The Royal Australasian College of Physicians (RACP) submission to the
National Drug Strategy Consultation Paper
March 2010
Acknowledgements
Physicians from the Australasian Chapter of Addiction Medicine who have
specialised knowledge of substance misuse disorders.
1
THE ROYAL AUSTRALASIAN COLLEGE OF PHYSICIANS
The Royal Australasian College of Physicians (RACP) is a Fellowship of more than
10,500 specialist physicians and 4,600 trainees who practise in more than 25
medical specialties including paediatrics, cardiology, respiratory medicine, general
medicine, neurology, oncology, public health medicine, occupational and
environmental medicine, rehabilitation medicine, palliative medicine, sexual health
medicine and addiction medicine. Beyond the drive for medical excellence, the RACP
is committed to developing health and social policies which bring vital improvements
to the well-being of patients. The College works to establish and achieve the highest
standards of contemporary knowledge and skill in the practice of medicine and
promote the health and well being of the community, and of its members. The
College, in collaboration with affiliated Specialty Societies, is the provider of
frameworks and standards of education for specialist physicians and Trainees.
2
The RACP welcomes the opportunity to present feedback from College members to
the National Drug Strategy (NDS) Consultation paper. The College would like to
congratulate the Ministerial Council on Drug Strategy (MCDS) for preparing the paper
and for conducting the evaluation which will allow us to better develop our
submission.
The College has worked in association with other medical colleges to develop a suite
of policies on addiction medicine issues that incorporate the social determinants of
health. These are the:

Prescription Opioid Policy

Alcohol Policy

Tobacco Policy

Illicit Drug Policy
These are all available on the College web site at
http://www.racp.edu.au/index.cfm?objectid=D7FAA378-C4E8-A2628B50B9D74850037D
The issues in the NDS consultation paper affect many of the College members as
most members would deal with the results of drug and alcohol morbidity and mortality
at sometime in a consultation process. In relation to this submission these particularly
involve the Division of Paediatrics & Childhealth as well as the Australasian Chapter
of Addiction Medicine. The College trains physicians in Addiction Medicine, which
was recently recognised by the Australian Medical Council and Minister for Health
and Ageing as a medical specialty.
The College has developed several training modules for physicians and other
medical practitioners to improve the treatment of drug and alcohol issues in the
community, particularly when pharmacotherapy is involved.
The College presents these comments as a summary of its views relevant to the
National Drug Strategy. The College would be interested to participate in draft plans
that emerge as a result of this consultation.
The College’s recommendations in this area focus on the following areas:
3
1. Ensuring there are clear and transparent process to declare any conflicts of
interest that may occur in the delivery of services, during presentations and in
publications of any written work in relation to drugs and alcohol;[1]
2. Presenting a strong evidence base for policy which also includes:
a. Social determinants of health[2]
b. Research[3-4]
c. Data collection[5-6]
d. Harm minimisation/reduction approach.[7]
3. Including early intervention as it relates to children, young people and their
parents or carers;[8-10]
4. Promoting community education and engagement[11]
5. Developing appropriate, relevant and evidence based resources for training
[12]
6. Supporting legislative measures[13-14]
a. Taxation
b. Sentencing[15-17]
7. Enhancing prevention efforts[18]
8. Enhancing treatment services particularly for women with children and their
rehabilitation options.[19-20]
Conflict of interest statement
No conflicts declared.
In the process of submitting this paper the College has restricted responses to the
questions asked by the National Drug Strategy Consultation group as well as
including some issues not included by the NDS.
4
Issues not addressed by questions posed in the consultation paper
Evidence based approach to policy
1.
The College would like to emphasise the importance for the National Drug
Strategy to be based on evidence. The need for this has been clearly
articulated by the Australian Prime Minister. There is now strong evidence
that the effectiveness of supply control for illicit drugs is not good, that
negative unintended consequences are very significant and that there is
almost no data on cost effectiveness. In contrast, the effectiveness of demand
and harm reduction for illicit drugs is generally much more impressive, that
negative unintended consequences are minor and some of the data on cost
effectiveness is very impressive.
Balance between supply, harm and demand reduction
2.
The College would like to support the need for funding for harm reduction in
particular funding for methadone and buprenorphine treatment and needle
syringe programs. Most literature on cost effective measures on harm
reduction focus only on supply and demand reduction and there is a lack of
balance for harm reduction programs that have been shown to be cost
effective.
Human rights and health
3.
The College would like more emphasis on a human rights approach in the
National Drug Strategy paper.[21] The UN system is based on a commitment
to three aspirations: economic development, national security and human
rights. The UN commitment to international action against illicit drugs while
important is not as high a priority as the commitment to human rights.
Australia would not have managed to control HIV among injecting drug users
without recognising and respecting their human rights. Respect for human
rights should also mean that Australia has no part in capital punishment
including collaboration with drug law enforcement authorities from other
countries where that could lead to capital punishment. This should also
influence Australia's actions in international arenas.
4.
Infants, children and young people
Early intervention involves providing advice or treatment before dependence has
occurred and long before end stage and irreversible complications have become
established. This involves pro-active identification, feedback regarding the nature and
5
extent of risks, clarification of goals and targets, provision of strategies and follow-up.
Different modes of brief alcohol interventions (BAI) have been found to be effective,
ranging from a less-than five-minute structured consultation where advice is given
about controlled drinking to a correspondence course by computer or mail.[22-23]
[24] Early intervention, sometimes also called BAI, is now supported by compelling
evidence of effectiveness in problem drinkers. A meta-analysis quotes brief
interventions in non-treatment seeking populations as improving given outcomes by
55 per cent compared with 45 per cent in controls.[25]
Education of medical students regarding the health effects of alcohol is important to
encourage their later adoption of screening, assessment and treatment of risky or
