Showing papers in "Drug and Alcohol Review in 2013"

Patterns of electronic cigarette use and user beliefs about their safety and benefits: An Internet survey

Abstract: Introduction and Aims As the popularity of electronic cigarettes (e-cigarettes) increases, it is becoming important to find out more about the characteristics of e-cigarette users, why and how they use the product and whether e-cigarettes are used exclusively or in combination with conventional cigarettes. The objective of this study was to investigate patterns and effects of e-cigarette use and user beliefs about e-cigarette safety and benefits.

Patterns of synthetic cannabinoid use in Australia.

Abstract: INTRODUCTION AND AIMS: To assess the demographic profile, use patterns, market characteristics, reasons for first use and self-reported harms associated with use of synthetic cannabinoids in Australia. DESIGN AND METHODS: An online questionnaire was administered to a purposive sample of 316 Australian synthetic cannabinoid users [96% cannabis users, 77% male, median age 27 years, interquartile range (IQR) 23-34] who self-reported demographic and drug use characteristics. RESULTS: The median duration of synthetic cannabinoid use was 6 months (IQR 2-10), 35% reported use weekly or more often and 7% reported daily use. Reasons for first use included curiosity (50%), legality (39%), availability (23%), recreational effects (20%), therapeutic effects (9%), non-detection in standard drug screening assays (8%) and to aid the reduction or cessation of cannabis use (5%). Users reported buying a median of 3 g (IQR 3-6) and paying a median of AU$60 (IQR 37-90). Most (68%) reported at least one side-effect during their last session of use, including decreased motor co-ordination (39%), fast or irregular heartbeat (33%), dissociation (22%), dizziness (20%), paranoia (18%) and psychosis (4%). 4 respondents reported seeking help. A greater number of side-effects were reported by males, those aged 18-25 years, water pipe ('bong') users and concurrent alcohol drinkers. DISCUSSION AND CONCLUSIONS: The sample reported first using synthetic cannabinoids due to curiosity, legality, availability, effects, non-detection in drug testing and to reduce their cannabis use. Harms were widely reported yet help-seeking was minimal. Inclusion of questions regarding synthetic cannabinoids in household surveys is warranted. Language: en

The Assessment of Recovery Capital: properties and psychometrics of a measure of addiction recovery strengths

Abstract: Introduction and Aims: Sociological work on social capital and its impact on health behaviours have been translated into the addiction field in the form of 'recovery capital' as the construct for assessing individual progress on a recovery journey. Yet there has been little attempt to quantify recovery capital. The aim of the project was to create a scale that assessed addiction recovery capital. Design and Methods: Initial focus group work identified and tested candidate items and domains followed by data collection from multiple sources to enable psychometric assessment of a scale measuring recovery capital. Results: The scale shows moderate test-retest reliability at 1week and acceptable concurrent validity. Principal component analysis determined single factor structure. Discussion and Conclusions: The Assessment of Recovery Capital (ARC) is a brief and easy to administer measurement of recovery capital that has acceptable psychometric properties and may be a useful complement to deficit-based assessment and outcome monitoring instruments for substance dependent individuals in and out of treatment.

A systematic review of school-based alcohol and other drug prevention programs facilitated by computers or the internet.

Abstract: Issues The use of alcohol and drugs amongst young people is a serious concern and the need for effective prevention is clear. This paper identifies and describes current school-based alcohol and other drug prevention programs facilitated by computers or the Internet. Approach The Cochrane Library, PsycINFO and PubMed databases were searched in March 2012. Additional materials were obtained from reference lists of papers. Studies were included if they described an Internet- or computer-based prevention program for alcohol or other drugs delivered in schools. Key Findings Twelve trials of 10 programs were identified. Seven trials evaluated Internet-based programs and five delivered an intervention via CD-ROM. The interventions targeted alcohol, cannabis and tobacco. Data to calculate effect size and odds ratios were unavailable for three programs. Of the seven programs with available data, six achieved reductions in alcohol, cannabis or tobacco use at post intervention and/or follow up. Two interventions were associated with decreased intentions to use tobacco, and two significantly increased alcohol and drug-related knowledge. Conclusion This is the first study to review the efficacy of school-based drug and alcohol prevention programs delivered online or via computers. Findings indicate that existing computer- and Internet-based prevention programs in schools have the potential to reduce alcohol and other drug use as well as intentions to use substances in the future. These findings, together with the implementation advantages and high fidelity associated with new technology, suggest that programs facilitated by computers and the Internet offer a promising delivery method for school-based prevention.

Pharmacotherapy of amphetamine-type stimulant dependence: an update.

Abstract: Between 2008–2010, about 1.2% or 1.3% of adults worldwide report use of amphetamine type stimulants (ATS) involving compounds that range from amphetamine to an array of amphetamine analogues, but exclude 3,4-methylenedioxy-N-methylamphetamine or ‘ecstasy’. This means that more individuals are estimated to use ATS than heroin or cocaine [1]. In many Asian countries, the prevalence of ATS use precipitating treatment is exceeded only by opioids. In Indonesia, ATS is the primary drug of abuse for more than one-third of people treated for substance use disorders. Indeed, the use of ATS continues to present a significant public health burden worldwide [2]. In Australia, recent (past 30 days) use of ATS (excluding ecstasy) declined among adults from a peak of 3.7% in 1998 to 2.1% in 2010, a rate that still remains one of the highest among other countries [3]. Ecstasy (a short-acting stimulant) also is used frequently by Australian adults (3.0%). In Australia and elsewhere, use of long-acting stimulants, particularly amphetamine and methamphetamine, is disproportionately popular among specific groups, including men who have sex with men [4], women [5] and criminal offenders [6]. Men aged 20–29 remain the group with the highest likelihood of amphetamine use in Australia, despite some evidence of declining rates over the past decade [3]. Methamphetamine use at levels of dependence is associated with multiple morbidities, including HIV infection, hepatitis, cardiac effects, family disruptions and prominent psychiatric consequences including psychosis [7,8]. Societal costs for methamphetamine abuse are high, estimated in 2005 at more than $23 billion in the United States and include premature death, crime, lost productivity, environmental damage, medical conditions, cognitive dysfunction, disruption of family life and infectious disease[7]. The primary interventions with evidence of efficacy are behavioural therapies, which reduce amphetamine use [9–12]. Yet the impact of these treatments is limited in that they require substantial investments in care delivery systems and trained professionals to implement the interventions with fidelity. Behavioural treatments also have moderate effect sizes in terms of abstinence and retention, underscoring the need for additional efficacious strategies, notably pharmacotherapy. This review describes the rationale and targets for pharmacotherapies for abuse or dependence on ATS, reviews the extant evidence for select agents, discusses emerging pharmacogenetic data and proposes directions for future work. A literature search was conducted by the first author using the PubMed and Google Scholar databases. An initial search for randomised placebo-controlled clinical trials treating amphetamine or methamphetamine use disorders published from 1980 through July 2012 produced 468 results. Further review identified 21 trials. The authors selectively included brief detoxification trials, human laboratory studies and pre-clinical data where appropriate.

