Studying for a postgraduate degree is strongly encouraged at NDARC. The involvement of theCentre staff in the supervision of postgraduate students has grown steadily over the years andNDARC offers both PhD and Masters Degrees by research in a wide variety of topic areas,depending on student background and interest.

Since 1994, when Nadia Solowij became the first NDARCian to be awarded her doctorate, therehave been 21 other postgraduate students who have submitted their theses. This includes CarolynDay and Peter Lawrinson who were both awarded their doctorates earlier this year.

Some examples of current PhD projects include:

Reducing alcohol related harm in rural communities in NSW

Heroin dependence and personality disorders

Evaluation of the health impacts of a medically supervised injection centre

Brief interventions for adolescent cannabis users

Health Service Evaluation: The regulation of injecting behaviour in Kings Cross

CLIMATE schools alcohol module: Evaluating the efficacy of a computer based preventativealcohol module for schools

Comorbid cocaine and heroin dependence

The important contribution that students make to the intellectual life of the Centre is recognised in this issue of CentreLines by having Katherine Mills write this month’s Issuing Forth. Here she isdiscussing some of the issues contained within her thesis which examines post traumatic stressdisorder among people with heroin dependence.

Many of our PhD students continue to work with us long after they have been awarded theirdoctorates. Some of these include some of our senior academic staff including Dr Jan Copeland, Dr Louisa Degenhardt and Dr Kate Dolan. These staff members, as well as other academics,continue to offer support and guidance to our current ‘crop’ of PhD candidates.

Paul Dillon, Editor

A bi-monthly newsletter from the National Centres for Drug and Alcohol ResearchPublished this issue by the National Drug and Alcohol Research Centre, Sydney

. . . . . . . . . . . . . . . . . . . . .1Paul Dillon introduces CentreLines

. . . . . . . . . . . . . . . . .2Director Richard Mattick discusses the development of Australia’s firstNational Cannabis Strategy

. . . . . . . . . . . . . .2In this month’s Issuing ForthNDARC PhD candidate, Katherine Mills, writes about post traumaticstress disorder (PTSD) amongst heroinusers, its impact upon treatmentoutcomes and the development of amore integrated treatment approach

. . . . . . . . . . . . .4The Methamphetamine TreatmentCohort Study

Evaluating the feasibility andeffectiveness of a computerisedschool-based prevention programaimed at reducing harmful alcoholconsumption and related harms: Acluster-randomised controlled trial

Examining drug use in pregnancyusing linked administrative data

. . . . . . . . . . . . . . . . . . .5Summaries of recently published articles

. .7

. . . . . . . . . . . . . . . . . . . . . . . .8staff list

recent publications

abstracts

project notes

issuing forth

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contents

NDARC (17)

October 2005

Funded by the National Drug Strategy

Registered by Australia Post – Print Post Publication No

PP236697/00013ISSN 1034-7259

CentreLines is a joint publication from theNational Drug and Alcohol Research Centre,Sydney and the National Drug ResearchInstitute, Perth. It is published bi-monthlyand produced alternately by each Centre.

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issuing forthPost traumatic stress disorder amongpeople with heroin dependence

National CannabisStrategyRichard Mattick

The Centre has recently been engaged by theAustralian Government Department of Healthand Ageing (AGDHA) to work on the developmentof what will be Australia’s first National CannabisStrategy. Cannabis is by far the most widelyused illicit drug in Australia; this widespread usemeans that the National Cannabis Strategy willbe a particularly important component of theNational Drug Strategy.

The current National Drug Strategy aims toprevent the uptake of harmful drug use andminimise drug-related harm. In keeping with thisunderlying philosophy, the National CannabisStrategy will need to focus on reducing theharm associated with cannabis use in thiscountry. In order to develop a strategy that willaim to minimise cannabis-related harm, a widevariety of issues need to be addressed thatinvolve a range of sectors in the community. Forexample, the education sector has an importantrole to play in preventing the use of cannabis byinforming young people about the harmfulaspects of the drug. The law enforcementsector is responsible for disrupting the supply ofcannabis. The health sector needs to be

involved in providing adequate treatment tothose who are dependent on cannabis.Additionally, researchers provide reliable andup-to-date information on a wide variety ofcannabis-related issues that help informgovernment policy and initiatives.

I have been appointed as the chair of theProject Management Group (PMG), which hasbeen established to lead the development ofthe Strategy. The PMG includes members of theAustralian National Council on Drugs, andrepresentatives from the health, education andlaw enforcement sectors. Four Reference Groupshave also been established to provide advice tothe PMG throughout the development of theStrategy. These Reference Groups include peoplewith knowledge and experience in four areasthat are particularly relevant to cannabis: MentalHealth; Treatment; Law Enforcement; and Research.

A Background Paper is currently beingdeveloped by staff at NDARC that provides anoverview of the cannabis situation in Australia atthe present time. This paper will provide thecontext for the National Cannabis Strategy. Itdraws on existing research and policydocuments and is guided by input from theNational Cannabis Strategy Reference Groups.

Given the range of issues that need to beaddressed, the development of the NationalCannabis Strategy needs to include a broad

consultation process. Representatives from arange of sectors have been invited to attendconsultation forums that are currently occurringaround the country. Attendees will have theopportunity to express their views on what shouldbe considered when developing the NationalCannabis Strategy during these forums.

Consultation forums are broad and inclusive.Forums are being held in all capital cities aswell as in at least one regional area in eachstate and territory. Invitations to attend theforums will be extended to: drug and alcoholworkers; criminal justice professionals includingpolice; representatives from all levels ofgovernment; researchers; educators; Indigenousrepresentatives; drug user groups; healthprofessionals; parent groups; and other relevantstakeholders. A special forum for canvassing theviews of young people is also being planned.

In addition to the face-to-face consultationforums, organisations and members of thegeneral community are able to submit theirviews in written form. Information about theNational Cannabis Strategy, including how tosubmit your views in written form, can be foundon the NDARC web site (http://ndarc.med.unsw.edu.au/ndarc.nsf/website/News).

