National Ambulance Surveillance System: A novel method using coded Australian ambulance clinical records to monitor self-harm and mental health-related morbidity.

Self-harm and mental health are inter-related issues that substantially contribute to the global burden of disease. However, measurement of these issues at the population level is problematic. Statistics on suicide can be captured in national cause of death data collected as part of the coroner's review process, however, there is a significant time-lag in the availability of such data, and by definition, these sources do not include non-fatal incidents. Although survey, emergency department, and hospitalisation data present alternative information sources to measure self-harm, such data do not include the richness of information available at the point of incident. This paper describes the mental health and self-harm modules within the National Ambulance Surveillance System (NASS), a unique Australian system for monitoring and mapping mental health and self-harm. Data are sourced from paramedic electronic patient care records provided by Australian state and territory-based ambulance services. A team of specialised research assistants use a purpose-built system to manually scrutinise and code these records. Specific details of each incident are coded, including mental health symptoms and relevant risk indicators, as well as the type, intent, and method of self-harm. NASS provides almost 90 output variables related to self-harm (i.e., type of behaviour, self-injurious intent, and method) and mental health (e.g., mental health symptoms) in the 24 hours preceding each attendance, as well as demographics, temporal and geospatial characteristics, clinical outcomes, co-occurring substance use, and self-reported medical and psychiatric history. NASS provides internationally unique data on self-harm and mental health, with direct implications for translational research, public policy, and clinical practice. This methodology could be replicated in other countries with universal ambulance service provision to inform health policy and service planning.

The National Ambulance Surveillance System: A novel method for monitoring acute alcohol, illicit and pharmaceutical drug related-harms using coded Australian ambulance clinical records.

Although harmful consumption of alcohol and other drugs (both illicit and pharmaceutical) significantly contribute to global burden of disease, not all harms are captured within existing morbidity data sources. Indeed, harms occurring in the community may be missed or under-reported. This paper describes the National Ambulance Surveillance System, a unique Australian system for monitoring and mapping acute harms related to alcohol and other drug consumption. Data are sourced from paramedic electronic patient care records provided by ambulance services from across Australia. Coding occurs in a purpose-built system, by a team of specialised research assistants. Alcohol, and specific illicit and pharmaceutical drugs, rather than broad drug classes, are manually coded and the dataset is reviewed and cleaned prior to analysis. The National Ambulance Surveillance System is an ongoing, dynamic surveillance system of alcohol and other drug-related harms across Australia. The data includes more than 140 output variables per attendance, including individual substances, demographics, temporal, geospatial, and clinical data (e.g., Glasgow Coma Scale score, naloxone provision and response, outcome of attendance). The National Ambulance Surveillance System is an internationally unique population-level surveillance system of acute harms arising from alcohol and other drug consumption. Dissemination of National Ambulance Surveillance System data has been used to inform and evaluate policy approaches and potential points of intervention, as well as guide workforce development needs and clinical practice at the local and national level. This methodology could be replicated in other countries.

Harms associated with extramedical use of prescription opioid analgesics in Australia: A scoping review.

BACKGROUND: Evidence is accumulating globally on harms from extramedical prescription opioid analgesic (POA) use. OBJECTIVE: The aim of this scoping review was to explore harms and documented risk factors associated with extramedical POA use in Australia. METHODS: MEDLINE, EMBASE, PsycINFO and CINAHL were searched for original studies published between January 2000 and February 2018. Studies were eligible for inclusion if: 1) POA use was explicitly reported, 2) extramedical use was evident 3) harm was explicitly reported, 4) data were collected in/after 2000, 5) conducted in adults and 6) undertaken in Australia. RESULTS: We identified 560 articles and 16 met the inclusion criteria. Harms reported from extramedical POA use included: increased health service utilization (n = 5), non-fatal overdose (n = 6), fatal overdose (n = 5), injection-related injuries or diseases (n = 4), engagement in crime (n = 2), loss of employment (n = 1), and foreign body pulmonary embolization (n = 1). Multiple drug toxicity was reported as the cause of death in up to 83% of fatal overdose cases. Risk factors for harm included being male, aged 31-49 years, a history of chronic non-cancer pain, mental health disorders and/or substance abuse, and concomitant use of benzodiazepines, antidepressants or other centrally-acting substances. CONCLUSION: Extramedical use of POAs is associated with a range of harms, including fatal and non-fatal overdose. Polysubstance use with other centrally-acting substances was often implicated. No published studies used linked data sources to provide a comprehensive overview of the extent of POA use or harm in Australia. Future research should focus on undertaking longitudinal cohort studies with linked data sources.

