Influence of placement stability on developmental outcomes of children and young people in out-of-home care: Findings from the Pathways of Care Longitudinal Study.

BACKGROUND: Placement stability is an important indicator of the functioning of an out-of-home care system. Previous research suggests that frequent placement changes have a negative impact on the outcomes for children and young people in out-of-home care. OBJECTIVE: This paper examines the association between placement stability in out-of-home care and children's socio-emotional, cognitive and physical health outcomes. PARTICIPANT AND SETTING: The Pathways of Care Longitudinal Study (POCLS) is the first large-scale prospective longitudinal study of children in out-of-home care in Australia. The sample consists of any study child who participated in any of the first three waves of the POCLS interview. METHODS: Unweighted data from the first three waves of the POCLS interview and administrative data was used. A measure of placement stability was developed that accounted for both number of placements and length of time in care. Mixed effect modelling was used to examine the link between placement stability and children's developmental outcomes. RESULTS: Placement stability was found to have a significant association with socio-emotional, cognitive (non-verbal) and physical health (gross and fine motor skill) development. A number of other factors were also found to be associated with positive development. CONCLUSIONS: The findings support the existing evidence that placement stability is an important factor for children's development. Other factors including placement type, carer wellbeing and carer support are also important for positive development. Appropriate policy and practice intervention to support children and families to improve placement stability is fundamental to achieving positive developmental outcomes for children in out-of-home care.

The impact of Indigenous-led programs on alcohol-related criminal incidents: a multiple baseline design evaluation.

OBJECTIVES: To evaluate the impact of a multi-component, Aboriginal-led strategy to reduce alcohol-related criminal incidents for Aboriginal people in four rural/remote communities in New South Wales (NSW), Australia. METHODS: A retrospective multiple baseline design (MBD), using interrupted time series analysis of routinely collected crime data. RESULTS: A statistically significant reduction in alcohol-related criminal incidents was observed in one community for both victims of crime (parameter estimate -0.195; p≤0.01) and persons of interest (parameter estimate -0.282; p≤0.001). None of the analyses show level shifts, meaning there were no measurable changes immediately post the introduction of the Breaking the Cycle (BTC) programs. CONCLUSIONS: It is not possible to conclude that the program was effective independently of any other community factors, because the statistically significant result was not observed across multiple communities. The statistically significant result in one community has clear practical benefits in that community: a sustained impact over two years would reduce Aboriginal victims of alcohol-related crime from an estimated 56 incidents per annum to 36, and reduce Aboriginal persons of interest in alcohol-related crime from an estimated 68 alcohol-related person of interest (POI) per annum to 40. IMPLICATIONS FOR PUBLIC HEALTH: The statistically and practically meaningful result in Community 1 highlights the potential of multi-component, Aboriginal-led strategies to reduce alcohol-related criminal incidents. Earlier engagement with researchers, to identify best-evidence strategies to reduce alcohol harms and to facilitate the use of prospective evaluation designs, would help translate the positive outcome in one community across multiple communities.

Characteristics and causes of death in children with neonatal abstinence syndrome.

AIM: To determine characteristics of death in children with neonatal abstinence syndrome (NAS). METHODS: A population-based linkage study of children from birth to 13 years of age in New South Wales (NSW), Australia, born 1 July 2000 to 31 December 2011. Infants with an International Statistical Classification of Diseases and Related Problems, Australian modification coding of NAS (P96.1, n = 3842) were compared to infants (n = 1 018 421) without NAS by birth, hospitalisation and death records linkage. RESULTS: Forty-five (1.2%) children with NAS died, compared to 3665 (0.4%) other children. Most deaths (n = 30, 66%) in NAS children occurred between 1 month and 1 year. Risk of death was independently increased in full-term children (hazard ratio 2.34, 95% confidence interval 1.63-3.35; P < 0.001) from lower socio-economic groups (1.23, 1.12-1.35; P < 0.001), most commonly from ill-defined or external causes, including assault and accidents (P < 0.001). CONCLUSIONS: Children with NAS, especially those of term gestation and from lower socio-economic groups, are more likely to die, especially from external causes.

Opioid Use Fueling HIV Transmission in an Urban Setting: An Outbreak of HIV Infection Among People Who Inject Drugs-Massachusetts, 2015-2018.

Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID).Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors.Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses.Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response.Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative.