The final National Cannabis Strategy will bepresented to the Ministerial Council on DrugStrategy in May 2006 for their consideration. cl

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Post traumaticstress disorderamong people withheroin dependenceKatherine Mills

Post traumatic stress disorder (PTSD) is ananxiety disorder that may develop followingexposure to extreme trauma, such as combatexperience, physical and sexual assault, beinginvolved in a life threatening accident or naturaldisaster, or any other event where the personperceives their own life or the life of another to be at risk. PTSD is characterised by anumber of distressing symptoms including re-experiencing the event, avoidance ofreminders of the event, increased arousal, and numbing of general responsiveness.

In the general population it is estimated thatapproximately 70% of adults will experience at least one traumatic stressor during theirlifetime, between 1-8% will meet DSM-IV criteriafor lifetime PTSD, and between 1-4% will meetDSM-IV criteria for current PTSD

1, 2. The

prevalence of trauma exposure and PTSD ishowever, much higher among people withsubstance use disorders, in particular heroindependence. Both disorders independently arechronic debilitating conditions. In combinationthey are associated with considerably greaterharm and poorer treatment outcomescompared to those with either disorder alone.This article outlines the extent of the problem,the harms associated with this comorbidity and its impact on substance abuse treatmentoutcomes, and describes the development of an intervention to treat this comorbidity.

Background There is a growing epidemiologic and clinicalliterature documenting the frequent co-occurrenceof PTSD among people with heroin dependence.The Australian National Survey of Mental Healthand Wellbeing (NSMHWB) found that one thirdof individuals with an opioid use disorder metcriteria for current PTSD, compared to 1% of thegeneral population

3. The prevalence of PTSD

was higher among individuals with an opioid usedisorder compared with all other drug classes.Similarly, the St Louis Epidemiologic CatchmentArea (ECA) study found that PTSD was higher

among individuals who had ever used heroin or cocaine compared to any other drug class

4.

Among clinical samples of people undergoingmethadone maintenance therapy (MMT) in theUnited States the rate of lifetime PTSD isestimated to be between 14-29% and the rate ofcurrent PTSD to be 20-31%

5-8. The only study to

examine the prevalence of PTSD among clinicalsamples in Australia has been the AustralianTreatment Outcome Study (ATOS)

9. Almost all

of the 615 participants (92%) had experiencedat least one extreme trauma, with the majority(81%) experiencing multiple traumas. Forty onepercent of the sample received a lifetimediagnosis of PTSD. Although an average of 12 years had passed since experiencing theirmost stressful event, 75% of those with PTSDhad experienced symptoms in the precedingyear. These proportions represent a significantnumber of people with heroin dependence whomay require additional treatment compared tothose with heroin dependence alone.

A number of hypotheses have been proposedto explain why elevated rates of PTSD are foundamong those with opioid and other substanceuse disorders. The self-medication hypothesispurports that following exposure to trauma,

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people use psychoactive substances to relievethe symptoms of PTSD, with many peoplepreferring opiates and other substances thatsuppress the central nervous system. Alternatively,heroin use and the lifestyle associated with it mayincrease the risk of trauma exposure, indirectlyincreasing the likelihood of subsequent PTSD. It isalso possible that there is no direct causal pathwaybetween PTSD and heroin dependence. It may bethat both disorders share common antecedents.For example, the presence of conduct problemsand antisocial behaviour increases the risk ofSUDs, trauma exposure, and PTSD. Bothdisorders could also share common geneticcauses or common neuropsychologic systems.

Regardless of which disorder came first, oncecomorbid heroin dependence and PTSD hasbeen established, they may both act to maintainor exacerbate the other. For example, PTSDsymptoms could promote and maintain therepeated use of heroin to ameliorate thesymptoms of PTSD. Repeated heroin use mayconcomitantly serve to maintain, prolong, orintensify PTSD symptoms by interfering with thenatural processing of trauma reactions orincreasing the likelihood of re-traumatisation.

Harms associated with comorbid PTSDPTSD places a significant burden on individualswith heroin dependence and presents asignificant challenge to treatment providers.Individuals with PTSD present to substanceabuse treatment with a more severe clinicalprofile compared to those without PTSD.Specifically, individuals with PTSD are less likelyto be employed, have more extensive polydruguse histories, report poorer general physicaland mental health, suffer greater psychiatriccomorbidity, and are more likely to have ahistory of overdose and attempted suicide

5, 8, 9.

Given this clinical profile it is unsurprising thatclinicians view this dual diagnosis as moredifficult to treat than either disorder alone. Theharms associated with this comorbidity highlightthe need for the assessment of PTSD amongtreatment entrants so that they may receiveappropriate treatment and referral.

Impact of PTSD on treatmentoutcomesGiven the clinical profile described above it isalso unsurprising that PTSD has consistentlybeen associated with poorer substance usetreatment outcomes. These include higherrelapse and readmission rates, more ongoingdrug use, and poorer psychosocial outcomes

6, 10-12.

Moreover, it appears that the poorer treatmentoutcomes found are specific to PTSD ratherthan to greater psychopathology in general

10.

The majority of these studies have however,been limited to small samples with very brieffollow-up periods (e.g., 3-6 months).

ATOS is the only study to examine the impact of PTSD on treatment outcomes for heroindependence over a two year period. Consistentwith previous research

6, 13, preliminary analysis

found no relationship between current PTSDand retention in maintenance therapy or thecompletion of detoxification. Current PTSD did

however, impact on treatment retention/completionin the short term for those in residentialrehabilitation. It is possible that some peoplewith current PTSD find the confrontation of issuesthat begins during the early months of residentialrehabilitation too challenging, resulting in higherdrop out rates. Individuals with current PTSDwere however, equally as likely to complete theprogram once past this point. Individuals withcurrent PTSD may need added support duringthe early stages of rehabilitation.