Insomnia and Regulation of Sleep-Wake Cycle With Drugs Among Adolescent Risky Drinkers.

STUDY OBJECTIVES: We aimed to explore symptoms of insomnia in a group of youths characterized as engaging in risky drinking, their use of drugs as sleep/ wake aids, and the relationships between alcohol and other drug use and insomnia. METHODS: Face-to-face interviews were conducted with 596 Australian 14 to 19-year-olds identified as engaging in regular risky drinking. They completed the Insomnia Severity Index and were assessed for recent alcohol and other drug use, including drugs used specifically as sleep aids or to stay awake. Alcohol-related problems, emotional distress, self-control, and working outside of traditional hours were also assessed using validated scales. RESULTS: More than one-third of the study participants (36%) reported moderate to very severe sleep-onset insomnia, and 39% screened positive for clinical insomnia using adolescent criteria. Three-fourths used drugs in the past 2 weeks to regulate their sleep cycle (65% used stimulants to stay awake, mainly caffeine, and 32% used a depressant to get to sleep, mainly cannabis). Regression analyses showed that after controlling for variables such as sex, emotional distress, self-control, alcohol use problems, and past 6-month illicit or non-prescribed drug use, those who used drugs specifically to get to sleep or to stay awake were 2.0 (P < .001) and 1.7 (P = .02) times more likely to report clinical insomnia, respectively. CONCLUSIONS: Insomnia was commonly reported in this community sample of adolescents characterized as engaging in risky drinking. Those with symptoms of insomnia appeared to be managing their sleep-related symptoms through alcohol and other drug use, which may have further exacerbated their sleep issues.

Youth perceptions of alcohol advertising: are current advertising regulations working?

OBJECTIVES: We investigated young people's exposure to alcohol advertising, their intentions to consume and purchase alcohol products following the viewing of advertisements, and whether they perceived the actors in the advertisements as being under the age of 25 years. METHODS: Face-to-face interviews were completed with 351 risky drinking 16-19-year-old Australians, with a sub-sample (n=68) responding to a range of alcohol advertisements in an in-depth interview. RESULTS: Participants were exposed to alcohol advertisements from an average of seven specific contexts in the past 12 months, with younger adolescents more likely to recall TV and outdoor billboards (n=351). Positive perception of advertisements was associated with increased intention to use and to purchase advertised products (n=68). A liqueur advertisement actor was perceived by 94% as being under 25 years-old, and almost 30% thought the advertisement was marketed at people younger than 18 years of age. CONCLUSIONS: Young people's perceptions of alcohol advertising are not necessarily in line with expert/industry assessment; products are sometimes marketed in a way that is highly appealing to young people. Greater appeal was associated with increased intention to consume and to purchase products. Implications for public health: These results indicate deficiencies in the effectiveness of current advertising codes in regard to protecting the health and wellbeing of adolescents.

Pharmaceutical opioid overdose deaths and the presence of witnesses.