Understanding remote Aboriginal drug and alcohol residential rehabilitation clients: Who attends, who leaves and who stays?

INTRODUCTION AND AIMS: Aboriginal residential rehabilitation services provide healing for Aboriginal people who misuse substances. There is limited available research that empirically describes client characteristics of these services. This study examined 5 years of data of a remote Aboriginal residential rehabilitation service. DESIGN AND METHODS: Retrospective analysis of 329 client admissions to Orana Haven Drug and Alcohol Rehabilitation Centre from 2011 to 2016. Multinomial and binary logistic regressions were conducted to identify trends in the data. RESULTS: There were 66 admissions recorded annually, of which most identified as Aboriginal (85%). Mean length of stay was 56 days, with one in three (36%) discharging within the first month. A third (32%) completed, 47% self-discharged and 20% house-discharged from the program. Client age significantly increased over time (P = 0.03), with most aged from 26 to 35. Older clients were significantly more likely to readmit (P < 0.002) and stay longer than 90 days (P = 0.02). Most clients were referred from the criminal justice system, significantly increasing from 79% (2011-2012) to 96% (2015-2016) (P < 0.001) and these clients were more likely to self-discharge (P < 0.01). Among a subset of clients, most (69%) reported concerns with polysubstance use and half (51%) reported mental illness. DISCUSSION AND CONCLUSIONS: The current study makes a unique contribution to the literature by empirically describing the characteristics of clients of a remote Aboriginal residential rehabilitation service to more accurately tailor the service to the client's needs. Key recommendations include integrating these empirical observations with staff and client perceptions to co-design a model of care, standardise data collection, and routinely following-up clients to monitor treatment effectiveness.

"I just feel comfortable out here, there's something about the place": staff and client perceptions of a remote Australian Aboriginal drug and alcohol rehabilitation service.

BACKGROUND: The need for effective, culturally safe residential rehabilitation services for Aboriginal people is widely acknowledged, however the combination of treatment components that is optimally effective, is not well defined. Most existing Aboriginal residential rehabilitation research has focused on describing client characteristics, and largely ignored the impact of treatment and service factors, such as the nature and quality of therapeutic components and relationships with staff. METHODS: This qualitative study was undertaken as part of a three-year mixed methods community-based participatory research (CBPR) project that aimed to empirically describe a remote Aboriginal drug and alcohol rehabilitation service. Researchers utilised purposive sampling to conduct 21 in-depth, semi-structured interviews. The interviews used a 'research yarning' approach, a form of culturally appropriate conversation that is relaxed and narrative-based. The interview transcripts were thematically coded using iterative categorization. The emerging themes were then analysed from an Interpretative Phenomenological Analysis, focusing on how participants' lived experiences before and during their admission to the service shaped their perceptions of the program. RESULTS: A total of 12 clients (mean age 35 years, SD 9.07, 91% Aboriginal) and 9 staff (2 female, 7 male, mean age 48 years, SD 8.54, 67% Aboriginal) were interviewed. Five themes about specific program components were identified in the interview data: healing through culture and country; emotional safety and relationships; strengthening life skills; improved wellbeing; and perceived areas for improvement. This research found that Aboriginal drug and alcohol residential rehabilitation is not just about length of time in treatment, but also about the culture, activities and relationships that are part of the treatment process. CONCLUSION: This study highlights that cultural elements were highly valued by both clients and staff of a remote Aboriginal residential rehabilitation service, with the country or location being fundamental to the daily practice of, and access to, culture. Developing reliable and valid assessments of the program components of culture and treatment alliance would be valuable, given this study has reinforced their perceived importance in achieving positive treatment outcomes. Further, strengthening the aftercare program, as part of an integrated model of care, would likely provide greater support to clients after discharge.

Hepatitis C testing in general practice settings: A cross-sectional study of people who inject drugs in Australia.