Current PTSD did not impact on any othertreatment outcomes; the pattern of change anddegree of change over time was the same forthose with and without PTSD. However, thosewith PTSD were more disabled at baseline andcontinued to be more disabled across the entiretwo year follow-up in terms of their physical andmental health, and their occupationalfunctioning. These findings are remarkable anda compliment to treatment providers; despitestarting off with a far sicker group of people theyare able to achieve the same improvements withboth those with and without PTSD. Nonetheless,the fact that individuals remain more disabledacross some areas indicates that the symptomsof PTSD and its associated disability remain,and suggest a need for the development of anintegrated treatment that addresses both disorders.

Development of an integratedtreatment for PTSDDespite PTSD being most prevalent amongpeople with heroin dependence compared toany other drug class, and a consensus in theliterature that both disorders should be treatedconcurrently, there are currently no treatmentprotocols available for the treatment of comorbidheroin dependence and PTSD. Although thereare a small number of treatment optionsavailable for the treatment of SUDs and PTSDmore broadly, many have been developed in theUnited States to treat specific populations suchas women

14, combat veterans

15, or individuals

with alcohol16

or cocaine dependence17.

Additionally, these protocols have not been wellresearched. To date, only “Seeking Safety” hasbeen evaluated in a randomised controlled trial,and two other protocols have undergoneuncontrolled pilot testing. Other treatments havebeen developed but have not been empiricallytested. Nonetheless, these psychotherapieshave offered an insight into which treatmentsmay be effective and demonstrate that it ispossible to implement treatments for PTSDamong people with substance use disorders.

A group of researchers from NDARC (KatherineMills, Maree Teesson, and Claudia Sannibale)and the PTSD Unit at Westmead Hospital (SallyHopwood and Prof Richard Bryant) are currentlydeveloping a treatment for PTSD, “TreatingTraumatic Stress,” among people who areheroin dependent. The CBT based interventionwill be designed for delivery alongside MMT.The intervention will combine successfulelements of existing psychological treatmentsfor heroin dependence, PTSD, and combinedtreatments. By addressing the symptoms ofPTSD it is hoped that the outcomes of thosewith PTSD could be improved. cl

References1. Kessler, R.C., Sonnega, A., Bromet, E., & Nelson,C.B. (1995). Posttraumatic stress disorder in theNational Comorbidity Survey. Archives of GeneralPsychiatry 52, 1048-1060.

2. Creamer, M., Burgess, P. & McFarlene, C. (2001).Post-traumatic stress disorder: Findings from theAustralian National Survey of Mental Health & Well-being. Psychological Medicine 31, 1237-1247.

3. Mills, K.L., Teesson, M., Ross, J., & Peters, L.(In press). Trauma, post traumatic stress disorder andsubstance use disorders: Findings from the AustralianNational Survey of Mental Health and Wellbeing.American Journal of Psychiatry In press.

4. Cottler, L.B., Comptom, W.M., Mager, D.,Spotznagel, E.L., & Janca, A. (1992). Posttraumaticstress disorder among substance users from thegeneral population. American Journal of Psychiatry149, 664-670.

5. Clark, H.W., Masson, C.L., Delucchi, K.L., Hall,S.M., & Sees, K.L. (2001). Violent traumatic eventsand drug abuse severity. Journal of Substance AbuseTreatment 20, 121-127.

6. Hien, D.A., Nunes, E., Levin, F.R., & Fraser, D.(2000). Posttraumatic stress disorder and short-termoutcome in early methadone maintenance treatment.Journal of Substance Abuse Treatment 19, 31-37.

7. Milby, J.B., Sims, M.K., Khuder, S., Schumacher,J.E., & Huggins, N. (1996). Psychiatric comorbidity:Prevalence in methadone maintenance treatment.American Journal of Drug & Alcohol Abuse 22, 95-107.

8. Villagomez, R.E., Meyer, T.J., Lin, M.M., & Brown,L.S. (1995). Post-traumatic stress disorder amonginner city methadone maintenance patients. Journal ofSubstance Abuse Treatment 12, 253-257.

9. Mills, K.L., Lynskey, M., Teesson, M., Ross, J., &Darke, S. (2005). Post traumatic stress disorderamong people with heroin dependence in theAustralian Treatment Outcome Study (ATOS):Prevalence and correlates. Drug and AlcoholDependence 77, 243-249.

10. Ouimette, P.C., Finney, J.W. & Moos, R.H. (1999).Two-year posttreatment functioning and coping ofsubstance abuse patients with posttraumatic stressdisorder. Psychology of Addictive Behaviors 13, 105-114.

11. Brown, P.J., Recupero, P.R. & Stout, R. (1995).PTSD substance abuse comorbidity and treatmentutilization. Addictive Behaviors 20, 251-254.

12. Brown, P.J., Stout, R.L. & Mueller, T. (1999).Substance use disorder and posttraumatic stress disordercomorbidity: Addiction and psychiatric treatmentrates. Psychology of Addictive Behaviors 13, 115-122.

13. Ouimette, P.C., Ahrens, C., Moos, R.H., &Finney, J.W. (1998). During treatment changes insubstance abuse patients with posttraumatic stressdisorder: The influence of specific interventions andprogram environments. Journal of Substance AbuseTreatment 15, 555-564.

14. Najavits, L.M. (2002). Seeking safety: A treatmentmanual for PTSD and substance abuse. New York:Guildford Press.

15. Donovan, B., Padin-Rivera, E. & Kowaliw, S. (2001).“Transcend”: Initial outcomes from a posttraumaticstress disorder/substance abuse treatment program.Journal of Traumatic Stress 14, 757-772.

16. Abueg, F. & Fairbank, J.A. (1992). Behavioraltreatment of posttraumatic stress disorder and co-occurring substance abuse. In: Saigh, P.A., (editor)Posttraumatic stress disorder: A behavioral approachto assessment and treatment. New York: MacmillanPublishing Company.