BACKGROUND: In the past two decades, rates of pharmaceutical opioid use and harms resulting from their use (including death) have risen. The present study identified a series of fatal opioid overdoses where there was evidence that witnesses had noted symptoms consistent with overdose, and examined associated contextual factors. METHODS: A retrospective review was undertaken utilising the Coroners Court of Victoria's Overdose Deaths Register for pharmaceutical opioid overdose deaths between 2011 and 2013. Information on the source of pharmaceutical opioids, co-contributing drugs, history of drug dependence, and mental illness was extracted and coded. RESULTS: Pharmaceutical opioids were involved in 587 deaths, and within these, 125 cases (21%) were witnessed. The majority of these witnessed deaths (77.6%) occurred at the deceased's residence, with the witness being a partner or unrelated acquaintance who did not realise the significance of what they were witnessing. The most common contributing pharmaceutical opioids were methadone (49.6%), codeine (32.0%), and oxycodone (19.2%), with the source more often prescribed than diverted. Co-contributing drugs were involved in 110 cases, with the most common being benzodiazepines. Evidence of current dependence and mental illness was found in 53.6% of cases. CONCLUSION: Most pharmaceutical opioid overdose deaths with a witness present occurred in the deceased's home, with symptoms of overdose being noted, but not acted upon. These findings support the trialling of education and/or naloxone to partners and family members of people who use pharmaceutical opioids in order to reduce overdose deaths.

The attribution of a death to heroin: A model to help improve the consistent and transparent classification and reporting of heroin-related deaths.

INTRODUCTION: Accurate attribution of heroin-related deaths, as well as the differentiation from other opioid analgesic-related deaths, is essential from a public health perspective. Heroin-related deaths involve a number of complexities where heroin-specific or non-specific metabolites and indicators (6-acetylmorphine [6-AM], morphine, and codeine) may or may not be detected. The aims of this study were therefore to develop a model for improved consistency in the attribution of heroin-related deaths and to determine areas of variation in the current decision-making processes. METHODS: A model was developed using different toxicological indicators of heroin use (6-AM, morphine to codeine ratio (M:C) or morphine alone) along with investigative evidence of heroin use (circumstances, scene and clinical findings) which were used to assign a weighted score. The combined scores for the toxicological and investigative evidence were used to determine the relative strength of association for the death being attributable to heroin according to three categories: suspected; likely; or strong. An expert panel was convened to validate the model and a series of test cases were provided to a cohort of forensic toxicologists and pathologists in order to identify sources of variation in decision-making within this group. The model was also evaluated for sensitivity and specificity by reviewing potential heroin-related cases and examining the evidence associated with the attribution of these cases to heroin or not. RESULTS AND DISCUSSION: Across all potential heroin-related death cases, the use of this model enabled a greater level of consistency in the attribution of death to heroin, especially in cases where 6-AM was not detected. The largest amount of variation in the attribution of a death to heroin was observed with potential intoxication-related deaths and in toxicity cases where a M:C ratio only was reported, even more than when no toxicological evidence was available. The reviewed cases highlighted the same variation in the attribution of a death to heroin, including a large number of cases that were attributed to morphine where 6-AM was not detected. CONCLUSION: This model provides a useful tool for improved accuracy and consistency in the differentiation, attribution and reporting of heroin-related deaths. Previously challenging cases where death occurred after a significant period of time and either no 6-AM was detected or no samples were taken, are able to be captured using this model.

Exploring mortality among drug treatment clients: The relationship between treatment type and mortality.

AIMS: Studies consistently identify substance treatment populations as more likely to die prematurely compared with age-matched general population, with mortality risk higher out-of-treatment than in-treatment. While opioid-using pharmacotherapy cohorts have been studied extensively, less evidence exists regarding effects of other treatment types, and clients in treatment for other drugs. This paper examines mortality during and following treatment across treatment modalities. METHODS: A retrospective seven-year cohort was utilised to examine mortality during and in the two years following treatment among clients from Victoria, Australia, recorded on the Alcohol and Drug Information Service database by linking with National Death Index. 18,686 clients over a 12-month period were included. Crude (CMRs) and standardised mortality rates (SMRs) were analysed in terms of treatment modality, and time in or out of treatment. RESULTS: Higher risk of premature death was associated with residential withdrawal as the last type of treatment engagement, while mortality following counselling was significantly lower than all other treatment types in the year post-treatment. Both CMRs and SMRs were significantly higher in-treatment than post-treatment. CONCLUSION: Better understanding of factors contributing to elevated mortality risk for clients engaged in, and following treatment, is needed to ensure that treatment systems provide optimal outcomes during and after treatment.