high risk levels of alcohol consumption in their patients and the general public in the
future.[26] It is also important to educate medical students about the need for their
involvement in community mobilisation about alcohol when they become doctors.
There are opportunities for early intervention in Australia as medical professionals
detect 30 per cent of alcohol-related problems. However, barriers to early
intervention include lack of time, perceived lack of training, uncertainty that BAI is
part of the medical role, reluctance to cause conflict with the patient, lack of specific
remuneration, and lack of feedback concerning outcomes which may not become
evident for some time.
Fetal Alcohol Spectrum Disorder (FASD)
FASD is not a diagnosis but comprises a number of diagnostic groups. Alcohol is
known to have teratogenic effects.[27] Drinking alcohol while pregnant increases the
risk of fetal problems developing, including all categories within Fetal Alcohol
Spectrum Disorder (FASD). Fetal alcohol syndrome (FAS) is a chronic disorder with
poor prognosis. There are no prevalence figures for FASD in Australia however the
birth prevalence data for (FAS) is low. [28] The prevalence in some Aboriginal
communities is estimated to be as high as 2.3 to 1.7 per 1000 live births, if cases
identified as partial FAS or alcohol-related neurodevelopmental disorder (ARND)
because of insufficient records, were assumed to have full FAS. In indigenous
children, the corresponding prevalence was calculated to be between 1.87 and 4.7
per 1000 live births. The difference between indigenous and non-indigenous rates of
FAS was significant (P < 0.0001).[29-31]
All pregnant women should be given information on the risks associated with drinking
alcohol during pregnancy and be advised that no level of alcohol consumption has
been determined as completely low risk for the fetus. The Australian Alcohol
6
Guidelines note that the first two to three weeks after conception, prior to the first
missed period, are probably the most crucial in relation to alcohol. During this period
it is unlikely the woman will know she is pregnant, particularly in the case of
unplanned pregnancy. For this reason, there is a strong need for education about low
risk drinking for all women of child-bearing age, including young women still at
school.
No high level evidence is available regarding the effectiveness of prevention and
early intervention programs for FASD. There is lower level evidence that professional
education improves obstetricians’ knowledge about FASD.[32] There is also limited
evidence that advocacy to enhance case management of at-risk mothers increases
their engagement and decreases their alcohol consumption.[33]
A systematic review of the literature of interventions for FASD reported that there
were some evidence to suggest that virtual reality training, cognitive control therapy,
language and literacy therapy, mathematics intervention and rehearsal training for
memory may be beneficial strategies. Three studies evaluating social communication
and behavioural strategies (two RCT) suggested that social skills training may
improve social skills and behaviour at home and Attention Process Training may
improve attention. [34]
Australian data suggest although up to 79- 65 per cent of women consume alcohol at
a high or risky level before or during early pregnancy, less than half of health
professionals routinely ask about alcohol use during pregnancy. Furthermore, selfreport of alcohol use may be unreliable and biochemical screening may be
appropriate to confirm alcohol use in high risk groups.[35-36]
Mothers of children with FASD often use a range of potentially harmful agents in
addition to alcohol, including nicotine, cocaine, heroin, solvents, methadone and
marijuana.[37] Children reported to the Australian Paediatric Surveillance Unit
(APSU) with FASD use multiple services. These include specialised paediatric, child
development, community, remedial education, respite and psychological medicine.
Case management alone is not sufficient: a model of para-professional advocacy for
at risk mothers has been developed which included the following interventions:[33]

public and professional education;
7

an alcohol and pregnancy information and crisis telephone line;

screening for alcohol use in prenatal clinics; and,

treatment programs for women who drink and children affected in utero.
This program resulted in increased knowledge of risks and early diagnosis and
referral for alcohol-related problems in pregnancy and infancy.[38] [39]
Children
In 2002, five per cent of 12 – 14 year-old children were at risk because of their own
alcohol consumption.[40] Most children are at risk because of risky or high risk levels
of alcohol consumption by adults, usually their parents.
Young people
Young people are particularly vulnerable to the harmful effects of alcohol because of
their lack of experience of drinking, and their frequent combination of high-risk
drinking with high-risk activity with a potential for accidental injury. Fortunately, most
teenagers drinking at high risk levels manage to survive a usually brief period of
adolescent turbulence without clinical interventions. Some, however, will continue to
drink at high risk levels and some will suffer irreparable harm.
Protective factors linked to positive outcomes, even when children are growing up in
adverse circumstances and are heavily exposed to risk, include:[41]