17. Back, S.E., Dansky, B.S., Carroll, K.M., Foa,E.B., & Brady, K.T. (2001). Exposure therapy in thetreatment of PTSD among cocaine-dependentindividuals: Description of procedures. Journal ofSubstance Abuse Treatment 21, 35-45.

The MethamphetamineTreatment Cohort StudyRichard Mattick, RebeccaMcKetin, Joanne Ross, ErinKelly, Grace Ho, and SarahStewart (NDARC), Robert Ali(Drug and Alcohol Services SouthAustralia and the University ofAdelaide), Dan Lubman(University of Melbourne), JakeNajman and Shelley Cogger(Queensland Alcohol and DrugResearch and Education Centre(QADREC), University ofQueensland), Amanda Baker(University of Newcastle), SharonDawe (Griffith University), NicoleLee (Turning Point Alcohol andDrug Centre), and Matthew Law(National Centre for HIV ClinicalEpidemiology and Research, UNSW)

Australia has a substantial and growingpopulation of dependent methamphetamineusers who inject or smoke the drug. In 2003/04there were 14,208 treatment episodes for‘amphetamines’ (including methamphetamineand amphetamine), placing the drug class infourth place after alcohol, heroin and cannabis.Despite the number of treatment admissions formethamphetamine use in Australia, there is adearth of information about the effectiveness oftreatment provided for methamphetamine use,and little research has examined thecharacteristics of people who enter treatmentfor methamphetamine dependence. Theexistence of comorbid mental health problemsamong this population is a particular concern.These problems impact on treatment outcomeand require treatment in their own right.

NDARC has recently received funding from the National Health and Medical ResearchCouncil (NHMRC) to investigate mental healthcomorbidity and treatment outcomes amongpeople who enter treatment formethamphetamine use in Australia. Themethodology of the study is based on thatemployed successfully by the AustralianTreatment Outcome Study (ATOS) to examinetreatment outcomes for heroin dependence.The methodology involves interviewing acohort of 300 people entering treatment formethamphetamine use in Sydney and an out-of-treatment comparison group of 100methamphetamine users from the samegeographic region. Treatment outcomes (i.e., abstinence, methamphetaminedependence, poly-drug use, psychiatric statusand other drug-related harms) will be examined3 months and 12 months post-treatment andcompared with baseline measures taken on

entry to treatment. Specific outcomes from theproject will include:

the prevalence of Major Depression, PanicDisorder, Agoraphobia, Social Phobia,Generalized Anxiety Disorder and psychoticsymptoms among methamphetamine usersentering treatment;

measurement of improvements in drug useand functioning following treatment formethamphetamine use by level of treatmentexposure; and

identifying factors predictive of positiveoutcomes, such as reduced drug use,improved mental health status, and reducedcriminal involvement.

The research project is a joint effort ofresearchers from NDARC, the QueenslandAlcohol and Drug Research and EducationCentre (QADREC), the Drug and AlcoholServices Council, Turning Point Alcohol andDrug Centre, the University of Melbourne, theUniversity of Newcastle, and Griffith University.The Australian Government Department ofHealth and Ageing have recently providedfunding to expand the study and includeBrisbane as an additional recruitment site. This arm of the study will be conducted incollaboration with QADREC. The study wasinitiated in June 2005 and will be carried outover four years, with an expected completiondate of June 2009.

Evaluating the feasibilityand effectiveness of acomputerised school-based prevention programaimed at reducing harmfulalcohol consumption andrelated harms: A cluster-randomised controlled trialLaura Vogl, Maree Teesson, PaulDillon and Bronwyn Steadman

Alcohol features prominently in Australiansociety. This is reflected by the 90% ofAustralians who report having consumedalcohol in their lifetime and just over 80% in thepast year. Most young Australians (i.e., 74% of14 -19 year olds) also report having consumedalcohol in their lifetimes. Of concern is the levelof alcohol related harm, to which many of theseyoung people expose themselves. Specifically,10% of 14-19 year olds report that in theprevious 12-months they consumed alcohol atlevels that placed them at greater than “low-level risk” of long-term alcohol related harms.More staggeringly, for those who had consumedalcohol in the previous 12 months, over 50%have consumed enough alcohol to place themat risk of short term harms, such as blackouts,hangovers, violence or unsafe sex. These

figures underscore the need for preventionprograms targeting risky levels of alcoholconsumption and alcohol related harms.

Obviously, the ideal time for alcohol preventionis in early adolescence, which for most, is priorto the experience of harm and theestablishment of harmful patterns of alcoholconsumption. The ideal location is in schools,where it is possible to capture large groups ofadolescents at one time. Although effectivealcohol prevention programs have beendeveloped for schools there have been majorobstacles encountered in their disseminationand implementation. Such obstacles include:

Poor packaging and marketing of evidence-based programs resulting in low use incomparison to other commercial(unevaluated) programs.

Insufficient resources and teacher training to implement evidence-based programs.

Incomplete and incorrect implementation.

The aim of the current project was to developand evaluate a computer driven preventionprogram based on a harm minimisationapproach, which would overcome the manyobstacles to implementation and disseminationin schools.

The interactive, computer-driven alcoholprevention module, Climate Schools: AlcoholModule was developed in collaboration withteachers, adolescents and experts in the field of drug and alcohol. Climate Schools: AlcoholModule was designed as an interactivecomputer driven package which ensurescomplete and correct implementation withoutthe necessity of extensive teacher training. Theevidence-based program consists of six lessonsdesigned to alter norms about the acceptabilityand prevalence of alcohol use and teach skillsto actively resist hazardous alcoholconsumption or manage the deleteriousconsequences. Climate Schools: AlcoholModule was designed to be embedded in thePersonal Development, Health and PhysicalEducation (PDHPE) curriculum to eradicate theneed for extra time and resources existingoutside the teaching of the standard curriculum.To capture the student’s attention and ensurethe relevance, the educational material andpractical activities are presented within thecontext of a teenage drama. In response toteacher’s requests, this module also includes anextensive selection of pre-prepared worksheetsand group activities to ensure that the learningand application of the material is interactive andis applied to real life situations. Thedevelopment of CLIMATE Schools: AlcoholModule was completed in March 2004.