Queensland Alcohol-related violence and Night Time Economy Monitoring project (QUANTEM): a study protocol.

BACKGROUND: Alcohol-related harm is a substantial burden on the community in Australia and internationally, particularly harm related to risky drinking practices of young people in the night-time economy. This protocol paper describes a study that will report on the changes in a wide range of health and justice outcome measures associated with major policy changes in the state of Queensland, Australia. A key element includes trading hours restrictions for licensed premises to 2 am for the state and 3 am in Safe Night Precincts (SNPs). Other measures introduced include drinks restrictions after midnight, increased patron banning measures for repeat offenders, mandatory ID scanning of patrons in late-night venues, and education campaigns. METHODS: The primary aim of the study is to evaluate change in the levels of harm due to these policy changes using administrative data (e.g., police, hospital, ambulance, and court data). Other study elements will investigate the impact of the Policy by measuring foot traffic volume in SNPs, using ID scanner data to quantify the volume of people entering venues and measure the effectiveness of banning notices, using patron interviews to quantify the levels of pre-drinking, intoxication and illicit drug use within night-time economy districts, and to explore the impacts of the Policy on business and live music, and costs to the community. DISCUSSION: The information gathered through this project aims to evaluate the effectiveness of the Policy and to draw on these findings to inform future prevention and enforcement approaches by policy makers, police, and venue staff.

Alcohol-related serious road traffic injuries between 2000 and 2010: A new perspective to deal with administrative data in Australia.

BACKGROUND: According to the most recent statistics from the World Health Organization, 1.2 million people die or are injured on the world's roads every year. Drink-driving continues to be a major risk factor for road traffic crashes, with 22% of serious road injuries (SRIs) in Victoria involving a blood alcohol concentration (BAC) equal to or above the legal driving limit of 0.05g/mL. Use of police and hospital data to determine alcohol involvement in SRIs is not reliable, with researchers using proxy measures such as high alcohol hours (HAH). This paper examines patterns of alcohol-related SRIs based on reported BAC versus the surrogate HAH measure. METHODS: Trends over a 10year period (2000-2010) were examined, comparing four different SRI rates (low alcohol hours (LAH), LAH with positive BAC, HAH, HAH with positive BAC). Discontinuities in the data series were also examined. SRI data were drawn from the Road Networks Database of VicRoads containing information on all reported road crashes in Victoria. RESULTS: For the 10year period there were 52,286 reported SRIs relating to the driver. Of the incidents where a driver's reading was recorded, 44% had a recorded BAC exceeding Victoria's legal limit of 0.05% and a further 23% had a BAC below the legal limit. During the period over 17,000 (or 34%) SRIs occurred during HAH. Where a BAC had been recorded during HAH, almost 60% exceeded the legal limit and a further 20% had some positive recording of BAC. Where SRI drivers had a recorded BAC during LAH, 58% had a positive BAC (31% with a BAC over the legal limit). While it is likely that an SRI occurring during HAH will be associated with a positive BAC (80%), of which 60% will be above the legal limit, almost 60% of SRIs during LAH had a positive BAC, with 31% above the legal limit. CONCLUSION: There was no significant change in overall alcohol-related SRI rates between 2000 and 2010, suggesting that policies and procedures implemented to decrease drink-driving have not reduced alcohol-related SRI rates. In the absence of a reliable direct measure (i.e., BAC readings) this paper demonstrated the utility of the surrogate HAH measure for determining changes in alcohol-related serious road injuries. Further, the unmet need for routine BAC testing in SRIs occurring during LAH requires further exploration given the significant proportion of SRIs involving positive BAC during these times.

Most recent risky drinking session with Australian teenagers.