strong bonds with family friends and teachers;

healthy standards set by parents, teachers and community leaders;

opportunities for involvement in families, schools and the community;

social and learning skills to enable participation; and,

recognition and praise for positive behaviour.
There has been a significant increase in regular binge drinking (drinking at least 5
drinks in one session) to the point of intoxication in young Australians in recent years.
Drinking to the point of intoxication and therefore exposure to risk has become more
common among young Australians in recent years. This rise has been especially
dramatic in young women. [42-43] In 2004, 87 per cent of Australian students aged
18-19 years reported drinking at least weekly.[44] In 2004, of all young people aged
14-19, 19 per cent of males and 15 per cent of females drank at least once a month
at risky or high risk levels.[45]Comparisons between 1996 and 2003 surveys show
that the proportion of female adolescent drinking in excess of levels associated with
chronic harm increased from one per cent to 10 per cent.[46-47]
8
In Australia, 11.4 per cent of Aboriginal and Torres Strait Island youth aged 15 to 24year-olds reported high-risk alcohol consumption in the previous month.[48] The
weight of evidence in relation to the risk and protective factors being “predictors” of
harmful alcohol consumption highlights the importance of focusing on women and
children and future generations of Indigenous people.
Adolescents may be at risk because of parental domestic intoxication, and some
already report problematic alcohol consumption. Adolescents growing up in
households where one or both parents have a drinking problem are at greater risk of
developing a drinking problem themselves or becoming abstinent from alcohol.[49]
A longitudinal study of the health of women in Australia reported that the majority of
women did not change their level of alcohol consumption.[50] Most women who
reported consuming alcohol at all were doing so at low levels of long-term risk.[43]
Manifestations of early problematic alcohol use
Adolescence is a time of experimentation with many different types of risks, including
the risks of drinking immoderate amounts of alcohol. Deciding when an adolescent
has crossed the line and has developed a clinically pathological pattern of alcohol
consumption is difficult. Consequently the issue of drinking by teenagers is a source
of much anxiety for parents, medical profession and the community. Acute alcoholic
poisoning and episodes of severe intoxication (e.g. blackouts) with or without
physical and social harm are all early warning signs of serious problems emerging in
a young person.
In young people with a strong family history of alcohol-related problems, clinicians
should ask about alcohol use and advise parents to discuss the risks of heavy
drinking and the options available, including clinical interventions.[51] Follow-up of
these young people and their families is important and helps the adolescent to
manage their alcohol intake.[52]
There is growing evidence that family life during the critical developmental phases of
early childhood is a significant factor in building resilience and reducing the risk of a
range of subsequent social and behavioural problems, including problematic alcohol
use.[53] Children and young people are particularly vulnerable during times of
9
developmental change. Transition to high school can herald a period of high risk
drinking.[54]
Risk factors in childhood and adolescence do not guarantee that young people will
suffer from alcohol-related problems. The interaction between risk and protective
factors initiated during childhood and adolescence continues into adulthood and
reinforces the importance of prevention and early intervention. [55]
Identifying alcohol-related harm in young people
Effective engagement of young people by health professionals is a crucial first step in
identifying alcohol-related harm. It is important to ask ALL young people who present
to health services about the use of alcohol and other risk behaviours as part of a
general psychosocial screening interview. This needs to be performed in an openminded, non-judgmental, developmentally appropriate way that takes into account
the level of cognitive and psychosocial development of each individual adolescent.
Research shows that assurance of confidentiality at the beginning of a consultation is
important to encourage accurate disclosure of sensitive health information.
Interventions for adolescents
The results from the School Health and Alcohol Harm Reduction Project (SHAHRP,
Western Australia) support the use of harm reduction goals and classroom
approaches in school alcohol education.[56] The table at the end of this chapter
identifies interventions that have been shown to be effective in reducing alcohol and
drug consumption by young people.
There is good evidence that brief motivational interventions help to reduce alcohol
consumption among adolescent heavy or binge drinkers. Furthermore, there is
evidence that crisis intervention, harm reduction, assertive outreach and the building
of social support networks are associated with better outcomes.[45] A study of the
prevalence and quality of alcohol prevention services delivered to adolescents in the
United States reported clinicians providing inconsistent alcohol prevention services,
and a failure to incorporate the most effective educational methods. Reported rates
of universal screening and counselling were low, and younger adolescents were less
likely to receive services. The clinicians’ beliefs about their alcohol management
skills and perceptions of resource availability were the most consistent correlates of
higher quality service.[57]
10
5.
Justice and health
The College would like more emphasis on harm reduction for the population of prison
inmates serving sentences for drug related offences by greater use of non-custodial
sentences and other reforms.[58] Prisons should only be used as a last resort.
Evidence that incarceration changes the behaviour of drug users is lacking. Only
about one half of drug dependent heroin users in Australia who want to and should
be in methadone[59] and buprenorphine[60] treatment are currently in treatment.
[61] The 1961 and the 1971 international drug treaties both emphasised the need for
'parties' (i.e. countries) to strongly support treatment and rehabilitation. People on
methadone and buprenorphine treatment pay 30% of their low income as copayment - no other chronic condition pays as high a co payment. It costs about the
same to have a person serve a 12 month prison sentence as to have 30 patients on
methadone or buprenorphine treatment in the community.
A WHO document stated that prisoners should have access to prevention and
treatment health services which are at least as good as in the community.[62-63]
There is a high prevalence of prison inmates serving sentences for alcohol and drug
related offences, and therefore the College would like to suggest improved access to
treatment available in prisons than in the community. There is abundant evidence of
HIV and HCV transmission in prisons (including Australian prisons) yet we do not
have any needle syringe program in any prison in Australia. [64]
6.
Improved treatment services
The College suggests that people with an alcohol or drug dependence who want to
undergo detoxification have improved access to detoxification treatment and
management services. Many alcohol and drug dependent persons with social
support can manage with ambulatory detoxification but those who are homeless or
lack social support require residential care.
7.
The College would like more emphasis on strengthening self help options for
people with problems from alcohol, tobacco, prescription and illicit drugs.[65]
Self help such as telephone help lines[66], and internet sites [67]would have
substantial benefits for the community.
8.
The College suggests abandoning criminal penalties for personal possession
of cannabis and replaces these with administrative mechanisms or small civil
penalties.
11
9.
The College supports application of best evidence in the use of medicines.
The College recognises that cannabis is used by some to treat symptoms
such as chronic pain and nausea. The College supports research that may
lead to effective medical treatments and notes that cannabis or its ingredients
should be submitted to the same scrutiny as other medicines.
10.
The College would like to see supervised disulfiram considered for the PBS.
Australia should encourage much greater use of pharmacotherapies for
alcohol dependence.
11.
The College would like to suggest rehabilitation services becoming more
“family friendly” with improved options for mothers and children.[68]
12.
The College would like to see improved access to quality treatment services.
The Non-Government Organisation Treatment Grants Program (NGOTGP),
Illicit Drug Diversion Initiative (IDDI), Amphetamine-type Stimulants Grants
Program (ATSGP), and National Comorbidity Initiative (NCI) has all been
important in expanding access to quality treatment. The NGOTGP has been
particularly instrumental in increasing treatment services across the country.
Resources for illicit drug treatment services have been allocated on the basis
of sound processes that rely on collaboration at the jurisdictional level to
deliver reasonable information about local needs, gaps, and opportunities and
constraints in the Alcohol and other drugs (AOD) system. There is a need to
continue to increase capacity for collaborative needs-based planning, more
integrated seamless service delivery, data collection, performance monitoring
and review.[69]
12
1.
Emerging issues and new developments identified in this paper and how
they might impact on patterns of tobacco, alcohol, illicit drug use and the
misuse of licit substances (e.g. pharmaceuticals, performance and image
enhancing substances) in the next five years, and appropriate responses
to these patterns;