The cluster randomised controlled trial to assessthe effectiveness of Climate Schools: AlcoholModule was commenced in April 2004. This trialinvolved the random allocation of 16 Catholicand Independent schools (n=1435 Year 8

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project notes

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students) to either receive the program or “drugeducation as usual”. Measures to assessefficacy included (1) regular alcoholconsumption, (2) hazardous levels of alcoholconsumption, (3) harmful consequencesassociated with alcohol consumption, (4)alcohol related expectancies and (5) alcoholrelated knowledge. Measures that couldpotentially mediate the effectiveness of thisprogram such as other drug use, depression,anxiety and perception of peer alcohol use werealso taken. The sample of 1438 students wassurveyed on four occasions at pre, post, 6 and12-month follow-up. The 24- month follow-up ofthese students remains to be conducted in June2006. Currently, the data is being entered andanalysed. Should Climate Schools: AlcoholModule be found to be effective in reducingalcohol consumption and related harms, it willprove to be an invaluable cost-effectiveresource which will overcome some of thecurrent obstacles to effective alcohol and otherdrug prevention in schools.

Examining drug use inpregnancy using linkedadministrative dataLucy Burns and Richard Mattick

Substance use in pregnancy is associated withpoor obstetric and perinatal outcomes includingsignificantly higher rates of stillbirth, foetalgrowth retardation, prematurity, first trimesterspontaneous abortion, premature delivery,meconium staining, maternal/neonatal

infections, neonatal withdrawal and neonatalmortality. Because of this, and as many of thenegative outcomes associated with thecontinued use of ‘street’ drugs such as poorhealth and nutrition and susceptibility to bloodborne viruses can also transmitted to the foetus,pregnant women are considered a prioritysubgroup to many treatment programs.

Despite being considered a priority group fortreatment there is only limited population levelinformation about the characteristics and needsof pregnant drug dependent women and thoseof their infants. To date most research has beenbased on case studies/series reports or smallselective samples from single sites. Drawinginferences and generalisations from thesestudies is problematic for a number of reasons.With respect to case reports and series,although useful in the formulation of questionsand hypotheses the small number of casesexamined means statistical associations cannotbe tested. Studies from specific treatmentagencies are limited in their generalisability dueto differences in the services provided byagencies and the different characteristics anddrug use patterns of their clients. These studiesalso often lack the statistical power to detectsignificant associations due to the small numberof pregnant drug dependent women seen inthese agencies.

An alternative method of examining the impactof substance use during pregnancy at thepopulation level is to use record linkage oflarge-scale population health databases.Record linkage involves bringing together

records from different sources, but relating tothe same individual. Previous studies usingrecord linkage have examined topics such asdeath and hospitalisation rates associated withthe use of illicit drugs. The present project aimsto expand that body of work by using linkedadministrative health data to describe theperinatal and obstetric outcomes associatedwith substance use in pregnancy. Linkeddatasets being examined are the NSWMidwives Data Collection, the NSW EmergencyDepartment Data Collection, the NSWPharmaceutical Drugs of Addiction System(PHDAS) and the NSW Inpatients StatisticsCollection. All the data has been linked by NSWHealth under strict privacy conditions andsupplied to NDARC as de-identified unit recordfiles. This project is funded by HERON (HealthEvaluation and Research Outcomes Network), acollaborative program auspiced by the SaxInstitute with The University of Sydney, TheUniversity of New South Wales, University ofTechnology Sydney, The Cancer Council NSWand NSW Health through NH&MRC grant #262121.

To date the project has examined the outcomesassociated with the use of alcohol, cannabis,stimulants and opioids in pregnancy and workis currently underway examining maternal andneonatal outcomes for women on the NSWmethadone program from 1992-2002. Byincreasing our knowledge of these outcomesthe project will assist in the identification of riskfactors and treatment needs of this mostdisadvantaged group of women and infants. cl

abstractsSurvey of Australiansusing cannabis formedical purposesHarm Reduction Journal 2, 18

Wendy Swift, Peter Gates and Paul Dillon

Background: The New South Wales StateGovernment recently proposed a trial of themedical use of cannabis. Australians whocurrently use cannabis medicinally do soillegally and without assurances of qualitycontrol. Given the dearth of local information onthis issue, this study explored the experiencesof medical cannabis users.

Methods: Australian adults who had usedcannabis for medical purposes were recruitedusing media stories. A total of 147 respondentswere screened by phone and anonymousquestionnaires were mailed, to be returned bypostage paid envelope.

Results: Data were available for 128participants. Long term and regular medicalcannabis use was frequently reported for

multiple medical conditions including chronicpain (57%), depression (56%), arthritis (35%),persistent nausea (27%) and weight loss (26%).Cannabis was perceived to provide “greatrelief” overall (86%), and substantial relief ofspecific symptoms such as pain, nausea andinsomnia. It was also typically perceived assuperior to other medications in terms ofundesirable effects, and the extent of reliefprovided. However, nearly one half (41%)experienced conditions or symptoms that werenot helped by its use. The most prevalentconcerns related to its illegality. Participantsreported strong support for their use fromclinicians and family. There was almost universalinterest (89%) in participating in a clinical trial ofmedical cannabis, and strong support (79%) forinvestigating alternative delivery methods.

Conclusions: Australian medical cannabis usersare risking legal ramifications, but consistent withusers elsewhere, claim moderate to substantialbenefits from its use in the management of theirmedical condition. In addition to strong publicsupport, medical cannabis users show stronginterest in clinical cannabis research, includingthe investigation of alternative delivery methods.