BACKGROUND: People who inject drugs (PWID) often do not receive confirmatory RNA testing following positive HCV antibody testing. Expanding access to adequate testing and assessment will improve the progression of patients through the HCV care cascade with the potential to improve diagnosis as well as linkage to treatment. We aimed to determine current utilisation of general practitioners (GPs) by PWID in Australia compared to other settings for HCV testing and post-test discussions. METHODS: A national sample (n=888) of people who had injected drugs regularly in the past 6 months was interviewed about HCV antibody, RNA testing, and post-test discussions, and the settings where these took place. RESULTS: The majority of participants (n=735; 93%) reported antibody testing. Among participants who reported a positive result (n=435), 54% identified their regular GP as the setting where their most recent antibody test was conducted. Confirmatory RNA testing was reported by 60% (n=274) of those who reported being antibody positive. Among those who reported RNA testing (n=257), the most common setting reported was their regular GP (48%). There were no differences in the proportions who recalled post-test discussions at GPs compared to other settings. CONCLUSION: HCV testing was most frequently undertaken by participants' regular GP. GPs are currently providing testing and post-test discussions at similar proportions to other more specialised settings. However, RNA testing is incomplete for more than one-third of the antibody positive PWID interviewed. Our findings suggest that the general practice setting is a common and accessible setting for PWID to access HCV testing. Targeting GPs to improve follow-up of positive antibody tests may help to improve patient progression through the HCV care cascade.

How does the use of multiple needles/syringes per injecting episode impact on the measurement of individual level needle and syringe program coverage?

BACKGROUND: Recent work by McCormack et al. (2016) showed that the inclusion of syringe stockpiling improves the measurement of individual-level syringe coverage. We explored whether including the use of a new parameter, multiple sterile syringes per injecting episode, further improves coverage measures. METHODS: Data comes from 838 people who inject drugs, interviewed as part of the 2015 Illicit Drug Reporting System. Along with syringe coverage questions, the survey recorded the number of sterile syringes used on average per injecting episode. We constructed three measures of coverage: one adapted from Bluthenthal et al. (2007), the McCormack et al. measure, and a new coverage measure that included use of multiple syringes. Predictors of multiple syringe use and insufficient coverage (<100% of injecting episodes using a sterile syringe) using the new measure, were tested in logistic regression and the ability of the measures to discriminate key risk behaviours was compared using ROC curve analysis. RESULTS: 134 (16%) participants reported needing multiple syringes per injecting episode. Women showed significantly increased odds of multiple syringe use, as did those reporting injection related injuries/diseases and injecting of opioid substitution drugs or pharmaceutical opioids. Levels of insufficient coverage across the three measures were substantial (20%-28%). ROC curve analysis suggested that our new measure was no better at discriminating injecting risk behaviours than the existing measures. CONCLUSION: Based on our findings, there appears to be little need for adding a multiple syringe use parameter to existing coverage formulae. Hence, we recommend that multiple syringe use is not included in the measurement of individual-level syringe coverage.

New psychoactive substances: Purchasing and supply patterns in Australia.

OBJECTIVE: To examine the purchasing and supply patterns of new psychoactive substance (NPS) consumers in Australia. METHOD: Data were obtained from a self-selected sample of 296 past-year NPS consumers, with comparisons made across dimethyltryptamine (n = 104), 2C-x (n = 59), NBOMe (n = 27), and synthetic cannabinoid (n = 22) users. RESULTS: Most consumers (58%) nominated a friend as their main NPS source, and almost half (46%) reported that they had supplied NPS to others in the past year (predominantly "social supply"). However, when comparisons were made across NPS, NBOMe users were more likely to nominate a dealer (30%) or online marketplace (22%) as their main source and to report: supplying NPS to others (63%); supplying to strangers (29%) and acquaintances (24%); and supplying NPS for cash profit (29%). Similarly, NPS consumers who nominated online markets as their main NPS source (9%; n = 26) were more likely to have supplied NPS to others (risk ratio [RR] 1.57); supplied to strangers (RR 6.05) and acquaintances (RR 12.11); sold NPS for cash profit (RR 4.36); and to have exchanged NPS for something else (RR 3.27) than those who reported alternative primary sources. CONCLUSION: NBOMe consumers and those who nominated online markets as their main NPS source reported greater engagement with for-profit supply; it is unclear if these individuals have "drifted" into dealing or if they were already engaged in such activities.

Trends in reports of driving following illicit drug consumption among regular drug users in Australia, 2007-2013: Has random roadside drug testing had a deterrent effect?

