conference’s 2004 Standard Guidelines for Corrections in Australia both state that prison inmates are entitled to a quality of health care – preventive and curative – of a standard at least as high as that found in the community.
I indicated that all Australian corrective services are in breach of this principle in failing to provide an evidence-based preventive health service, namely needle syringe exchange programs (prison NSPs), in their institutions.
Publication of drug policy research reports I have been working for some years as a member of a multi-disciplinary, multi-centre research collaboration called the Drug Policy Modelling Project. It is based at Turning Point Alcohol & Drug Centre in Melbourne where the Project is headed by Dr Alison Ritter.
With colleagues Dr Gabriele Bammer and Ms Gabrielle Breen, I investigated aspects of illicit drugs policy. The results of the study may be downloaded, in summary form, from the link mentioned above – see Bulletin no. 3, Drug policy – mapping structures and enhancing processes.
With Dr Alison Ritter I also investigated the diverse taxonomies of drug policy responses; see Bulletin No. 5: Drug policy response schema.
Full reports on the study have been published and are available online. They include two that I have co-authored: Ritter, A & McDonald, D 2005, Drug policy interventions: a comprehensive list and a review of classification schemes, Drug Policy Modelling Project Monograph Series no. 2, and McDonald, D, Bammer, G & Breen, G 2005, Australian illicit drugs policy: mapping structures and processes, Drug Policy Modelling Project Monograph Series no. 4.
Completion of a project for Land & Water Australia This week we concluded a consultancy undertaken for the Social and Institutional Research Program of Land & Water Australia. Dr Gabriele Bammer of the National Centre for Epidemiology and Population Health at The Australian National University and I have been working with LWA staff and consultants to establish a Social and Institutional Advisory Function. Its purpose is to assist LWA people to gain access to sources of expertise on the social and institutional aspects of their work, and to incorporate it with the biophysical science inputs to natural resource management.
Prison NSP proposed for Canberra The Australian Capital Territory Minister for Health, Simon Corbell MLA, has announced that he will be proposing to his Cabinet colleagues that the new Canberra prison have a needle syringe program (NSP) as part of its comprehensive health plan.
Prison needle syringe program proposal Today a Public Forum was held in Canberra addressing the difficult topic of providing sterile injecting equipment to prisoners, i.e. operating a prison needle syringe program (NSP) (or needle exchange program NEP) in prisons. The impetus for this Forum was the impending decisions on the health services to be provided in the new Canberra prison, the Alexander Maconochie Centre, which is expected to open some time next year.
As one would expect, there was some difference of opinion on the desirability and feasibility of having a NSP in our new prison, with people from the public health community unanimously in support of it and those from the corrections area holding serious reservations.
As is commonplace in debates on illicit drugs, those advocating for the NSP in the prison presented the results of many high quality evaluation studies showing that these interventions are highly effective, without adverse unintended consequences. On the other hand, the conservative elements opposing the prison NSP proposal presented no research evidence at all supporting their position, simply stating that they are 'not convinced' by the evidence.
This is a classic case study of the challenges that we face in public health in converting scientific evidence into policy and practice.
I have an annotated bibliography of the key documents on this topic, many of which are available on-line. Please contact me if you would like a copy.
Also see their article in the excellent new International Journal of Prisoner Health: Lines, R, Jürgens, R, Betteridge, G & Stöver, H 2005, 'Taking action to reduce injecting drug-related harms in prisons: the evidence of effectiveness of prison needle exchange in six countries', International Journal of Prisoner Health, vol. 1, no. 1, pp. 49-64. This article is currently available online in full text, without charge, here. You need to register to get it.
Australian Professional Society on Alcohol and Drugs (APSAD) Conference Over the period 7-9 November I participated in the annual national conference of the Australian Professional Society on Alcohol and Drugs (APSAD) held in Melbourne.
I gave two oral presentations and one poster presentation. The abstracts follow.
School-based peer drug education: a policy analysis Peer education in schools, addressing alcohol, tobacco and other drugs, is being expanded nationally as an initiative of the Australian Government Department of Education, Science and Training. A policy analysis in this area was undertaken for Australian Capital Territory Government agencies. It concluded that the current widespread enthusiasm for school-based peer drug education does not adequately reflect the limited evidence base for its effectiveness. The implications of this conclusion for policy activity in the health and education sectors are discussed as an illustration of the sometimes problematic nature of the evidence-policy-practice nexus in the drugs field.
The evaluation of the AIVL National Hepatitis C Education Program (poster) AIVL (the Australian Injecting and Illicit Drug Users League) is the national peak organisation representing the Australian State and Territory-based drug user organisations and addresses issues of national significance for people who use illicit drugs. For some years it has been funded by the Australian Government to develop and implement a National Hepatitis C Education Program for people who use illicit drugs. This is a multi-faceted intervention, employing diverse messages and communication channels aimed at specific categories of people who use illicit drugs. I will describe the strategy used to evaluate the 2003-2005 phase of the Program, drawing particular attention to the utilisation of a program logic approach. The results of the evaluation, and their implications other formal hepatitis C education programs, will also be presented.
Initiating a trial of syringe vending machines in the Australian Capital Territory Syringe vending machines are a particularly controversial harm reduction intervention in most jurisdictions in Australia and abroad. The Government of the Australian Capital Territory has initiated a twelve month trial of syringe vending machines which will conclude in early 2006. The policy analysis underlying this intervention is described, along with the challenges facing evaluation research in this field and how they have been address in the trial’s evaluation. The preliminary findings of the trial will also be presented. This was a poster presentation.
Please contact me if you would like more information on any of these presentations.