The impact of changes to heroin supply onblood-borne virusnotifications and injectingrelated harms in NewSouth Wales, AustraliaBMC Public Health 5, 84

Carolyn Day, Louisa Degenhardt,Stuart Gilmour and Wayne Hall

Background: In early 2001 Australia experienceda sudden and unexpected disruption to heroinavailability, know as the ‘heroin shortage’. This‘shortage has been linked to a decrease inneedle and syringe output and therefore possiblya reduction in injecting drug use. We aimed toexamine changes, if any, in blood-borne viralinfections and presentations for injecting relatedproblems related to injecting drug use followingthe reduction heroin availability in Australia, in thecontext of widespread harm reduction measures.

Methods: Time series analysis of State leveldatabases on HIV, hepatitis B, hepatitis Cnotifications and hospital and emergency

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department data. Examination of changes inHIV, hepatitis B, hepatitis C notifications andhospital and emergency departmentadmissions for injection-related problemsfollowing the onset of the heroin shortage; non-parametric curve-fitting of number of hepatitisC notifications among those aged 15–19 years.Results: There were no changes observed inhospital visits for injection-related problems.There was no change related to the onsetheroin shortage in the number of hepatitis Cnotifications among persons aged 15–19 years,but HCV notifications have subsequentlydecreased in this group. No change occurred inHIV and hepatitis B notifications.Conclusion: A marked reduction in heroinsupply resulted in no increase in injection-related harm at the community level. However, a delayed decrease in HCV notifications amongyoung people may be related. These changesoccurred in a setting with widespread, publiclyfunded harm reduction initiatives.

Recent trends in heroinsupply to markets inAustralia, the United Statesand Western EuropeInternational Journal of Drug Policy 16,293-299

Amy Gibson, Louisa Degenhardt,Carolyn Day and Rebecca McKetin

Heroin causes its users and the community adisproportionate amount of harm, and evidencesuggests that heroin markets have increased inscale over recent decades. Most of the world’sheroin is produced in South West (SW) Asia(Afghanistan in particular) and South East (SE)Asia (especially Myanmar), with a much smallerproportion produced in South America. The banon opium production in Afghanistan in 2000resulted in a substantial decrease in globalopium production for the following year and asharp increase in the wholesale price of opiumin Afghanistan. The current paper examines theprice of wholesale and retail heroin in the contextof general heroin market conditions in WesternEurope, the United States and Australia over the time that this reduction in opium supplyoccurred. Little evidence was found of a priceshift in these three heroin markets as aconsequence of the decrease in opiumproduction in Afghanistan. There was noconsequent shift in the overall price of heroin in either Europe or the United States. AlthoughAustralia did experience dramatic disruption toits heroin supply in 2001, and a large increase inthe price of heroin, this change was not directlyattributable to the reduction in opium productionin Afghanistan. Australian heroin markets aresupplied predominantly by SE Asia and theshortage of heroin and consequent price risewas related to regional drug supply factorsincluding local law enforcement activities. Inconclusion, the drastic reduction in global opiumproduction witnessed in 2000 did not directlyimpact on the prices of heroin in these threeestablished heroin markets. This observationhighlights the complexity of factors influencingdrug prices in destination heroin markets andsuggests caution in anticipating clear retail levelimpacts following changes in drug production.

Patterns of illicit drug use in NSW, Australiafollowing a reduction in heroin supplyInternational Journal of Drug Policy 16,300-307

Louisa Degenhardt, Carolyn Day,Stuart Gilmour and Wayne Hall

Objective: To examine whether a reduction inthe availability of heroin in New South Wales(NSW) in 2001 was associated with communitylevel changes in heroin and other drug use.

Method: Data from the NSW Alcohol and DrugInformation Service (ADIS) on the number ofpersons calling about different drug types wereused to examine NSW trends in calls of concernabout heroin and other drugs. ADIS is a 24-htelephone information and counselling service inNSW; data from ADIS has previously beenshown to be related to trends in drug use. Datafrom an inner Sydney needle and syringeprogram on drugs injected by clients were alsoused to examine time trends among a sentinelgroup of injecting drug users (IDU). Time seriesanalysis was used to model the series.

Results: There was a significant reduction incalls regarding heroin associated with thereduction in heroin supply. Increases in callsabout cocaine and methamphetamine were alsoassociated with the heroin shortage. Thereduction in calls about heroin appeared to besustained, whereas the increases in calls aboutcocaine and methamphetamine were not.

Conclusions: Decreases in heroin supply wereassociated with sustained decreases in the useof heroin at a community level. Substitution ofother drugs probably occurred among someusers, such substitution did not appear to besustained, as the number of calls returned topre-shortage levels.

Implications: Drug supply reduction may lead toincreases in use of other drug types. The healthimplications of such changes need to be bornein mind by law enforcement and health services.

Public opinion towardssupervised injectingcentres and the SydneyMedically SupervisedInjecting CentreInternational Journal of Drug Policy 16,275-280

Hla-Hla Thein, Jo Kimber, LisaMaher, Margaret MacDonald andJohn M. Kaldor

Objective: To describe public opinion towardssupervised injecting centres (SICs) and theSydney Medically Supervised Injecting Centre(MSIC) before and after the opening of the MSIC.

Methods: In 2000 and 2002, telephoneinterviews were conducted with 515 and 540residents and 209 and 207 businesses in KingsCross, Australia, 7 months before and 17months after the MSIC opened in Kings Cross.

Information was obtained on respondents’characteristics, knowledge of the MSIC, andagreement with SICs. Differences in publicopinion before and after the MSIC opened wereassessed using the chi-square statistical test.

Results: Two-thirds of the businesses and halfthe residents knew the correct location of theSydney MSIC in 2002. The level of support forestablishment of a MSIC in Kings Cross (68–78%,p < 0.001) and other areas of high-drug use(71–80%, p = 0.003) increased significantlyamong residents between 2000 and 2002. Bothgroups were more likely to disagree than agreethat SICs would encourage illicit drug injection.

Conclusion: Public opinion towards SICs andthe establishment of the MSIC generally wassupportive in the short-term. Assessing whetherthis level of support is sustained over time willinvolve further research that demonstrates thebenefits and effectiveness of such facilities.