INTRODUCTION: Driving following illicit drug consumption ('drug-driving') is a potential road safety risk. Roadside drug testing (RDT) is conducted across Australia with the dual aims of prosecuting drivers with drugs in their system and deterring drug-driving. We examined trends over time in self-reported past six-month drug-driving among sentinel samples of regular drug users and assessed the impact of experiences of RDT on drug-driving among these participants. METHODS: Data from 1913 people who inject drugs (PWID) and 3140 regular psychostimulant users (RPU) who were first-time participants in a series of repeat cross-sectional sentinel studies conducted in Australian capital cities from 2007 to 2013 and reported driving in the past six months were analysed. Trends over time were assessed using the χ2 test for trend. Multivariable logistic regressions assessed the relationship between experiences of RDT and recent drug-driving, adjusting for survey year, jurisdiction of residence and socio-demographic and drug use characteristics. RESULTS: The percentage of participants reporting recent (past six months) drug-driving decreased significantly over time among both samples (PWID: 83% [2007] vs. 74% [2013], p<0.001; RPU: 72% vs. 56%, p<0.001), but drug-driving remained prevalent. Lifetime experience of RDT increased significantly over time (PWID: 6% [2007] vs. 32% [2013], p<0.001; RPU: 2% vs. 11%, p<0.001). There were no significant associations between experiencing RDT and drug-driving among either PWID or RPU. CONCLUSION: Although there is some evidence that drug-driving among key risk groups of regular drug users is declining in Australia, possibly reflecting a general deterrent effect of RDT, experiencing RDT appears to have no specific deterrent effect on drug-driving. Further intervention, with a particular focus on changing attitudes towards drug-driving, may be needed to further reduce this practice among these groups.

The recovery of online drug markets following law enforcement and other disruptions.

INTRODUCTION: Online drug markets operating on the 'darknet' ('cryptomarkets') facilitate the trade of illicit substances at an international level. The present study assessed the longitudinal impact on cryptomarket trading of two major disruptions: a large international law enforcement operation, 'Operation Onymous'; and the closure of the largest cryptomarket, Evolution. METHODS: Almost 1150 weekly snapshots of a total of 39 cryptomarkets were collected between October 2013 and November 2015. Data were collapsed by month and the number of unique vendor aliases operating across markets was assessed using interrupted time series regression. RESULTS: Following both Operation Onymous and the closure of Evolution, significant drops of 627 (p=0.014) and 910 vendors (p<0.001) were observed, respectively. However, neither disruption significantly affected the rate at which vendor numbers increased overall. CONCLUSIONS: Operation Onymous and the closure of Evolution were associated with considerable, though temporary, reductions in the number of vendors operating across cryptomarkets. Vendor numbers, however, recovered at a constant rate. While these disruptions likely impacted cryptomarket trading at the time, these markets appear resilient to disruption long-term.

Neonatal Abstinence Syndrome and High School Performance.

BACKGROUND AND OBJECTIVES: Little is known of the long-term, including school, outcomes of children diagnosed with Neonatal abstinence syndrome (NAS) (International Statistical Classification of Disease and Related Problems [10th Edition], Australian Modification, P96.1). METHODS: Linked analysis of health and curriculum-based test data for all children born in the state of New South Wales (NSW), Australia, between 2000 and 2006. Children with NAS (n = 2234) were compared with a control group matched for gestation, socioeconomic status, and gender (n = 4330, control) and with other NSW children (n = 598 265, population) for results on the National Assessment Program: Literacy and Numeracy, in grades 3, 5, and 7. RESULTS: Mean test scores (range 0-1000) for children with NAS were significantly lower in grade 3 (359 vs control: 410 vs population: 421). The deficit was progressive. By grade 7, children with NAS scored lower than other children in grade 5. The risk of not meeting minimum standards was independently associated with NAS (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 2.2-2.7), indigenous status (aOR, 2.2; 95% CI, 2.2-2.3), male gender (aOR, 1.3; 95% CI, 1.3-1.4), and low parental education (aOR, 1.5; 95% CI, 1.1-1.6), with all Ps < .001. CONCLUSIONS: A neonatal diagnostic code of NAS is strongly associated with poor and deteriorating school performance. Parental education may decrease the risk of failure. Children with NAS and their families must be identified early and provided with support to minimize the consequences of poor educational outcomes.

Managing Maternal Substance Use in the Perinatal Period: Current Concerns and Treatment Approaches in the United States and Australia.