Lack of international consensus in low-risk drinking guidelines

Abstract: Introduction and Aims: To encourage moderate alcohol consumption, many governments have developed guidelines for alcohol intake, guidelines for alcohol consumption during pregnancy, and legislation relating to blood alcohol limits when driving. The aim of this study was to determine the degree of international consensus within such guidelines. Design and Methods: Official definitions of standard and consumption guidelines were searched for on government websites, including all 27 European Union Member States and countries from all global geographic regions. Results: There was a remarkable lack of agreement about what constitutes harmful or excessive alcohol consumption on a daily basis, a weekly basis, and when driving, with no consensus about the ratios of consumption guidelines for men and women. Discussion and Conclusions: International consensus in low risk drinking guidelines is an important - and achievable - goal. Such agreement would facilitate consistent labelling of packaged products and could help to promote moderate alcohol consumption. However, there are some paradoxes related to alcohol content labelling and people’s use of such information: although clearer information could increase people’s capacity to monitor and regulate their alcohol consumption, not all drinkers are motivated to drink moderately or sensibly, and drinkers who intend to get drunk may use alcohol content labelling to select more alcoholic products.

Using quantitative wastewater analysis to measure daily usage of conventional and emerging illicit drugs at an annual music festival

Abstract: Introduction and Aims: Wastewater analysis provides a non-intrusive way of measuring drug use within a population. We used this approach to determine daily use of conventional illicit drugs [cannabis, cocaine, methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA)] and emerging illicit psychostimulants (benzylpiperazine, mephedrone and methylone) in two consecutive years (2010 and 2011) at an annual music festival. Design and Methods: Daily composite wastewater samples, representative of the festival, were collected from the on-site wastewater treatment plant and analysed for drug metabolites. Data over 2 years were compared using Wilcoxon matched-pair test. Data from 2010 festival were compared with data collected at the same time from a nearby urban community using equivalent methods. Results: Conventional illicit drugs were detected in all samples whereas emerging illicit psychostimulants were found only on specific days. The estimated per capita consumption of MDMA, cocaine and cannabis was similar between the two festival years. Statistically significant (P<0.05; Z=-2.0-2.2) decreases were observed in use of methamphetamine and one emerging illicit psychostimulant (benzyl piperazine). Only consumption of MDMA was elevated at the festival compared with the nearby urban community. Discussion and Conclusions: Rates of substance use at this festival remained relatively consistent over two monitoring years. Compared with the urban community, drug use among festival goers was only elevated for MDMA, confirming its popularity in music settings. Our study demonstrated that wastewater analysis can objectively capture changes in substance use at a music setting without raising major ethical issues. It would potentially allow effective assessments of drug prevention strategies in such settings in the future.

Novel psychoactive drug use among younger adults involved in US nightlife scenes.

Abstract: Introduction and Aims The emergence of novel psychoactive substances has been reported in clinical studies and recent studies of users. The use of these substances in European nightlife scenes is well documented. Little research has been done to identify the prevalence of these drugs among young adults active in other regions. We focus our sample on socially active young adults to gain an indication of the prevalence and understanding of demographic factors associated with past year mephedrone (‘meph’, ‘bath salts’) and synthetic cannabinoid (‘spice’, ‘K2’) use. Design and Methods This study reports on the results of a field-based survey of 1740 patrons at nightlife venues in New York City. Results Within the sample, 8.2% reported use of synthetic cannabinoids and 1.1% reported the use of mephedrone. Gay and bisexual men reported higher prevalence of mephedrone use. Latinos reported higher prevalence of synthetic cannabinoid use. Multivariate analyses indicate that sexual minority identity is associated with mephedrone use and younger age and Latino ethnicity are associated with synthetic cannabinoid use. Discussion and Conclusion The findings suggest that the use of synthetic cannabinoids and mephedrone among adults in US nightlife scenes remains relatively low in comparison with European nightlife scenes, and is low relative to other drug use among young people within these scenes. [Kelly BC, Wells BE, Pawson M, LeClair A, Parsons JT, Golub SA. Novel psychoactive drug use among younger adults involved in US nightlife scenes. Drug Alcohol Rev 2013;32:588–593]

Substance use initiation: the role of simultaneous polysubstance use.