High risk and risky consumption of alcohol, illicit drugs and tobacco
smoking
Alcohol and tobacco tax reform
Alcohol and tobacco tax reform has proven to be cost effective and to have good
outcomes when dealing with high risk and risky consumption of alcohol and daily
cigarette tobacco smoking. [70] This strategy was mentioned in the 2006 the Royal
Australasian College of Physicians (RACP) policy on alcohol and tobacco.[71-73]
There is now a body of literature that demonstrates that young people are very
sensitive to prices increases in alcohol and tobacco.[74] The majority of alcohol
consumed in a community by young people is drunk at high levels of risk of shortterm harms.[8] Even small increases in taxation would achieve a worthwhile benefit
(and be easier to achieve and sustain). Large increases risk stimulating a black
market. Finally the College would like to suggest volumetric taxation of alcohol to be
extended to home brewing supplies

Misuse of licit substances (e.g. pharmaceuticals, performance and
image enhancing substances)
Consideration of definitions used in the National Drug Strategy paper
Often these licit substances are inappropriately prescribed rather than misused. This
and other terms adapt poorly to the situation where prescription drugs are misused.
In April 2009 the Royal Australasian College of Physicians (RACP) released a policy
report Prescription Opioid Policy: Improving management of chronic non-malignant
pain and prevention of problems associated with prescription opioid use.[75] This
document outlines a number of other definitions of terms that may be more
appropriate in relation to prescription pharmaceuticals.
Substance dependence is a pattern of maladaptive behaviours, including loss of
control over use, craving and preoccupation with non-therapeutic use, and continued
use despite harm resulting from use (with or without physical dependence or
tolerance) [WHO, DSM]. The terminology used in this field is constantly under review
and may change in the future. This document uses the following terms as indicated:
13
(a) ‘Inappropriate prescriber behaviour’ which refers to physician behaviour;
(b) ‘Problematic opioid use’ which refers to patient behaviour; and
(c) ‘Illicit or illegal use of prescription drugs’ which refers to the possession or
consumption by anyone other than the person to whom they were initially
prescribed.
Appropriate prescriber behaviour refers to prescription decisions based on the
best available current evidence at the time of assessment and taking into account the
patient’s perspective.
Inappropriate prescriber behaviour refers to persistent prescribing of opioids
despite absence of sustained improvement in function, deterioration of function
and/or the development of unacceptable side effects.
Problematic opioid use refers to patient behaviour defined as ‘deviating from an
appropriately prescribed program’ of opioid treatment for CNMP. It is usually
unsanctioned, but may be associated with inappropriate prescriber behaviour.
In general the term ‘problematic drug use’ may be clearer, more descriptive and less
judgemental than terms such as ‘drug misuse’ or ‘abuse’. 1 The AAPM/APS/ASAM
consensus[76] defines ‘problematic opioid use’ as a pattern of overwhelming focus
on opioid issues arising in the therapeutic context of prescribed opioids and impeding
progress with other issues, with:

early refills or escalating drug use;

frequent accounts of lost, spilt, stolen medications; and/or

use of supplemental sources of opioids
This policy document uses a wider definition of ‘problematic opioid use’ to include the
above and other behaviours such as:

use of oral medication parenterally by injecting or snorting;

use to excess and/or in combination with other psychoactive drugs or
alcohol to produce intoxication; and/or,

diversion to or from the black market.
Notes to this definition:
1
The Pain Society, Recommendations for the appropriate use of opioids for persistent Noncancer pain: A consensus statement prepared on behalf of the Pain Society, the Royal
College of Anaesthetists, the Royal College of General Practitioners and the Royal College of
Psychiatrists March 2004. London. Access on 21.04.2008)
http://www.britishpainsociety.org/pdf/opioids_doc_2004.pdf
14
1. Problematic use and dependence are distinct but overlapping concepts.
2. Problematic opioid use is usually unsanctioned. However, in circumstances
where such behaviours are tolerated by the prescriber (i.e. sanctioned), the
problem becomes one of inappropriate prescriber behaviour. (See conceptual
table below.)
3. The term ‘iatrogenic opioid dependence’ is not used in this document except
when quoting studies, as this may imply medical negligence.
Illicit or illegal use of prescription drugs refers to their possession or consumption
by anyone other than the person to whom they were prescribed.
Sanctioned use of opioids is use, according to instructions, by a person to whom
they were prescribed.
Unsanctioned use of opioids is use by the person to whom they were prescribed
but not according to instructions (problematic use) or any use by someone other than
the person to whom they were prescribed (illicit use).
1.2
Other emerging issues that you think are relevant to the next phase of
the National Drug Strategy
Prescription opioid use
The RACP policy on opioids was tabled at the Ministerial Council on Drug Strategy
meeting in November 2009 and a communiqué from the meeting reported that
Ministers agreed to develop a National Pharmaceutical Misuse Strategy, in close
consultation with the Australian Health Ministers Conference (AHMC) and with expert
groups such as the Medical Colleges. Furthermore it was recognised that the issue of
prescription drug misuse had been identified by both law enforcement and health
agencies across Australia as an emerging issue of significant concern. Ministers
agreed there was a need for a consolidated national response and endorsed the
development of a strategy that would address prevention, reduction of supply,
reduction of drug use and related harms, improved access to quality treatment.
The College would like to see MBS item numbers &/or PIP payments promoting
quality use of those pharmaceuticals of potential misuse. Also we would like
systematic feedback/monitoring re those doctors with higher prescribing habits.
The College recommends improved post marketing surveillance of adverse events in
relation to drug and alcohol in particular opioid prescribing.
15
1.3
The College believes that the top priorities for action over the next five
years should be:

Increased use of prescribed opioids;[75]

Benzodiazepines are now widely used in Australia as prescribed drugs
and for recreational purposes; however, they have the potential to lead to
addiction in vulnerable individuals. [77] Benzodiazepine use is a
considerable problem in Australia among the elderly, middle aged people
with severe medical illnesses and young polydrug users. Many young
polydrug users on methadone or buprenorphine treatment also consume
considerable quantities of benzodiazepines and this group has poorer
outcomes for all treatment objectives. This is a much neglected problem.

