Submission in response to the Australia’s National Drug Strategy
Beyond 2009 Consultation Paper
Associate Professor Tricia Nagel
Dr Rama Jayaraj
Anthony Ah Kit
Valerie Thompson
Neil Spencer
Menzies School of Health Research
John Mathews Building
Royal Darin Hospital Campus
Casuarina
NT 0810
This submission represents the view of the above individuals rather than the institution.
Introduction
The Northern Territory (NT) demonstrates many of the hazards of problem drinking in
Australia. We have the highest estimated rates of per capita alcohol consumption (Matthews
et al. 2002) and these high rates have persisted over many years (Chikritzhs et al. 2000;
Stockwell et al. 2000). Indigenous people comprise 32% of the NT population but suffer
much higher proportions of the negative outcomes of substance misuse (Perkins et al. 1994)
(Kowalyszyn and Kelly 2003).
While the mortality rate due to alcohol has dropped nation wide, the rate of hospitalisations
from alcohol-caused injury and disease has rapidly increased. The leading cause of
hospitalisations was alcohol dependence while alcohol-caused death was primarily associated
with alcoholic liver cirrhosis (National Drug Research Institute 2009). The percentage of
hospitalisations among Indigenous males for conditions associated with high levels of alcohol
use were between two and seven times higher than for non-Indigenous males in 2002–2003
(Overcoming Indigenous Disadvantage: Key Indicators 2005).
There remains a significant gap in our knowledge and understanding of the link between
alcohol misuse and harm, especially in remote communities (Gray et al. 2006; Matthews et al.
2002). Our knowledge of the trends in substance use in remote communities is also limited
(Clough et al. 2002) and little is known about the association between problem drinking and
assaults (Kelly and Kowalyszyn 2003).
It is not known to what extent alcohol use directly leads to violence. What is known is that
while alcohol consumption among all Territorians has been known to be consistently high
(Gray et al. 2000) (Matthews et al. 2002) and Darwin has long held the status of the highest
alcohol consuming capital in the world (Alcohol-Related Violence Growing in Darwin 2010)
alcohol related violence statistics have been rising.
Key Point
There is a need to understand the link between alcohol misuse and harm, especially in remote
communities.
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1
Changes over time
Alcohol consumption has only recently become an accepted social habit among Indigenous
Australians (Brady 1997). Today its consequences are unacceptable. Nation wide Indigenous
Australians are six times more likely than non-Indigenous people to drink at high-risk levels
(Chikritzhs and Brady. 2006). Indigenous men are more likely to consume alcohol at risky
levels than Indigenous women, while women are more likely to begin risky consumption at
younger ages (25-34 years) compared with Indigenous men (34-44 years) leading to major
health concerns in their child bearing years (National Aboriginal and Torres Strait Islander
Health Survey).
Colonisation has been linked with suffering for Indigenous peoples which continues to the
present day. Racism and separation from family and land continues to impact upon the health
of Indigenous people (Kowanko I et al. 2004; Paradies Y 2006; Zubrick SR et al. 1995).
Substance misuse is one of the many negative social consequences of the avalanche of change
experienced since the first settlers arrived. The pattern of drinking, too, is linked with history
and cultural conflict. Binge drinking was encouraged by the lack of legal access for
Indigenous Australians to drinking venues (Ministerial Council on Drug Strategy 2006). This
prohibition was only lifted in the last few decades, thus there has only been a relatively short
span of time in which to develop and test successful treatment and intervention strategies.
There is a need for innovation which looks beyond the ‘disease’ and abstinence approaches of
the past, to an understanding of individual and community risk which calls for individual and
community wide strategies. While separation from family, land, and culture is linked with
emotional distress there is evidence that community development approaches to health
improvement which strengthen culture and empower communities have shown success
(Burgess P et al. 2008; Rowley K et al. 2000).
Historic and cultural factors have influenced the pattern of drinking and the severity of
alcohol related distress (Alati R et al. 2000). This has led to a multitude of approaches to
treatment. Attempts to harness Indigenous Australia’s cultural identity and cultural strength in
provision of harm reduction strategies have been limited. Often the time that is needed for
‘proper’ community consultation is not invested. Proper consultation is inclusive of the whole
community. Many current supply reduction strategies are merely prohibition in modern guise,
reminiscent of historic forms of social control and political oppression of Indigenous peoples.
The way forward will be to develop new approaches which strengthen cultural identity and
social inclusion, promote cultural continuity and challenge institutionalised racism (Kirmayer
L 2003; Murray R et al. 2002).
It is emotional distress and intergenerational trauma which usually drives substance misuse,
and emotional distress which is most often its hidden consequence. Conversely it is resilience
and well being which will provide protection from substance misuse and emotional distress
for current and future generations (Chandler M and Proulx T 2006; Chandler and Lalonde
1998). Strategies which promote wellbeing, identity and cultural continuity must be
implemented, whether community-wide, family focused or targeting individuals (Murray R et
al. 2002).