Abstract: Introduction and Aims. Simultaneous polysubstance use (SPU) is a common phenomenon, yet little is known about its role in substance use initiation. Design and Methods. In the present study, 226 cannabis users completed structured interviews about their substance use history. For each substance ever used, participants provided details of their age of first use, their use in the preceding 30 days and whether they co-administered any other licit or illicit substances the first time they used the substance. Results. For most illicit substances [powder cocaine, crack, amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA; ecstasy), heroin, opium, gamma-hydroxybutyric acid (GHB), ketamine, psilocybin (magic mushrooms), mescaline, phencyclidine (PCP), peyote and inhalants], results showed that a clear majority of participants (≥75%) reported SPU during their first-ever use of the substance. While SPU was less common on occasions of first use of alcohol, tobacco and cannabis, a high proportion of SPU on occasions of first use of ‘harder’ drugs could be accounted for by the co-use of alcohol, tobacco and/or cannabis. Discussion and Conclusions. Such findings raise the possibility that specific alcohol, tobacco and/or cannabis use episodes might directly contribute to the initiation of new substance use. Understanding the role of SPU on occasions of first use might help better identify risk factors for substance use progression and improve intervention efforts.[Olthuis JV, Darredeau C, Barrett SP. Substance use initiation: The role of simultaneous polysubstance use. Drug Alcohol Rev 2013;32:67–71]

Trends in fentanyl prescriptions and fentanyl-related mortality in Australia

Abstract: Introduction and Aims The study aims to quantify trends in fentanyl prescribing and fentanyl mortality in Australia within the context of concern among health professionals concerning increasing accessibility of fentanyl, and the harms that may arise as a result. Design and Methods This paper presents data on prescribing patterns of fentanyl by 10 year age group adjusted by population rate, detailed analyses of fentanyl-related deaths from the National Coronial Information System and deaths adjusted for prescribing levels within Australia. Results Fentany prescriptions have increased and are most prevalent among Australians aged over 80 years. One hundred and thirty-six fentanyl-related deaths were recorded during 2000–2011; 54% of decedents had a history of injecting drug use and, among this group, 95% had injected fentanyl at the time of death; 62% of deaths recorded misuse (most notably injection) of fentanyl; 50% recorded a history of drug dependence and 40% a mental health problem; 37% recorded a history of chronic pain; and 36% recorded fentanyl as being prescribed at the time of death. Deaths were primarily among Australians under 47 years of age. Discussion and Conclusions There have been significant increases in fentanyl prescribing in Australia. It is unclear what proportion of this increase represents legitimate treatment of pain. Fentanyl deaths have also increased, although mortality is currently low in Australia. A large proportion of the deaths involved the injection of diverted fentanyl, highlighting the need for messages regarding safer injecting practices targeting people who inject drugs, and strategies to minimise the risks of diversion.

Australian university students' attitudes towards the use of prescription stimulants as cognitive enhancers: perceived patterns of use, efficacy and safety

Abstract: Introduction and Aims Recent, high profile articles in leading science journals have claimed that the enhancement use of prescription stimulants is a common practice among students worldwide. This study provides empirical data on Australian university students' perceptions of: (i) the prevalence of prescription stimulant use by their peers for cognitive enhancement; (ii) motivations for such use; (iii) efficacy; and (iv) its safety. Design and Methods Participants were 19 Australian university students with an average age of 24 who were recruited through emails lists, notice board posters and snowball sampling. Semi-structured interviews were conducted during 2010 and 2011, recordings transcribed and responses coded using thematic analysis. Results Participants typically did not believe the use of stimulants for cognitive enhancement was common in Australia. Perceived motivations for use included: (i) getting ahead' to perform at high levels; (ii) keeping up' as a method of coping; and (iii) going out' so that an active social life could be maintained in the face of study demands. Australian students were generally sceptical about the potential benefits of stimulants for cognitive enhancement and they identified psychological dependence as a potential negative consequence. Discussion and Conclusions This study is an important first step in understanding the use of stimulants for cognitive enhancement in Australia, amid calls for more widespread use of cognitive enhancing drugs. It is important to conduct further studies of the extent of cognitive enhancement in Australia if we are to develop appropriate policy responses. [Partridge B, Bell S, Lucke J, Hall W. Australian university students' attitudes towards the use of prescription stimulants as cognitive enhancers: Perceived patterns of use, efficacy and safety. Drug Alcohol Rev 2013;32:295-302]

Prevalence and key covariates of non-medical prescription opioid use among the general secondary student and adult populations in Ontario, Canada.

Abstract: Introduction and Aims To assess the prevalence and key covariates of non-medical prescription opioid use (NMPOU) in two representative surveys of adults (Centre for Addiction and Mental Health Monitor, CM) and secondary-school students (Ontario Student Drug Use and Health Survey, OSDUHS). Design and Methods Data from the 2010 and 2011 cycles (n = 4023) of CM—a stratified, multi-stage, random-digit-dialling telephone survey of adults (18 years and older)—and the 2011 cycle of OSDUHS (n = 3266)—a self-administered written questionnaire-based survey of grade 7–12 public system students—were used. Besides NMPOU prevalence, associations were assessed by univariate and multi-step multivariate (logistic regression) analyses. NMPOU and key socioeconomic (i.e. sex, age, Aboriginal ethnicity, household location, income, subjective social status), health indicators (physical health status, psychological distress, suicidal ideation), drug use (cigarette smoking, binge drinking, cannabis use, other drug use) were measured. Results NMPOU (past year) prevalence was 15.5% in students and 5.9% in adults. Various univariate associations with social, health and drug use factors were found in both populations, with differences by sex. Based on multivariate analyses, other drug use (male students) and rural residence, subjective social status, other drug use and suicidal ideation (female students); marital status and cannabis use (male adults) and binge drinking (female adults) were independently associated with NMPOU in the respective study populations. Discussion and Conclusions NMPOU was high in adults and especially students. Independent predictors of NMPOU were largely inconsistent by sex. Notably, NMPOU is widely distributed across socio-demographic and -economic strata, and thus requires broad-based interventions.

The place of volition in addiction: Differing approaches and their implications for policy and service provision

Abstract: Introduction. ‘Addiction’ is an ambiguous concept. Its meaning, and how it is used in drug policy and treatment, depends on how it is conceptualised. While the ‘disease’ model of addiction is prevalent in Australia, differing, sometimes contradictory, interpretations of this model are mobilised. Methods. Drawing on 20 semi-structured interviews conducted with professionals working in the area of drug use in Victoria, Australia, this paper develops a typology delineating different approaches to addiction. Results. Five domains of meaning related to addiction were identified in the data. These were: (i) the sign of craving; (ii) susceptibility; (iii) social and psychological issues producing addiction; (iv) self-concept; and (v) social functions of addiction. These domains are further divided into two subtypes based on how the participants understood the role of a key notion in addiction: volition, that is, whether or not an ‘addict’ has control over drug use and other aspects of life. Discussion. By systematically mapping different conceptualisations of addiction, this typology identifies the ambiguities and contradictions in the models currently in use, especially with respect to the notion of volition. While a homogeneous approach to these issues is neither practical nor desirable, there is a need to consider the implications of this lack of coherence. Conclusions. Service providers, medical practitioners and policy makers need to reflect on their assumptions, and consider the implications of their different approaches for clients, some of whom encounter more than one approach when undergoing treatment for drug use.