Alcohol and tobacco tax reform;[71]

Effective prevention and early intervention.[9] This area has not received
the focus that it deserves during the current and earlier phases of the
National Drug Strategy (NDS). Nevertheless, the NDS Campaigns,
Community Partnerships Initiative (CPI), National Comorbidity Initiative
(NCI), and National Cannabis Prevention and Information Centre (NCPIC)
all provide resources to strengthen early intervention and prevention (in
the absence of an explicit prevention agenda within the NDS);[69]

Research and best practice resource development. Important
achievements in the sector have been made by applying research-based
evidence to policy and practice, and Australian researchers have
contributed significantly to the evidence base. The National Drug
Research Centres have made major contributions, as have researchers
from other institutions. While National Drug Law Enforcement Research
Fund (NDLERF) provides funds for drug law enforcement research,
insufficient work has been done in developing the evidence base in this
area, partly because of the lack of NDS-supported drug law enforcement
research infrastructure. Still more could be done to use research evidence
to respond to drug trends. The NDS still has no integrated national drug
research strategy;[69]

Research in pharmacotherapies such as amphetamine stimulant
treatments for which good evidence of treatment is needed; and

Increased research action on nicotine and alcohol dependence a major
health burden as a result of nicotine and alcohol related disease.
16
2.
Improved definition for “Harm minimisation”
The polarisation that the language of harm minimisation has produced is a
distraction. Its use in the National Drug Strategy does not imply a particular
view of the merits or otherwise of prohibition, or when it is an appropriate
strategy. It does imply, however, that the choice between strategies should
simply be determined by their relative costs and benefits. Moreover, the harm
that is eliminated by any strategy needs to be greater than the harm that it
imposes.[78]
A preferred definition is the Internal Harm Reduction Association (IHRA)
definition “What is Harm Reduction?” A position statement from the
International Harm Reduction Association, International Harm Reduction
Association, London, United Kingdom, September 2009. Available at
www.ihra.net
2.1 Cross Sectoral Approaches. Structures and processes that could
assist the National Drug Strategy more effectively engage with
sectors outside health, law enforcement and education are as
follows:
Strengthened partnerships and collaborations between levels and sectors
of government and the public, private and not-for-profit service delivery
sectors. Examples include the State Reference Groups that that assess
grant applications under the Non-Government Organisation Treatment
Grants Program (NGOTGP), and the collaborations involved in
implementing Project STOP.[69]
2.2 Sectors that are particularly important for the National Drug Strategy
to engage with are:
Aboriginal and Torres Strait Islander health and community sectors

Indigenous Centre for Excellence in Tobacco Control

Inaugural National Coordinator for Tackling Indigenous Smoking, Mr
Tom Calma

National Indigenous Drug & Alcohol Committee
17

Close the Gap Steering Committee

NACCHO
2.3 How the IGCD and MCDS could more effectively access external
expert advice

Hold community meetings across Australia

Give people the opportunity to list to a live recording of the meetings
3. Indigenous Australians
Where efforts should be focused in reducing substance use and associated
harms in Indigenous communities?

Prevention of alcohol and drug problems remains a high priority, and
this should include urban as well as regional and remote areas. Too
often scarce funds have been poured into education alone, which
typically has a limited impact. Approaches such as community
empowerment, and enhancement of resilience need to be further
supported. The Gatehouse Project enhanced the connection between
school, teachers, communities and home and the sense of belonging
of young people, to promote resilience and success in young
people[79]. This was associated with reduced likelihood to engage in
substance abuse.[80] The potential of this approach in Indigenous
communities has not been adequately explored. Also, past successful
initiatives such as the Living With Alcohol Program in the NT have
been ceased because of lack of funding[81]

Increased effort in workforce development for the Aboriginal alcohol
and other drug workforce, including support and incentives to attend
accredited training, advanced work placements, and on the job
mentoring by specialist staff.
3.1 To reduce harm from substance use in Indigenous communities
efforts should be placed in the following areas:

Support for ACCHSs to incorporate social and emotional wellbeing
services into PHC: Substance misuse and mental illness are tightly
18
intertwined, yet too often services are not available to deal with mental
health and substance misuse comorbidity. Prevention and early
intervention for mental illness is critical yet many ACCHSs do not have
well resourced Social and Emotional Wellbeing services to provide
prevention, early intervention and treatment integrated with primary
health care. This is despite the fact that the majority of ACCHS s
identify Social and Emotional Wellbeing as a priority and many past
reviews recommend increasing Social and Emotional Wellbeing
services in ACCHSs. ACCHSs have the appropriate expertise in
providing culturally secure services in this complex and difficult areas.
They can reach out to the most marginalized and provide holistic care
addressing both mental and physical illness whilst addressing issues
early in people at high risk of developing AOD problems through
screening and early intervention, both opportunistically and
incorporated into adult health checks if they are supported.

These services should include support for substance use and
psychiatric comorbidity which is particularly common in Aboriginal
populations. Both substance misuse and mental health problems have
common determinants including the legacies of past policies such as
forced child removal, low levels of education, poverty and
unemployment etc. [82]

ACCHSs should be funded to employ psychologists and social
workers as well as Aboriginal Mental Health workers and community
workers who are well trained and supported. Visiting medical
specialists including addiction medicine specialists and psychiatrists
could provide support for the most complex patients.