The impact of the SydneyMedically SupervisedInjecting Centre (MSIC)on crimeDrug and Alcohol Review 24, 173-184

Karen Freeman, Craig Jones,Don Weatherburn, Scott Rutter,Catherine J Spooner and NeilDonnelly

The current study aimed to model the effect ofAustralia’s first Medically Supervised InjectingCentre (MSIC) on acquisitive crime and loiteringby drug users and dealers. The effect of theMSIC on drug-related property and violentcrime was examined by conducting time seriesanalysis of police-recorded trends in theft androbbery incidents, respectively. The effect of theMSIC on drug use and dealing was examinedby (a) time series analysis of a special proxymeasure of drug-related loitering; (b)interviewing key informants; and (c) examiningtrends in the proportion of Sydney drugoffences that were recorded in Kings Cross.There was no evidence that the MSIC trial led to either an increase or decrease in theft orrobbery incidents. There was also no evidencethat the MSIC led to an increase in ‘drug-related’ loitering at the front of the MSIC after itopened, although there was a small increase in‘total’ loitering (by 1.2 persons per occasion ofobservation). Trends in both ‘drug-related’ and‘total’ loitering at the front of the MSIC steadilydeclined to baseline levels, or below, after itopened. There was a very small but sustainedincrease in ‘drug-related’ (0.09 persons percount) and ‘total’ loitering (0.37 persons percount) at the back of the MSIC after it opened.Key informant interviews noted an increase inloitering across the road from the MSIC but thiswas not attributed to an influx of new users anddealers to the area. There was no increase inthe proportion of drug use or drug supplyoffences committed in Kings Cross that couldbe attributed to the opening of the MSIC. Theseresults suggest that setting up an MSIC doesnot necessarily lead to an increase in drug-related problems of crime and public loitering.

page seven

For more information on or copies ofthese publications, please contact therelevant researcher

Technical Reports and MonographsGibson, A. & Degenhardt, L. (2005). Mortalityrelated to naltrexone in the treatment of opioiddependence – a comparative analysis.Technical Report 229. Sydney: National Drugand Alcohol Research Centre.McKetin, R., McLaren, J., Kelly, E., Hall, W., &Hickman, M. (2005). Estimating the number ofregular and dependent methamphetamine usersin Australia. Technical Report 230. Sydney:National Drug and Alcohol Research Centre.

Published Articles,Chapters & BooksCopeland, J. (2005). Addiction and Life Course(book review). Addiction 100, 1032-1033.Copeland, J. (2005). Cannabis problems andtheir management. Drugs and Alcohol Today5(2), 20-25.Darke, S., Ross, J. & Teesson, M. (2005).Twelve-month outcomes for heroin dependncetreatments: does route of administration matter?Drug and Alcohol Review 24, 165-171.Day, C., Degenhardt, L., Gilmour, S., & Hall, W.(2005). The impact of changes to heroin supplyon blood-borne virus notifications and injectingrelated harms in New South Wales, Australia.BMC Public Health 5:84. Degenhardt, L. (2005). Illicit drug usersrespond to price changes (book review). NordicStudies on Alcohol and Drugs 22, 185-188.

Degenhardt, L., Conroy, E., Day, C., Gilmour,S., & Hall, W. (2005). The impact of a reductionin drug supply on demand for and compliancewith treatment for drug dependence. Drug andAlcohol Dependence 79, 129-135.

Degenhardt, L., Copeland, J. & Dillon, P. (2005).Recent trends in the use of ‘club drugs’: AnAustralian review. Substance Use & Misuse 40,1241-1256.

Degenhardt, L., Day, C., Conroy, E., Gilmour,S., & Hall, W. (2005). Age differentials in theimpacts of reduced heroin: effects of a ‘heroinshortage’ in NSW, Australia. Drug and AlcoholDependence 79, 397-404.

Degenhardt, L., Day, C., Gilmour, S., & Hall, W.(2005). Patterns of illicit drug use in NSW,Australia following a reduction in heroin supply.International Journal of Drug Policy 16, 300-307.

Degenhardt, L., Day, C., Dietze, P., Pointer, S.,Conroy, E., Collins, L., & Hall, W. (2005).Effects of a sustained heroin shortage in threeAustralian states. Addiction 100, 908-920.

Degenhardt, L., Hall, C., Day, C., Dietze, P.,Collins, L., & Pointer, S. (2005). Mapping theconsequences of an unanticipated drug supplychange of uncertain origins: responses to thecommentaries. Addiction 100, 930-932.

Degenhardt, L., Roxburgh, A. & Barker, B. (2005).Underlying causes of cocaine, amphetamineand opioid related deaths in Australia. Journalof Clinical Forensic Medicine 12, 187-195.

Dillon, P. (2005). Over The Influence, The HarmReduction Guide for Managing Drugs andAlcohol (book review). Drug and Alcohol Review24, 290-291.

Freeman, A., Jones, C.G.A., Weatherburn,D.J., Rutter, S., Spooner, C.J., & Donnelly, N.(2005). The impact of the Sydney MedicallySupervised Injecting Centre (MSIC) on crime.Drug and Alcohol Review 24, 173-184.Gibson, A., Degenhardt, L., Day, C., &McKetin, R. (2005). Recent trends in heroinsupply to markets in Australia, the United Statesand Western Europe. International Journal ofDrug Policy 16, 193-299.Lawrinson, P., Copeland, J. & Indig, D. (2005).Development and validation of a briefinstrument for routine outcome monitoring inopioid maintenance pharmacotherapy. Drugand Alcohol Dependence 80, 125-134.Martin, G., Copeland, J. & Swift, W. (2005).The Adolescent Cannabis Check-up: feasibilityof a brief intervention for young cannabis users.Journal of Substance Abuse Treatment 29,207-213.O’Brien, S. & Swift, W. (2005). Mental healthand adolescent cannabis use. Sydney: NSWDepartment of Education and Training.Shewan, D., Stover, H. & Dolan, K. (2005).Injecting in prisons. In: Pates, R., McBride, A.& Arnold, K. (eds), Injecting illicit drugs, (pp 69-81). London: Blackwell Publishing. Spooner, C. (2005). Structural determinants ofdrug use – a plea for broadening our thinking(Editorial). Drug and Alcohol Review 24, 89-92.Swift, W., Gates, P. & Dillon, P. (2005). Surveyof Australians using cannabis for medicalpurposes. Harm Reduction Journal 2:18.Thein, H., Kimber, J., Maher, L., MacDonald,M., & Kaldor, J. (2005). Public opinion towardssupervised injecting centres and the SydneyMedically Supervised Injecting Centre.International Journal of Drug Policy 16, 275-280.