Trends in drug use among gay and bisexual men in Sydney, Melbourne and Queensland, Australia.

Abstract: Introduction and Aims The findings of Australian drug surveys are typically not stratified by sexual orientation, despite the higher prevalence of drug use generally reported among gay and bisexual men. This paper aims to examine trends in drug use among gay and bisexual men in eastern Australia between 2004 and 2011. Design and Methods Data from the cross-sectional, ongoing Gay Community Periodic Surveys (GCPS) were used to analyse drug trends among gay and bisexual men in Sydney, Melbourne and Queensland. Between 2004 and 2011, 45 273 eligible questionnaires were completed. Results There was a downward trend in recent drug use (previous 6 months) between 2004 and 2011 from 62.2% to 57.5%. However, this trend was not found among men in Queensland, bisexual men, men aged over 40 years or HIV-positive men. Club drug use peaked in 2006 (45.1%), before steadily declining to 32.4% in 2011. There were significant reductions in use of ecstasy, methamphetamine, ketamine and cannabis, increased use of cocaine, gamma hydroxybutyrate, erectile dysfunction medications, amyl nitrite and lysergic acid diethylamide, and no change in heroin use. Recent injecting drug use fluctuated over time but experienced an overall downward trend from 5.5% in 2004 to 4.0% in 2011. Discussion and Conclusions Drug use trends among gay and bisexual men in Australia are broadly consistent with downward and upward drug trends reported in other Australian drug surveys. The risks associated with drug use in this population and high rates of use supports the ongoing role of the GCPS in monitoring drug trends among homosexually active men.

Counting Fetal Alcohol Spectrum Disorder in Australia: the evidence and the challenges

Abstract: Issues. Alcohol exposure in utero is associated with a range of adverse outcomes in pregnancy and can cause long-term disability. Fetal alcohol spectrum disorder (FASD) is an umbrella term to describe a range of effects from prenatal alcohol exposure including fetal alcohol syndrome (FAS). Determining the prevalence of FASD is challenging. Approach. This narrative review collates information on the prevalence of FASD in Australia and documents the various methods used for attaining estimates and the limitations of the available data. Key Findings. Birth prevalence of FASD is most commonly measured through clinic-based studies, passive surveillance systems and active case ascertainment. Alcohol use in pregnancy and FAS in Australia is predominantly monitored through passive surveillance systems and under-ascertainment of cases is likely. State- and territory-based studies have reported birth prevalence rates of FAS of between 0.01 and 0.68 per 1000 live births. Prevalence rates of FASD have not been estimated in Australia. As reflected in the international data, Australian studies have found higher rates of FAS among some Indigenous communities. This likely reflects patterns of alcohol use and other socioeconomic risk factors. Implications. Under-recognition of FASD reflects incomplete and inconsistent data collections recording alcohol use in pregnancy, lack of awareness among health professionals and a lack of diagnostic and support services. Conclusion. Accurate measurement of FASD prevalence is crucial to inform policy, resource and service development in the areas of health, education, justice and community. There is a need for consensus on the collection and best use of data. [Burns L, Breen C, Bower C, O' Leary C, Elliott EJ. Counting fetal alcohol spectrum disorders in Australia: the evidence and the challenges. Drug Alcohol Rev 2013;32:461–467]

Alcohol use in pregnancy: prevalence and predictors in the Longitudinal Study of Australian Children

Abstract: Introduction and Aims This study aimed to estimate the prevalence and describe the patterns of alcohol use during pregnancy among Australian mothers. The study also aimed to examine the characteristics associated with alcohol use in pregnancy. Design and Methods Data comprised two representative samples of families (infant cohort = 5107 parents of 0- to 1-year-olds; child cohort = 4983 parents of 4- to 5-year-olds) from the 2005 Longitudinal Study of Australian Children. Results Alcohol use in pregnancy was reported by 37.6% of mothers of infants aged 0–1 years and 27.6% of mothers of children aged 4–5 years. The majority of women reported low level/occasional use of alcohol but, when extrapolated to population level, this equates to 131 250 children in these two age groups exposed to alcohol in utero, with over 1000 children exposed to alcohol most days and an estimated 671 infants exposed to three or more drinks per occasion. Among mothers of infants, alcohol use in pregnancy was associated with increasing maternal age, higher education, greater economic advantage and fewer physical health problems in pregnancy. Among mothers of children, maternal drinking in pregnancy was associated with increasing maternal age and smoking in pregnancy. Discussion and Conclusions Alcohol use during pregnancy is common with around one-third of all mothers reporting use. Most women reported only occasional use, and among those who were asked, consumed one standard drink on average per occasion. Significant numbers were exposed to three or more drinks on one occasion or to alcohol most days while in utero. National guidelines recommend abstinence as no ‘safe’ threshold has been determined. Public health campaigns are needed to educate pregnant women regarding national guidelines. [Hutchinson D, Moore EA, Breen C, Burns L, Mattick RP. Alcohol use in pregnancy: Prevalence and predictors in the Longitudinal Study of Australian Children. Drug Alcohol Rev 2013;32:475–482]

Investigating the 'bath salt' panic: the rarity of synthetic cathinone use among students in the United States.