Substance use in pregnancy can have adverse effects on mother and fetus alike. Australia and the US are countries with high levels of substance use and policies advising abstinence, although the Australian approach occurs within a broader framework of harm minimization. Less attention has been paid to treatment of the mothers' substance use and what is considered gold standard. This is despite evidence that prior substance use in pregnancy is the most important factor in predicting future substance use in pregnancy. This paper draws together information from both the peer-reviewed and gray literature to provide a contemporary overview of patterns and outcomes of the three main drugs, alcohol, tobacco, and cannabis, used in Australia and the US during pregnancy and discusses what are considered gold standard screening and treatment approaches for these substances. This paper does not set out to be a comprehensive review of the area but rather aims to provide a concise summary of current guidelines for policy makers and practitioners who provide treatment for women who use substances in pregnancy.

Epidemiological Evidence for a Decreasing Incidence of Neonatal Abstinence Syndrome, 2000-11.

BACKGROUND: This study analyses the incidence of Neonatal Abstinence Syndrome (NAS) in a large geographically defined population in Australia. METHOD: Database linkage analysis of all births between 2000 and 2011 in New South Wales (NSW), Australia. The diagnosis of NAS was derived from hospital coding P96.1, 'Neonatal withdrawal symptoms from maternal use of drugs of addiction'. Temporal trends were studied by comparing epoch 1 (2000-05) with epoch 2 (2006-11). The relationship with changes in maternal factors was further analysed. RESULTS: The NAS was coded in 3842 of 1 022 263 live born infants (0.38%). NAS incidence peaked at 5.07 per 1000 live births in 2002, decreasing to 3.18 in 2011 and was negatively correlated with maternal age (r = -0.7). The rate of NAS in epoch 2 (3.4 per 1000 births, 95% CI 3.28, 3.58) was significantly lower than in epoch 1 (4.1 per 1000 births, 95% CI 3.96, 4.33). Epoch 2 mothers were significantly older (mean 29.8 years vs. 28.3 years), less likely to be multiparous (OR 0.7, 95% CI 0.6, 0.9) or smoke (OR 0.4, 95% CI 0.4, 0.5). They were more likely to engage in antenatal care earlier (mean first visit: 14.1 vs. 18.9 weeks). Most infants (~80%) were born at term (>37 weeks gestation). CONCLUSION: The incidence of NAS as a discharge diagnosis has decreased in our population since 2002. Mothers are also older and engaging earlier in prenatal care. Whether these changes alter NAS presentation and diagnosis or whether pregnant women are using drugs that do not cause typical NAS (e.g. amphetamines) is uncertain and requires further study.

Reasons for Rehospitalization in Children Who Had Neonatal Abstinence Syndrome.

BACKGROUND AND OBJECTIVES: Neonatal abstinence syndrome (NAS) occurs after in utero exposure to opioids, but outcomes after the postnatal period are unclear. Our objectives were to characterize childhood hospitalization after NAS. METHODS: Population-based linkage study of births, hospitalization, and death records of all children registered in New South Wales (NSW), Australia, between 2000 and 2011 to a maximum of 13 years. Infants with an International Statistical Classification of Disease and Related Problems, 10th Edition, Australian Modification, coding of NAS (P96.1, n = 3842) were compared with 1,018,421 live born infants without an NAS diagnosis. RESULTS: Infants with NAS were more likely to be admitted into a nursery (odds ratio 15.6, 95% confidence interval: 14.5-16.8) and be hospitalized longer (10.0 vs 3.0 days). In childhood, they were more likely to be rehospitalized (1.6, 1.5-1.7), die during hospitalization (3.3, 2.1-5.1), and be hospitalized for assaults (15.2, 11.3-20.6), maltreatment (21.0, 14.3-30.9), poisoning (3.6, 2.6-4.8), and mental/behavioral (2.6, 2.1-3.2) and visual (2.9, 2.5-3.5) disorders. Mothers of infants with NAS were more likely to be Indigenous (6.4, 6.0-7.0), have no antenatal care (6.6, 5.9-7.4), and be socioeconomically deprived (1.6, 1.5-1.7). Regression analyses demonstrated that NAS was the most important predictor of admissions for maltreatment (odds ratio 4.5, 95% confidence interval: 3.4-6.1) and mental and behavioral disorders (2.3, 1.9-2.9), even after accounting for prematurity, maternal age, and Indigenous status. CONCLUSIONS: Children with NAS are more likely to be rehospitalized during childhood for maltreatment, trauma, and mental and behavioral disorders even after accounting for prematurity. This continues to adolescence and emphasizes the critical need for continued support of this vulnerable group after resolution of NAS.