Key point
There needs to be greater recognition of the emotional distress which drives substance misuse
and exploration of community development strategies to build resilience.
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Alcohol related injury, assault and hospitalisation
Crime, hospital, inmate and community statistics provide insight into the problem of injury
and assault among Indigenous peoples. Nationally, homicide and violence accounted for 16%
of the Aboriginal and Torres Strait Islander injury burden (Anderson 2008). Violence was the
most common cause of hospital admission for injury in the NT (You and Guthridge 2005)
accounting for 38% of the total injury admissions for Indigenous people.
It is not clear to what extent these crimes are perpetrated by intoxicated people, or to what
extent victims and perpetrators are Indigenous, however Indigenous prisoners are vastly
overrepresented in the NT. They currently represent 82% (850) of the daily average prison
population. Evidence of the link between violence, assault and alcohol misuse is scant.
Reports from offenders clearly link alcohol in violent assaults and crime (Morgan and
McAtamney 2009). The Drug Use Monitoring Australia (DUMA) program reported that 50%
of all offenders detained by police across Australia in 2007 for disorder and violent offences
had consumed alcohol in the 48 hours prior to their arrest (Adams et al. 2007).
It is known that factors which influence transition from remote communities to Darwin are:
family violence, lack of housing, over crowding in communities and easy access to alcohol in
Darwin (Catherine and Eva 2008) and that the harm associated with high risk alcohol
consumption in Indigenous Australians includes family conflict, domestic violence and
assaults (Kelly and Kowalyszyn 2003; Kowalyszyn and Kelly 2003). Further, it has been
reported that most of the assaults against women in remote NT communities, are perpetrated
by a drunken husband or other family member (Barber et al. 1988).
Although the factors which render alcohol-fuelled violence more likely are not fully
understood, there is evidence that some places represent greater risk compared with others.
Both customers and employees of licensed premises are at more serious risk of becoming
involved in a violent incident than other locations (Graham and Homel 2008 ). Premises for
the consumption of alcohol and the location of assaults are always interconnected with much
greater rates of alcohol-related violence and fighting, particularly among non-indigenous
males, than any other setting (Poynton 2005; Teece and Williams 2000; Wells 2005)
(McIlwain and Homel 2009). In contrast, the close family members and friends involved in
the group drinking activity face greater risk in the Indigenous context, and it is likely that the
site for Indigenous assaults reflects where the drinking is taking place (bushes or private
homes or parks or narrow pathways). Whatever the drinking location, facial trauma is a
frequent end result of alcohol-fuelled violence.
Key point
There is a need to better understand the context of alcohol fuelled violence and the risk
factors for facial injury secondary to assault.
Alcohol-related facial trauma
Binge drinking is strongly linked with violence-related facial trauma (Gassner et al. 1999) and
high risk alcohol consumption is an important contributor to such trauma in the Indigenous
population. The incidence of facial fractures in the Northern Territory (more than 350 per
year) is by far the highest in the world. While only 32% of the population is Indigenous, 60%
of all facial fractures seen are in Indigenous patients and 89% of these are a result of interpersonal violence (Thomas and Jameson. 2007).
February 2010
3
Facial injury is often accompanied by emotional distress. In addition to the restoration of
physical appearance and functional status for those who face violent associated facial trauma,
there is also an urgent need for psychosocial care (Wong et al. 2007). There is an increasing
consciousness of the risk for posttraumatic stress disorder (PTSD) after the incidence of
violence-related facial injury (Bisson et al. 1997; Lento et al. 2004; Roccia et al. 2005a;
Roccia et al. 2005b) and depression is also reported as a result of facial injury (Hull et al.
2003a; Hull et al. 2003b; Levine et al. 2005). In this setting of emotional distress the
additional problem of substance misuse complicates rehabilitation (Passeri et al. 1993). In the
NT Indigenous population pathways to recovery will be further complicated by cultural
difference.
Key point
There is a need to develop integrated assessment and treatment for combined emotional
distress (and cultural and spiritual distress), alcohol misuse and facial injury
Strategies for change
A comprehensive array of supply reduction, harm reduction, and demand reduction strategies
are recommended in the complementary action plan of the national drug strategy addressing
Indigenous Australians. In the NT, a range of supply reduction strategies have been
introduced including: restricting take away sales, restricting cask sizes, and limiting trading
hours (d'Abbs and Togni 2000; Hogan et al. 2006).
The key take home message from The ‘Living with Alcohol’ program (1992 -2002) in the
Northern Territory (NT) was that interventions can make a difference, and that the
components of success include a focus on treatment services and broader awareness raising
campaigns linked with supply reduction through alcohol taxes (ChikritzhsT et al. 2004).