Abstract: Introduction and Aims Until recently, synthetic cathinones marketed as ‘bath salts’ were legally sold at convenience stores and online in the USA. Media reports initiated concerns of a growing ‘bath salt’ epidemic. Despite media attention and the recent legal action banning synthetic cathinones, little is known about its prevalence or users. Design and Methods A self-report survey was administered to 2349 students in 40 randomly selected courses at a large university in the Southeastern United States. The resulting sample was 51.6% female, 68.9% white, 24.4% black, 2.8% Hispanic and 4.0% other races, with a mean age of 20.06 years and median family income of $75 000–99 999. Results Only 25 (1.07%) of the students reported using synthetic cathinones at least once. Synthetic cathinone use was found to be more common among men (1.68% vs. 0.50% of women, P = 0.005), Hispanics (4.7%) and Native Americans (4.3% vs. 0.89% of whites and 0.72% of blacks, P = 0.002), and student athletes (4.0% vs. 0.90% of non-athletes, P = 0.001), but in each of these groups, synthetic cathinones were used more rarely than marijuana (58.14%, P < 0.001), cocaine (9.08%, P < 0.001), Salvia divinorum (7.89%, P < 0.001), synthetic cannabinoids (14.28%, P < 0.001), methamphetamines (1.92%, P = 0.002), 3,4-methylenedioxy-N-methylamphetamine (MDMA) (12.54%, P < 0.001) and several other drugs and pharmaceuticals. Discussion and Conclusions ‘Bath salts’ have received a great deal of media attention in the USA, yet the prevalence of synthetic cathinone use among our sample was extremely rare. We suggest that the media attention focusing on synthetic cathinone use as a growing epidemic may be largely misplaced. [Stogner JM, & Miller BL. Investigating the ‘bath salt’ panic: The rarity of synthetic cathinone use among students in the USA. Drug Alcohol Rev 2013;32:545–549

Are people who inject performance and image-enhancing drugs an increasing population of Needle and Syringe Program attendees?

Abstract: Australian studies of people who inject performance and image-enhancing drugs (PIED) have identified subgroups including professional sportspeople, occupational users (those in protective services/entertainment industries), body image users and adolescents [1]. Between 2000 and 2010, the proportion of respondents in the National Drug Strategy Household Survey who reported non-medical use of steroids remained low and stable at 0.3% or less [2], and PIEDs injectors comprised just 1–2% of respondents in surveys of Needle and Syringe Program (NSP) attendees [3]. Anecdotal reports from NSP services in New South Wales (NSW) and Queensland suggest substantial recent increases in the number of people who inject PIEDs accessing injecting equipment.This study investigates temporal trends in prevalence and patterns of PIEDs injection among Australian Needle and Syringe Program Survey (ANSPS) respondents.

Maternal factors associated with heavy periconceptional alcohol intake and drinking following pregnancy recognition: A post‐partum survey of New Zealand women

Abstract: Introduction and Aims Alcohol consumption during pregnancy places the foetus at risk of Foetal Alcohol Spectrum Disorders. Little is known about the current prevalence and patterns of alcohol consumption before and following pregnancy recognition in New Zealand. Design and Methods A retrospective survey of 723 post-partum women resident in maternity wards located across New Zealand was conducted using a self-administered questionnaire. Maternal sociodemographic and obstetric characteristics and alcohol intake before and after pregnancy recognition were assessed. Results Of the 968 women invited to participate, 78% agreed. Eighty-two percent of women reported consuming alcohol prior to pregnancy and 20% reported typically consuming >4 New Zealand standard drinks per occasion. Overall, 34% of women reported drinking at some time during pregnancy. Twelve percent of pregnancies were at high risk of heavy alcohol exposure in early gestation. In fully adjusted analysis, pregnancies most at risk were those of indigenous Māori women, Pacific women, smokers and drug users. Almost one-quarter (24%) of drinkers continued to drink following pregnancy recognition, and in fully adjusted analysis, continuing to drink was positively associated with frequency of alcohol consumption before pregnancy (P < 0.001 for linear trend). Discussion and Conclusions To reduce the burden of alcohol-related harm to the foetus, these findings suggest that New Zealand alcohol policy should be focused not only on promoting total abstinence when planning a pregnancy and when pregnant, but also on reducing ‘binge drinking’ culture and the frequent consumption of lower levels of alcohol.[Mallard SR, Connor JL, Houghton LA. Maternal factors associated with heavy periconceptional alcohol intake and drinking following pregnancy recognition:A post-partum survey of New Zealand women.Drug Alcohol Rev2013;32:389–397]

Public opinion and drug policy in Australia: engaging the 'affected community'.

Abstract: Introduction Policy should be informed by the people it directly affects; however, the voices of people who use illicit drugs have been marginalised from drug policy debate. In Australia, the majority of survey data regarding attitudes to drug policy are collected at the population level and the opinions of people who inject drugs remain underexplored. This study aimed to investigate how people who inject drugs perceive drug policy in Australia and whether these opinions differ from those of the broader general population. Methods Drug-related policy questions were drawn from the National Drug Strategy Household Survey (NDSHS) and added to the 2011 Illicit Drug Reporting System (IDRS) Survey (n = 868). The results were analysed for the full IDRS sample and by recent drug use. IDRS responses were compared with the general population using the 2010 NDSHS. Results There was a high level of support among IDRS participants for measures to reduce the problems associated with heroin, but heterogeneity in levels of support for legalisation and penalties for sale/supply across different drug types. Differences between the opinions of the IDRS sample and the NDSHS sample were identified regarding support for harm reduction, treatment, legalisation and penalties for sale/supply. Discussion These findings provide a springboard for further investigation of the attitudes of people who use illicit drugs towards drug policy in Australia, and challenge us to conceptualise how the opinions of this community should be solicited, heard and balanced in drug policy processes.

Emergence of a methamphetamine crisis in Iran.