The effectiveness of community action in reducing risky alcohol consumption and harm: a cluster randomised controlled trial.

BACKGROUND: The World Health Organization, governments, and communities agree that community action is likely to reduce risky alcohol consumption and harm. Despite this agreement, there is little rigorous evidence that community action is effective: of the six randomised trials of community action published to date, all were US-based and focused on young people (rather than the whole community), and their outcomes were limited to self-report or alcohol purchase attempts. The objective of this study was to conduct the first non-US randomised controlled trial (RCT) of community action to quantify the effectiveness of this approach in reducing risky alcohol consumption and harms measured using both self-report and routinely collected data. METHODS AND FINDINGS: We conducted a cluster RCT comprising 20 communities in Australia that had populations of 5,000-20,000, were at least 100 km from an urban centre (population ≥ 100,000), and were not involved in another community alcohol project. Communities were pair-matched, and one member of each pair was randomly allocated to the experimental group. Thirteen interventions were implemented in the experimental communities from 2005 to 2009: community engagement; general practitioner training in alcohol screening and brief intervention (SBI); feedback to key stakeholders; media campaign; workplace policies/practices training; school-based intervention; general practitioner feedback on their prescribing of alcohol medications; community pharmacy-based SBI; web-based SBI; Aboriginal Community Controlled Health Services support for SBI; Good Sports program for sports clubs; identifying and targeting high-risk weekends; and hospital emergency department-based SBI. Primary outcomes based on routinely collected data were alcohol-related crime, traffic crashes, and hospital inpatient admissions. Routinely collected data for the entire study period (2001-2009) were obtained in 2010. Secondary outcomes based on pre- and post-intervention surveys (n = 2,977 and 2,255, respectively) were the following: long-term risky drinking, short-term high-risk drinking, short-term risky drinking, weekly consumption, hazardous/harmful alcohol use, and experience of alcohol harm. At the 5% level of statistical significance, there was insufficient evidence to conclude that the interventions were effective in the experimental, relative to control, communities for alcohol-related crime, traffic crashes, and hospital inpatient admissions, and for rates of risky alcohol consumption and hazardous/harmful alcohol use. Although respondents in the experimental communities reported statistically significantly lower average weekly consumption (1.90 fewer standard drinks per week, 95% CI = -3.37 to -0.43, p = 0.01) and less alcohol-related verbal abuse (odds ratio = 0.58, 95% CI = 0.35 to 0.96, p = 0.04) post-intervention, the low survey response rates (40% and 24% for the pre- and post-intervention surveys, respectively) require conservative interpretation. The main limitations of this study are as follows: (1) that the study may have been under-powered to detect differences in routinely collected data outcomes as statistically significant, and (2) the low survey response rates. CONCLUSIONS: This RCT provides little evidence that community action significantly reduces risky alcohol consumption and alcohol-related harms, other than potential reductions in self-reported average weekly consumption and experience of alcohol-related verbal abuse. Complementary legislative action may be required to more effectively reduce alcohol harms. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12607000123448.

Identifying individual- and population-level characteristics that influence rates of risky alcohol consumption in regional communities.

OBJECTIVE: To examine the extent to which individual- and community- level characteristics account for differences in risky alcohol consumption. METHOD: A cross-sectional postal survey of 2,977 randomly selected individuals from 20 regional communities in NSW, Australia. Individuals drinking at harmful levels on the AUDIT and for risk of harm in the short term and long-term were identified. Multi-level modelling of the correlates of risky alcohol consumption at the individual and community level was conducted. RESULTS: There were differences between communities in alcohol consumption patterns. Being male, unmarried and reporting worse health were significant individual-level correlates for drinking at levels for risk of harm in the long term. The number of GPs (+) and police (-) were significant community characteristics. Being younger (≤25), unmarried, Australian born and with a larger income was associated with drinking at levels for risk of harm in the short term and harmful drinking on the AUDIT. The number of hotels and clubs was positively associated with drinking at levels for risk of harm in the short term. CONCLUSIONS: Rates of risky drinking vary significantly between communities and both individual and community characteristics are significantly associated with risky alcohol consumption. IMPLICATIONS: A combination of individual- and population-level interventions, tailored to the risk profile of individual communities, is most likely to be optimally effective.

Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.