ACCHSs in remote areas should also be supported to provide these
services through innovative models such as regional specialist staff
shared by two or more ACCHSs working with local teams in
communities.

The social and emotional well-being and substance use disorders of
Aboriginal prisoners need to be addressed given the very high
morbidity in this group. If feasible, ACCHSs should be supported to
deliver this service but if this is not possible, prison health services
should take advice from their local ACCHSs on how best to support
19
Aboriginal prisoners. Relapse prevention services, including for
alcohol dependence should be available to inmates during
incarceration, delivered in culturally appropriate ways. Planning for
release should include offer of relapse prevention medications where
appropriate and arrangement of follow-up counselling to reduce risk of
relapse.
3.2 Aboriginal and Torres Strait Islander peoples needs could be better
addressed through the main National Drug Strategy Framework in
the following way:

Collaborating with “Close the Gap” steering committee and
incorporating alcohol and drug goals and targets; [83]

Working closely with the Indigenous Centre for Excellence in Tobacco
Control as well as the new inaugural National Coordinator for Tackling
Indigenous Smoking, Mr Tom Calma;

Strengthen aboriginal workforce development programs at Universities
of Sydney, Newcastle and Wollongong;

As Aboriginal and Torres Strait Islander peoples are often part of
mainstream communities, and attend mainstream services, there is a
need for the main National Drug Strategy Framework to address their
needs. However as stated below, given their particular burden of
disease in relation to substance misuse, a more detailed
complementary plan would also be advisable;

Measures to reduce alcohol availability and increase cost will reduce
alcohol related harm in all Australians including Indigenous
Australians[71]. The College supports the recommendation of the
Preventative Health Taskforce on Alcohol control. In remote areas,
communities must be supported to develop and implement alcohol
management plans that are acceptable to the community as well as
being evidence based. More broadly, to improving social determinants
of health including employment and housing are likely to reduce
harmful AOD use in the long term;

Substantial investment has been made by the Australian government
in tobacco control in Aboriginal communities through the Council of
Australian Governments (COAG) package. This is a welcome
20
investment. However the training and support of the 57 tobacco
coordinators and 200 Tobacco action workers to be employed through
this package is not clear. There must be investment in training and
support of these workers otherwise this investment is unlikely to make
an optimal contribution to reduction in Indigenous smoking rates. A
high quality formative evaluation needs to be implemented so that the
roll out of the package can be modified according to progress.
3.3 In that context, would a separate National Drug Strategy Aboriginal
and Torres Strait Islander Complementary Action Plan continue to
have value?
The inequalities between Indigenous and non-Indigenous Australian health
status and outcomes are well documented, and this is also apparent within
drug dependence, high risk and risky consumption of alcohol and tobacco
smoking.
The College believes that the problems with drug use amongst Indigenous
peoples are so significant, that a separate review and more detailed plan are
useful. Oppression and dispossession of Indigenous peoples over time has
resulted in severe traumatisation and vulnerability for Indigenous peoples.
However a compendium should not replace coverage of Indigenous health in
the main plan: otherwise only those interested in Indigenous health read the
specialised plan. It is important that Indigenous health becomes more and
more part of mainstream health consciousness. A more detailed supplement
should be made available such as the National Drug Strategy Aboriginal and
Torres Strait Islander Peoples Complementary Action Plan 2003-2009. The
Complementary plan was comprehensive and formed under appropriate
consultation but not funded to achieve its aims. The College would support
revision and extension of a similar plan to complement the National Drug
Strategy and Preventative Health Agency’s work.
Many Aboriginal people access health care and other services from
mainstream services not primarily designed for that population so that it is
important to include Aboriginal people in the development of such services,
and in consequence, in the overall NDS.
21
4. Capacity building
4.1 The support and development of drug and alcohol sector workforce
should be focused over the coming five years in the following ways:

Recognising and taking appropriate action as early as possible for
children and young people of substance-abusing parents, and to be
able to assist these children and families in seeking treatment as early
as possible. [84]

Provide resources to ensure that Medical schools to include pain
management and addiction medicine into their curriculums.

Training for counselors, psychologists, nurses, working in drug and
alcohol field should include a core curriculum, which should be
evidence based.

Workforce development and structures. An appropriately sized, skilled
and qualified workforce is critical in sustaining effective delivery of
interventions. Capacity to implement programs has been limited by
staff shortages and turnover, and skill gaps in the alcohol and other
drug (AOD) sector specifically and in the Australian workforce
generally. The NDS contribution to training programs and resources is
highly valued, as is the work of NCETA in developing a concept of
workforce development far broader than education and training. More
attention is needed to building the capacity and profile of
professionally-trained, specialist AOD workers. [69]

Attention is needed to competitive pay and conditions, incentives and
benefits. A new national AOD workforce development strategy, as proposed
by NCETA and recently discussed by IGCD, will be an important initiative.