Abstract: Sir—We write to alert your readers to the emerging methamphetamine situation in Iran. Iran has a long-term historical background of opiates being the most common drugs of abuse. Before 2000, the use of stimulants (i.e. cocaine and amphetamines) was very uncommon in Iran. Methamphetamine entered Iran’s market in the early 2000s [1]. After just a decade, methamphetamine use is becoming one of the most serious social concerns in Iran. It has led to significant health problems, affected the use of methadone for addiction treatment, and has also become a serious threat to HIV/AIDS prevention programs among drug users nationwide. Methamphetamine use has propagated in Iran very rapidly for various reasons. First, 42% of Iran’s current population is aged between 20 and 40 years [2]—this is possibly due to the policies to encourage population growth in the 1980s during and following the Iran–Iraq war. In a rapidly developing and competitive environment, methamphetamine can be very appealing for young people. Second, as methamphetamine is the only strong stimulant easily available in Iran, its demand is on the rise and gaining momentum. The third reason is novelty.There is a well-established history of opiate addiction in Iran.Opium use,abuse and its withdrawal syndromes have been familiar to the Iranian society since the 10th century [3]. However, people are not well aware of the signs and symptoms of methamphetamine use and dependence. In this context, methamphetamine was introduced in Iran as a nonaddictive drug because of the lack of significant physical signs and symptoms during its withdrawal. The last reason could be the low price of methamphetamine in Iran. Methamphetamine was at first smuggled to Iran from South-East Asia, so it was very expensive, but its price dropped after production started in Iran and drug dealers expanded their distribution networks. The Iranian drug abuse treatment network is going to face to a series of serious challenges in the near future because of the methamphetamine crisis. These challenges could be categorised as follows:

Brief intervention content matters.

Abstract: For more than 30 years, there have been concerted efforts internationally to develop the evidence base for brief interventions in general practice 1. The choice of this setting reflected strategic judgements about where in health systems heavy drinking and alcohol problems were likely to be most encountered and thus where these interventions may be optimally delivered. This literature is usually interpreted along the lines that efficacy is now well established in general practice and that there is a need to extend study to new settings 2,3. This year has seen the publication of two large general practice cluster randomised effectiveness trials that in different ways draw attention to a crucial limitation of the evidence base in this setting; the lack of well-developed study of intervention content. Although both undertaken in the UK, they are likely to be seen internationally as important studies. The three-arm Screening and Intervention Programme for Sensible drinking (SIPS) trial compared a leaflet control condition against the same leaflet plus five minutes advice and the addition subsequently of 20 minutes counselling 4. Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT) compared training practitioners to address behaviour change for the big four key lifestyle risk factors (diet, exercise, smoking and alcohol) versus delayed training, thus entailing a non-intervention control condition 5. Both trials found no differences in alcohol outcomes for hazardous and harmful drinkers over a 12-month study period following interventions delivery by general practitioners and practice nurses. The authors of these studies identify contrary implications for practice from these null findings. The SIPS authors conclude that the control condition: ‘screening followed by simple feedback and written information may be the most appropriate strategy to reduce hazardous and harmful drinking in primary care’ 4. One commentator, however, is concerned that this provides: ‘false reassurance that we have taken care of unhealthy alcohol use and will waste time and money’ 6 by delivering more time consuming interventions. In contrast, the PRE-EMPT authors, including myself, conclude that: ‘enduring behaviour change and improvements on biochemical and biometric measures are unlikely after a single routine consultation with a clinician trained in behaviour change counselling, without additional intervention’ 5. Attention to the detailed content of the evaluated interventions and consideration of their relationship to the existing general practice literature is necessary for interpreting study findings. Following screening in SIPS, leaflet delivery was accompanied by the standard script reproduced in Box 1 (interested readers are strongly encouraged to examine the study website 7 for detailed information on all interventions). It will be seen that the feedback is very brief. The leaflet comprises content on health and social consequences, awareness of units (standard drinks), recommendations on daily consumption and where to get help. The advice intervention covers similar material providing additional tips on planning and the benefits of cutting down after being shown that drinking exceeded the majority of the population, without having further dedicated content on decision making, i.e. whether one should cut down 7. This was based on the Drink-Less material developed approximately 20 years ago, and in SIPS one hour training in delivery was given 7. The counselling intervention provides quite different material, being influenced by motivational interviewing, and requiring some understanding of this approach, though not proficiency in it 7. Counselling required a return visit to general practice, and just over half took this up 4. Box 1. The SIPS control condition ‘Thank you for taking part in this project. Your screening test result shows that you're drinking alcohol above safe levels, which may be harmful to you. This leaflet describes the recommended levels for sensible drinking and the consequences for excessive drinking. Take time to read the leaflet. There are contact details on the back [Indicate where these are] should you need further help or advice’. [http://www.sips.iop.kcl.ac.uk/pil.php] PRE-EMPT is a training trial that examined the effects of the ‘Talking Lifestyle’ training program on outcomes following a routine practice consultation. This program aims to enhance skills in undertaking behaviour change discussions 5. This intervention was thus not specific to alcohol, which may have been discussed only for those screening positive, most likely for those for whom this was their only positive screen. To see the detailed content of the training program visit http://www.3trials.net: login = ku.ca.fc@01tseug, password = guest10, and then click on the Talking Lifestyles icon. Although there were good levels of engagement with the training program, skill acquisition was sub-optimal even though it was not designed for advanced practice. The listening skills that are a key feature of motivational interviewing were not included within the training program 5. Approximately one-third of the trials included within the Cochrane primary care review compared a brief intervention with no intervention (as in PRE-EMPT), and in the other two-thirds the control conditions were the provision of leaflets or usual care in the form of general practitioner (GP) advice to cut down (as in SIPS) 8. This review incorporates some emergency room studies as well as those conducted in general practice. Overall evaluated brief interventions were found to be effective in reducing drinking by approximately 38 grams of alcohol per week more than the control conditions 8. This means that the findings from both SIPS and PRE-EMPT differ from previous studies in ways that remains to be explained, though the existing literature is not straightforward to interpret 9. Both trials were pragmatic, intended by design to measure real world effectiveness, for which detailed investigation of intervention conduct could have interfered. The slow development of process study 10,11 has previously been widely recognised as a key weakness of this literature (see, e.g. 2) and the corollary to this is that we do not know as much about effective content as we should. As a result, there has been little or no evidence-based innovation in the design of advice interventions. In SIPS, there appears little difference in content between the evaluated leaflet and advice interventions other than in the extent of verbal interaction. Providing relatively patient-centred counselling after this type of advice 7 may not be optimal. As a training trial, the detailed content of the intervention was not the object of evaluation in PRE-EMPT, making it impossible to know how exactly these discussions were conducted 5. Counselling that simply calls upon the perspective of motivational interviewing, though does not implement it, as is the case in both trials, may simply not be helpful enough; non-specific forms of counselling do not have a good track record in this field (e.g. 12). Brief intervention content research questions are difficult to answer rigorously in pragmatic trials where effects may not survive well the translation into routine practice 6. This would be true even if the specific content has previously been established as efficacious, which it has not been for brief interventions. It is an interesting possibility that leaflets with SIPS content accompanied by minimal verbal interaction can be effective in their own right and as effective as lengthier discussions, however unlikely this appears. Brief interventions in routine practice can be very brief 13, and this SIPS intervention deserves to be evaluated in well-designed randomised controlled trials that overcome barriers to interpretation cited by the SIPS authors, such as assessment effects 14. Saitz 6 suggests that the SIPS trial results are vulnerable to unhelpful interpretations and I suggest this is true of PRE-EMPT too. Applying findings from these studies directly to influence policy and practice is misguided, as they conflict with what was previously known in ways which call for better understanding of the literature as a whole. A leaflet and a few words about drinking may well be enough for some, though we have no idea who they are and this is not what the wider literature indicates. It would be inadvisable to expect that anything delivered briefly as an intervention should be effective. There is reason to be concerned that many who might value the opportunity to talk about their drinking, and benefit from so doing, should not be denied that opportunity. It remains to be established which skills practitioners need to have, or how they need to be applied and for how long, in order to be able to discuss drinking or other behaviours in ways which do help people. Brief intervention content matters and we should study it.