Turning to harm reduction strategies in the NT, these have generally focused on custodial care
and residential treatment. ‘Night patrols’ in Darwin often provide free transport to safe
locations such as sobering-up shelters or the police watch house for intoxicated rural and
remote Indigenous Australians under custodial care legislation. Sobering-up shelters are
neither detoxification centres, nor rehabilitation centres, but provide temporary refuge or
asylum for intoxicated individuals at risk of causing harm to themselves or others. They also
redirect intoxicated Indigenous population from police custody. Sobering-up centres provide
temporary care for high risk individuals and the opportunity for brief interventions by drug
and alcohol workers, and referrals for further assistance (Brady et al. 2006). They are only
one component of a comprehensive approach to harm reduction, however, and there is as yet
no evidence of effectiveness of these albeit limited interventions.
Key point
There is a need to explore the effectiveness of sobering up shelters and other options for
custodial care as harm reduction strategies.
Treatment for Indigenous substance misuse
Political and socio-cultural influences underpin the vulnerability of Australian Indigenous
peoples to high risk binge drinking. Strategies to address supply reduction must be mixed
with culturally adapted treatment approaches. These approaches need to directly address the
February 2010
4
underlying socio-political causes of emotional distress and substance misuse, which include
disempowerment and cultural discontinuity. They need to build an Indigenous workforce able
to advocate strongly and treat effectively using community, family and individual approaches
which promote cultural identity, kinship and the cultural values of Australian Indigenous
peoples.
In specialist treatment settings (rehabilitation services for example) culturally adapted
strategies for treatment and models of understanding have only recently begun to flourish
(Brady 2007; Brady M et al. 1998). Indigenous rehabilitation services have struggled with
issues of isolation secondary to political and historic influences (Alati R et al. 2000). This has
led to services which operate separate to mainstream with little evidence of effectiveness and
limited systems for self evaluation (Brady M 2002). As a result there is a strong push for
engagement of Indigenous services with mainstream services but a clear risk that adopting a
‘one size fits all’ approach will not work given differences of worldview, language and
literacy (Ministerial Council on Drug Strategy 2006). This risk will apply to outcome
measures as well. Measuring the success of interventions will require the application of
culturally valid outcome measures and acknowledgement that differences of world view and
cultural framework affect such measures.
There have been important recent attempts to investigate and explore culturally adapted
models of service delivery and outcome measurement (Nagel T 2007; Nagel T et al. 2008;
Schlesinger CM et al. 2007). These recent studies have resulted from exploration of the high
comorbidity of substance misuse with mental illness. This is a strong reason why a focus on
supply reduction must work hand in hand with development of treatment services. Limiting
the supply of one particular intoxicant will not address the underlying emotional distress
within individuals, families and communities that drives its use.
Key point
A focus on supply reduction must work hand in hand with development of treatment services
which nurture strong partnerships with Indigenous service providers and use culturally
validated outcome measures.
Evidence that culturally adapted treatment may be effective stems from a mixed methods
study in two remote communities in the NT. This study showed that participatory action
research can result in tools for treatment which can be developed and successfully applied in
resource-poor cross cultural settings. A brief psychological intervention was tested, using a
randomised controlled design, in the setting of comorbid substance dependence and mental
health and found to be effective (Nagel T 2007; Nagel T et al. 2008; Nagel T et al. 2009b;
Nagel T and Thompson C 2007). Concurrent development of Indigenous specific screening
tools has further added to the cross cultural resources available in the field (Schlesinger CM et
al. 2007).
Additional positive change in the field is the development of a community based Indigenous
workforce which is developing its own model of engagement with communities using
principles of community development combined with best practice in brief interventions
(Nagel T et al. 2009a). These two recent NT initiatives represent important new directions
toward engaging the strength of culture in development of resilience and resistance to
substance misuse.
February 2010
5
Key point
There is a need for evaluation and expansion of community preventive and treatment
initiatives which are developed in collaboration with Indigenous peoples and integrate
community development approaches.
Conclusion
Political and socio-cultural influences underpin the vulnerability of Australian Indigenous
peoples to high risk binge drinking. There is an epidemic of alcohol fuelled assault which is
frequently the result of family violence and is frequently complicated by facial injury. These
high rates of alcohol misuse and injury are likely to be driven by underlying distress and link
with high rates of mental and physical illness, social disadvantage and incarceration.
Strategies to address supply reduction must be mixed with culturally adapted treatment
approaches. These approaches need to directly address the underlying socio-political causes
of emotional distress and substance misuse, which include disempowerment and cultural
discontinuity. They need to build an Indigenous workforce able to advocate strongly and treat
effectively using community, family and individual approaches which promote cultural
identity, kinship and the cultural values of Australian Indigenous peoples.
Key point
Many of the above issues are specific to the context of Indigenous peoples and support the
relevance of a separate National Drug Strategy Aboriginal and Torres Strait Islander
Complementary Action Plan
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