The generalist specialist for example, the Addiction Medicine
specialists should be supported to work more closely with primary
health care and other health professionals to improve the linkages
between the AOD system and other health practitioners which have
less well developed linkages between most other specialist areas and
other health practitioners. Shared care schemes in alcohol
dependence and opiate dependence should be supported and
replicated throughout the system if evaluations are positive.
22

More broadly, training and support to workers within community health
care and welfare should be supported to enable workers to screen,
identify and refer people with significant problems as well as delivering
appropriate brief interventions to those who either refuse more formal
help or who do not require formal help at this stage. Brief intervention
training in tobacco cessation should be delivered to a broad range of
professionals including welfare and youth workers and in a variety of
settings.
4.2 Efforts should be focussed over the coming five years to increase the
capacity of the generalist health workforce to identify and respond to
substance use problems in the following way:

The Training of doctors, nurses, psychologists and counesllors should
include a core curriculum on alcohol and other drugs, which should be
evidence based. Currently it is of concern that different branches of
the health care system periodically offer conflicting advice on
management of alcohol and drug problems (e.g. a doctor will advise a
client to enter a methadone maintenance program, a counselor may
advise them to enter a rehabilitation unit which requires them to be
methadone free, and a private detoxification service may market rapid
opioid detoxication. This creates considerable stress and confusion
for members of the public.
5. New Technologies and On-Line Services
5.1
The particular opportunities and challenges that technology
development is likely to pose for the community and the alcohol and
drug sector over the next five years are as follows:
23

Electronic prescribing and the potential this may have to prevent
diversion through the use of electronic prescriptions as opposed to
paper based prescriptions;

Develop a best practice system for monitoring the prescription of drugs
of dependence. This system should be web based, confidential and real
time. This will enable prescribing doctors and dispensing pharmacists to
monitor prescriptions, to provide more effective, safer and cost-effective
health care, and for government to monitor the overall use of these
medications and evaluate the effectiveness of policy and other
interventions.
The Colleges recommend improved systems for collection of data
regarding the prescription and use of opioid analgesics and other
prescription drugs of dependence. Such systems could have the
following features:
i)
Robust identification of the patient, similar to evidence needed to
establish, for instance, a bank account, with photo ID or
biometric ID;
ii) Online, real time medication history available to potential
prescribers at the time of prescribing, and to pharmacists at the
time of dispensing;
iii) Protected PIN held by the patient or accessible via a secure
mechanism;
iv) 24 hours per day, 7 days per week access by prescribers and
pharmacists to prescription shopping information systems to
identify unsanctioned use;
v) Privacy safeguards; and
vi) An audit trail to identify when patient’s record are accessed.

Use modern IT solutions to provide widespread access to credible
information and internet based intervention tools for D&A problems.

Timely periodic reports on alcohol and tobacco use should be nationally
available, along with detailed reports addressing demographic patterns
of substance use. Likewise periodic reports on treatment services and
places should be made available, in relation to measures of need and
unmet need.
24
6. Increased vulnerability
6.1 The National Drug Strategy could better complement the social
inclusion agenda such as addressing unemployment, homelessness,
mental illness and social disadvantage in the following way:
The College supports the principles outlined in the social inclusion document[85]
and would like to particularly note the following areas as being important:

Targeting jobless families with children to increase work opportunities,
improve parenting and build capacity;

Improving the life chances of children at greatest risk of long term
disadvantage;

Reducing the incidence of homelessness;

improving outcomes for people living with disability or mental illness
and their carers;

Closing the gap for Indigenous Australians; and

Breaking the cycle of entrenched and multiple disadvantage in
particular neighbourhoods and communities.
6.2
Effort be focused in reducing substance use and associated harms
among vulnerable populations in the following way:

Ensuring the recommendations from the Government’s social
inclusion paper “A Stronger, Fairer Australia” are implemented;

Supporting existing policy recommendations such as “Close the Gap;”

Implementing the findings from the Productivity Commission Inquiry
announced in November 2009 into ways of improving long-term care
and support for people with disability – including the feasibility of a nofault social insurance scheme for people with profound disability;

In the broadest sense that is with consideration of the social
determinants of health.
7. Performance Measures
25
7.1
Publicly available performance measures against the National Drug
Strategy that are desirable should include:

The number of times an organisation, person and/or publication have
included a declaration statement on any potential or actual conflicts of
interest;

The number of recommendations from key policy documents
previously mentioned implemented and evaluated;
7.2
Measures that would give a high level indication of progress under the
National Drug Strategy include:

Program performance monitoring and evaluation. Increase the
capacity to engage in performance monitoring, review and evaluation.
These include programs that have been implemented without
documented or funded monitoring and evaluation components built in
from the outset. Although a commitment to monitoring and evaluation
is part of every phase of the NDS, more action is needed to make it a
reality.
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