Cigarette smoking as a target for potentiating outcomes for methamphetamine abuse treatment

Abstract: Introduction and Aims. Cigarette smoking occurs frequently among individuals with methamphetamine (MA) dependence. Preclinical and clinical evidence has suggested that the common co-abuse of MA and cigarettes represents a pharmacologically meaningful pattern. Methods. The present study is a secondary analysis of a randomised, placebo-controlled trial of bupropion treatment for MA dependence (bupropion n = 36; placebo n = 37). A hierarchical logistic modelling approach assessed the efficacy of bupropion for reducing MA use separately among smokers and non-smokers. Among smokers, relations between cigarettes smoked and MA use were assessed. Results. Smoking status did not affect treatment responsiveness in either the bupropion condition or the placebo condition. In the placebo condition, increased cigarette use was associated with an increased probability of MA use during the same time period. This effect was not observed in the bupropion condition. Discussion and Conclusions. Initial smoking status did not impact treatment outcomes. Among smokers, results suggest that bupropion may dissociate cigarette and MA use. The effect was modest and a precise pharmacological mechanism remains elusive. Cholinergic systems may be relevant for MA use outcomes. Future studies should continue to assess the role of smoking in MA treatment outcomes.[Brensilver M, Heinzerling KG, Swanson A-N, Telesca D, Furst BA, Shoptaw SJ. Cigarette smoking as a target for potentiating outcomes for methamphetamine abuse treatment. Drug Alcohol Rev 2013;32:96–99]

Trends in quetiapine use and non-fatal quetiapine-related ambulance attendances

Abstract: Introduction and Aims. Concern about the non-medical use of quetiapine and related acute harms is growing. Case series cite quetiapine as a potential drug of misuse, while recent research questions its relative safety in comparison with other atypical antipsychotic preparations. This paper explores population-level patterns of quetiapine-related ambulance attendances over time, identifying associated risk factors and potential subpopulations at-risk of acute harms. Design and Methods. A retrospective analysis of quetiapine-, olanzapine- and risperidone-related ambulance attendances in metropolitan Melbourne and prescription data in Victoria, Australia. Trends in ambulance attendance and prescription rates, attendance characteristics, and associated risk factors were explored from 2001 to 2010. Results. Quetiapine was consistently associated with substantially higher rates of ambulance attendances relative to prescription availability than olanzapine or risperidone. Quetiapine prescribing rates increased at a significantly greater magnitude than olanzapine or risperidone, leading to substantial increases in quetiapine attendances by population. Quetiapine-related attendances were associated with concurrent heroin and opioid replacement therapy toxicity, history of heroin and alcohol misuse, mood disorders, low Glasgow Coma Scale and women. Discussion and Conclusions. Trends in quetiapine-related ambulance attendances indicate rising community-level harms and greater harm relative to other atypical antipsychotics, while prescription patterns suggest increasing quetiapine availability. The association of quetiapine-related attendances with concurrent heroin and opioid replacement therapy toxicity as well as previous heroin and alcohol misuse suggest illicit and poly-drug users are a subpopulation at greater risk of quetiapine-related harms, consistent with emerging evidence of the use, misuse and diversion of quetiapine.

Factors influencing pharmacy services in opioid substitution treatment.

Abstract: Introduction and Aim Heroin dependence is a serious health burden in Australia. Opioid substitution treatment (OST) has been delivered in Australian community pharmacies since 1985. The effectiveness of pharmacy-based OST is evident and the demand is increasing; however, the participation rate of community pharmacies is low, with over 60% non-providers. While previous Australian studies have focused on perspectives of community pharmacists providing the service, the views of non-providers have not yet been explored. This study aimed to further investigate factors influencing pharmacists' participation in provision of OST in the community pharmacy setting in New South Wales, Australia. Design and Methods Semi-structured interviews were conducted with 35 NSW community pharmacists (20 providers, 15 non-providers). Transcripts of interviews were thematically analysed. Results Factors influencing non-providers were mainly stigma and fear, the nature of an opt-in scheme, professionals' moral responsibilities, lack of awareness and knowledge, disproportionate distribution of clients and lack of financial support for OST clients. Providers were motivated by positive attitudes, functional relationships with OST clients/stakeholders, professional satisfaction and financial rewards. Recommendations to improve participation in OST services were offered by both groups. Discussion and Conclusion This study explored views from both OST providers and non-providers, revealing a number of previously undocumented barriers that affect the uptake of OST provision in New South Wales community pharmacies. There were also profound ethical issues raised for consideration. These findings may help inform future policies aimed at encouraging pharmacists' provision of OST, to address the unmet needs of the ever-increasing number of heroin-dependent clients in the community. [Chaar BB, Wang H, Day CA, Hanrahan JR, Winstock AR, Fois R. Factors influencing pharmacy services in opioid substitution treatment. Drug Alcohol Rev2013;32:426–434]

Hypertension, chronic obstructive pulmonary disease, diabetes and depression among older methadone maintenance patients in British Columbia.