BACKGROUND: Buprenorphine maintenance treatment has been evaluated in randomised controlled trials against placebo medication, and separately as an alternative to methadone for management of opioid dependence. OBJECTIVES: To evaluate buprenorphine maintenance compared to placebo and to methadone maintenance in the management of opioid dependence, including its ability to retain people in treatment, suppress illicit drug use, reduce criminal activity, and mortality. SEARCH METHODS: We searched the following databases to January 2013: Cochrane Drugs and Alcohol Review Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Contents, PsycLIT, CORK, Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress, reference lists of identified studies and reviews. We sought published/unpublished randomised controlled trials (RCTs) from authors. SELECTION CRITERIA: Randomised controlled trials of buprenorphine maintenance treatment versus placebo or methadone in management of opioid-dependent persons. DATA COLLECTION AND ANALYSIS: We used Cochrane Collaboration methodology. MAIN RESULTS: We include 31 trials (5430 participants), the quality of evidence varied from high to moderate quality.There is high quality of evidence that buprenorphine was superior to placebo medication in retention of participants in treatment at all doses examined. Specifically, buprenorphine retained participants better than placebo: at low doses (2 - 6 mg), 5 studies, 1131 participants, risk ratio (RR) 1.50; 95% confidence interval (CI) 1.19 to 1.88; at medium doses (7 - 15 mg), 4 studies, 887 participants, RR 1.74; 95% CI 1.06 to 2.87; and at high doses (≥ 16 mg), 5 studies, 1001 participants, RR 1.82; 95% CI 1.15 to 2.90. However, there is moderate quality of evidence that only high-dose buprenorphine (≥ 16 mg) was more effective than placebo in suppressing illicit opioid use measured by urinanalysis in the trials, 3 studies, 729 participants, standardised mean difference (SMD) -1.17; 95% CI -1.85 to -0.49, Notably, low-dose, (2 studies, 487 participants, SMD 0.10; 95% CI -0.80 to 1.01), and medium-dose, (2 studies, 463 participants, SMD -0.08; 95% CI -0.78 to 0.62) buprenorphine did not suppress illicit opioid use measured by urinanalysis better than placebo.There is high quality of evidence that buprenorphine in flexible doses adjusted to participant need,was less effective than methadone in retaining participants, 5 studies, 788 participants, RR 0.83; 95% CI 0.72 to 0.95. For those retained in treatment, no difference was observed in suppression of opioid use as measured by urinalysis, 8 studies, 1027 participants, SMD -0.11; 95% CI -0.23 to 0.02 or self report, 4 studies, 501 participants, SMD -0.11; 95% CI -0.28 to 0.07, with moderate quality of evidence.Consistent with the results in the flexible-dose studies, in low fixed-dose studies, methadone (≤ 40 mg) was more likely to retain participants than low-dose buprenorphine (2 - 6 mg), (3 studies, 253 participants, RR 0.67; 95% CI: 0.52 to 0.87). However, we found contrary results at medium dose and high dose: there was no difference between medium-dose buprenorphine (7 - 15 mg) and medium-dose methadone (40 - 85 mg) in retention, (7 studies, 780 participants, RR 0.87; 95% CI 0.69 to 1.10) or in suppression of illicit opioid use as measured by urines, (4 studies, 476 participants, SMD 0.25; 95% CI -0.08 to 0.58) or self report of illicit opioid use, (2 studies, 174 participants, SMD -0.82; 95% CI -1.83 to 0.19). Similarly, there was no difference between high-dose buprenorphine (≥ 16 mg) and high-dose methadone (≥ 85 mg) in retention (RR 0.79; 95% CI 0.20 to 3.16) or suppression of self-reported heroin use (SMD -0.73; 95% CI -1.08 to -0.37) (1 study, 134 participants).Few studies reported adverse events ; two studies compared adverse events statistically, finding no difference between methadone and buprenorphine, except for a single result indicating more sedation among those using methadone. AUTHORS' CONCLUSIONS: Buprenorphine is an effective medication in the maintenance treatment of heroin dependence, retaining people in treatment at any dose above 2 mg, and suppressing illicit opioid use (at doses 16 mg or greater) based on placebo-controlled trials.However, compared to methadone, buprenorphine retains fewer people when doses are flexibly delivered and at low fixed doses. If fixed medium or high doses are used, buprenorphine and methadone appear no different in effectiveness (retention in treatment and suppression of illicit opioid use); however, fixed doses are rarely used in clinical practice so the flexible dose results are more relevant to patient care. Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use.