recent publications

Twelve-month outcomesfor heroin dependencetreatments: does route of administration matter?Drug and Alcohol Review 24, 165-171

Shane Darke, Joanne Ross andMaree Teesson

A sample of 442 heroin users (394 injectingheroin users: IHU, 48 non-injecting heroin users:NIHU) recruited for the Australian TreatmentOutcome Study were reinterviewed at 12 monthsafter entrance to treatment for heroindependence. Route of administration was stableover the follow-up period with 4% of NIHUhaving made a transition to heroin injecting, and 0.3% of IHU having made a transition tonon-injecting. Given the clinical profile of NIHUpresented in the literature, it might be expectedthat they would exhibit better treatment retentionand 12-month outcomes than IHU. At 12months, however, there were no differencesbetween NIHU and IHU in heroin use, heroindependence symptoms, polydrug use,

criminality, current self-reported physical healthor psychopathology. The only group differencesat 12 months were that NIHU were more likely to be employed and had fewer injection-relatedproblems. It is concluded that, among thosepresenting for treatment, route of administrationis not an indicator of likely outcome.

Age differentials in theimpacts of reducedheroin: Effects of a“heroin shortage” in NSW, AustraliaDrug and Alcohol Dependence 79, 397-404

Louisa Degenhardt, Carolyn Day,Elizabeth Conroy, Stuart Gilmourand Wayne Hall

Background: This paper uses a unique event, theAustralian heroin shortage, to see whether anabrupt, substantial and sustained change in heroinsupply had different effects on harms related toheroin use among younger and older heroin users.

Method: Indicator data were examined by agegroup on the number of persons enteringtreatment for heroin and amphetaminedependence, arrests for heroin use/possessionand number of drug related deaths in NSW,Australia. Data were analysed using timesseries analysis.

Results: There was a 41% reduction in thenumber of new registrations for opioidpharmacotherapy per month among 25–34 yearolds, and a 26% reduction among 15–24 yearolds, but no apparent changes among older agegroups. Similarly, reductions in the number of non-pharmacological heroin treatment episodes weremost pronounced among younger age groups.There was a 49% reduction in the number ofheroin possession/use offences among thoseaged 15–24 years, compared to declines of31–40% among older age groups. Declines inheroin related deaths were greatest among 15–24year olds (65% reduction). There was no changein other drug related deaths in any age group.

Conclusions: A reduction in heroin supply wasfollowed by greater reductions in heroin relatedharms among younger than older people,across a number of outcome domains. cl

National Drug andAlcohol Research CentreStaff as of 1 October, 2005Richard Mattick Director, ProfessorMaree Teesson Deputy Director, AssociateProfessorShane Darke Associate ProfessorJan Copeland Senior LecturerLouisa Degenhardt Senior Lecturer Kate Dolan Senior LecturerLucy Burns LecturerJoanne Ross LecturerWendy Swift LecturerDelyse Hutchinson Research FellowPeter Lawrinson Research FellowRebecca McKetin Research Fellow Claudia Sannibale Research FellowAnthony Shakeshaft Research FellowEva Congreve ArchivistPaul Dillon Media Liaison/InformationManagerStuart Gilmour Statistical OfficerMarian Shanahan Health EconomistHeli Wolk Professional OfficerCourtney Breen Senior Research OfficerElizabeth Conroy Senior Research OfficerCathy Finney Lamb Senior Research OfficerAmy Gibson Senior Research OfficerCherie Kam Senior Research OfficerSharlene Kaye Senior Research OfficerGreg Martin Senior Research OfficerEtty Matalon Senior Research OfficerJen McLaren Senior Research OfficerSusannah O’Brien Senior Research OfficerHeather Proudfoot Senior Research OfficerAmanda Roxburgh Senior Research OfficerFiona Shand Senior Research OfficerJames Shearer Senior Research OfficerJenny Stafford Senior Research OfficerKate Hetherington Doctoral CandidateDevon Indig Doctoral CandidateLaura Vogl Doctoral CandidateMaria Agaliotis Research OfficerEmma Black Research OfficerMatthew Dunn Research OfficerPeter Gates Research OfficerAlys Havard Research OfficerGrace Ho Research OfficerErin Kelly Research OfficerBriony Larance Research OfficerSarah Larney Research OfficerElizabeth Maloney Research OfficerCaitlin McCue Research OfficerKatherine Mills Research OfficerEdmund Silins Research OfficerSarah Stewart Research OfficerMichelle Torok Research OfficerAnna Williamson Research OfficerElissa Wood Research OfficerCate Wallace Public Health Officer TraineeRox DeLuca Administrative AssistantJulie Hodge Administrative Assistant/

ReceptionistJosephina Kim Personal Assistant to DirectorCarla Santos Administrative Assistant/

Receptionist

Conjoint AppointmentWayne Hall Visiting ProfessorJames Bell Associate ProfessorAndrea Mant Associate ProfessorCatherine Spooner Senior LecturerAdam Winstock Senior LecturerAlex Wodak Senior LecturerMark Montebello Lecturer

Visiting FellowsRobert Ali Visiting FellowJohn Howard Visiting FellowJohn Lewis Visiting FellowIngrid Van Beek Visiting Fellow

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