Abstract: Introduction and Aims Risk factors in older methadone maintenance treatment (MMT) patients may put them at a greater risk of acquiring chronic diseases; however, this group might experience barriers to treatment resulting in reduced recommended prescriptions. The research objective for this study was to assess whether MMT patients were significantly different from a matched control group in terms of medications dispensed for hypertension, chronic obstructive pulmonary disease (COPD), diabetes and depression. Design and Methods The research design was a case-control study, where prescription claims data from the British Columbia database were used. MMT patients 50 years of age and older were randomly selected, and control subjects were individually matched in terms of age, sex, social assistance coverage and geographic jurisdiction. Results Each group consisted of 199 participants. Odds ratios (OR) were calculated to compare the odds of MMT patients to non-MMT patients on a first-line medication for each chronic disease under investigation. The MMT group was significantly more likely to receive medications for COPD (OR = 32.68, P < 0.001) and depression (OR = 4.07, P < 0.001), and no significant differences for hypertension (OR = 0.86) or diabetes (OR = 0.74). Discussion Higher rates of COPD among MMT clients is likely explained by elevated smoking, and higher rates of depression may be explained by multiple disadvantages associated with substance use. Although the groups were similar for diabetes prescriptions, the MMT group likely experienced barriers to receiving treatment since prior research suggests their rates should be elevated due to methadone use. [Maruyama A, Macdonald S, Borycki E, Zhao J. Hypertension, chronic obstructive pulmonary disease, diabetes and depression among older methadone maintenance patients in British Columbia. Drug Alcohol Rev 2013;32:412–418]

Can harms associated with high intensity drinking be reduced by increasing the price of alcohol

Abstract: INTRODUCTION AND AIMS: Increasing the price of alcohol is consistently shown to reduce the average level of consumption. However, the evidence for the effect of increasing the price on high-intensity drinking is both limited and equivocal. The aim of this analysis is to estimate the effect of changes in price on patterns of consumption. DESIGN AND METHODS: Self-reported patterns of alcohol consumption and demographic data were obtained from the Australian National Drug Strategy Household Surveys, conducted in 2001, 2004 and 2007. A pooled three-stage least-squares estimator was used to simultaneously model the impact of the price on the frequency (measured in days) of consuming no, low, moderate and high quantities of alcohol. RESULTS: A 1% increase in the price of alcohol was associated with a statistically significant increase of 6.41 days per year on which no alcohol is consumed (P ≤ 0.049), and a statistically significant decrease of 7.30 days on which 1-4 standard drinks are consumed (P ≤ 0.021). There was no statistically significant change for high or moderate-intensity drinking. CONCLUSIONS: For Australia, and countries with a similar pattern of predominant high-intensity drinking, taxation policies that increase the price of alcohol and are very efficient at decreasing harms associated with reduced average consumption may be relatively inefficient at decreasing alcohol harms associated with high-intensity drinking. Language: en

Australia's double standard on Thailand's alcohol warning labels

Abstract: Introduction and Aims Since 2010, members of the World Trade Organization (WTO), including Australia, have opposed Thailand's proposal for graphic warnings on alcohol containers. This paper aims to provide an account of the arguments for/against Thailand and to examine the arguments' legal and political validity. Design and Methods This paper reviews primary WTO records in relation to Thailand's proposal to reveal the arguments for/against Thailand's proposal. The paper analyses these arguments in light of WTO cases to identify the legal strengths and weaknesses of Thailand's position. The paper then considers whether the attacks on Thailand by Australia are justified in light of the Australian Government's position on (i) alcohol warning labels in Australia and (ii) tobacco plain packaging. Results The legal arguments against Thailand are: only harmful alcohol consumption should be prevented; there is no evidence that graphic warning labels can reduce alcohol-related harm; the labels unnecessarily restrict international trade. There are some legal weaknesses in Thailand's proposal. Yet, Australia's opposition to Thailand cannot be justified whilst Australia is (i) mandating pregnancy-related alcohol warnings in Australia and (ii) defending its plain packaging law against similar WTO attacks. Discussion No WTO member is obliged to challenge another member for being non-compliant. The case tests the willingness of WTO members like Australia to respect the autonomy of other countries to pursue their public health goals and trial novel interventions. Conclusions Australia's actions suggest it is willing to protect its alcohol industry at the expense of public health in Thailand.

Monitoring the Internet for emerging psychoactive substances available to Australia

Abstract: Introduction and Aims. Novel psychoactive substances are increasingly available, both in traditional storefronts and via the Internet.While some use of such substances has been captured in Australian consumer surveys and wastewater analyses, there is little information about the products that are available to Australia via the Internet. Design and Methods. Systematic monthly Internet monitoring for emerging psychoactive substances was conducted between July 2011 and July 2012.Webstores identified through searches were examined to determine if they sold stimulant or psychedelic emerging psychoactive substances to Australia. Internet search numbers for these products were examined over time using commercial tools. Results. In 12 months, 43 unique webstores were identified selling to Australia, averaging two new webstores per month; however, two-fifths had closed within six months.Over 200 unique chemically unspecified products sold by purported effect (e.g. ‘charge’) were identified over 12 months, averaging 10 new products per month. Almost half of these products had disappeared from the market within six months. Eighty-six unique chemically specified products (e.g. methylenedioxypyrovalerone) were identified over 12 months, averaging four new novel substances per month. Once released, these products typically remained available, with almost 90% still available for purchase over a 6-month period. Almost 40 000 searches for these products emanated from Australia per month. Discussion and Conclusion. This market is fast paced as retailers strive to beat both regulatory processes and competitors. Ongoing attention to these markets, incorporating surveillance of both Internet and traditional storefronts, is crucial as several of the substances identified have demonstrated potential for health and neurological harm.