OBJECTIVE: Despite declines in Australian alcohol consumption, youth alcohol related harms remain prevalent. These alcohol-related consequences appear to be driven by a subset of risky drinkers who engage in 'high intensity' drinking episodes and are underrepresented in national health surveys. This project aims to investigate high risk drinking practices and alcohol-related harms amongst young people not otherwise recorded in existing data. METHODS: A community sample of the heaviest drinking 20-25% 16-19 year olds were surveyed across three Australian states (n=958; 80% metropolitan). We examined the context of their last risky drinking session through online and face-to-face surveys. RESULTS: Males consumed a mean of 17 and females 14 standard drinks, and 86% experienced at least one alcohol-related consequence during this session. More than a quarter of the face-to-face sample had Alcohol Use Disorders Identification Test (AUDIT) scores indicative of alcohol dependence. Indications of dependence were 2.3 times more likely among those who felt uncomfortable about seeking alcohol treatment, and less likely if harm reduction strategies were frequently used while drinking. CONCLUSIONS: It is clear this underrepresented population experiences substantial acute and potentially chronic consequences. IMPLICATIONS: Within the context of increasing alcohol-related harms among young Australians, the understanding of this group's drinking habits should be prioritised.

Characteristics of individuals presenting to treatment for primary alcohol problems versus other drug problems in the Australian patient pathways study.

BACKGROUND: People seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC. METHODS: Seven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann-Whitney U tests. RESULTS: Rates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC. CONCLUSIONS: While those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances than those with a primary drug problem, they experience similarly high levels of substance dependence severity and mental health and AOD service use. These findings reinforce the need for AOD services to integrate or coordinate care with programs that address the many complexities clients frequently present with, while also acknowledging differences between those seeking treatment for alcohol versus other drug problems.

Understanding trends in Australian alcohol consumption-an age-period-cohort model.

AIMS: To decompose Australian trends in alcohol consumption into their age, period (survey year) and cohort (birth year/generation) components. In particular, we aimed to test whether recent declines in overall consumption have been influenced by reductions in drinking among recently born cohorts. DESIGN: Seven cross-sectional waves of the Australian National Drug Strategy Household Survey (1995-2013). Age, period and cohort effects were estimated using a linear and logistic cross-classified random-effects models (CCREMs). SETTING: Australia PARTICIPANTS: A total of 124 440 Australians (69 193 females and 55 257 males), aged 14-79 years. MEASUREMENTS: Whether or not respondents consumed alcohol in the 12 months prior to the survey and, for those who did, the estimated volume of pure alcohol consumed, derived using standard quantity-frequency survey questions. FINDINGS: Controlling for age and period effects, there was significant variation in drinking participation and drinking volume by birth cohort. In particular, male cohorts born between the 1965 and 1974 and female cohorts born between 1955 and 1974 reported higher rates of drinking participation (P < 0.05), while the most recent cohorts (born in the 1990s) had lower rates of participation (P < 0.01). Among drinkers, the most recently born cohort also had sharply lower average consumption volumes than older cohorts for both men and women (P < 0.01). CONCLUSION: Recent birth cohorts (born between 1995 and 1999) in Australia report significantly lower rates of both drinking participation and drinking volume than previous cohorts, controlling for their age distribution and overall changes in population drinking. These findings suggest that the recent decline in alcohol consumption in Australia has been driven by declines in drinking among these recently born cohorts. These trends are consistent with international shifts in youth drinking.

Spatial variations in the consumption of illicit stimulant drugs across Australia: A nationwide application of wastewater-based epidemiology.

Obtaining representative information on illicit drug use and patterns across a country remains difficult using surveys because of low response rates and response biases. A range of studies have used wastewater-based epidemiology (WBE) as a complementary approach to monitor community-wide illicit drug use. In Australia, no large-scale WBE studies have been conducted to date to reveal illicit drug use profiles in a national context. In this study, we performed the first Australia-wide WBE monitoring to examine spatial patterns in the use of three illicit stimulants (cocaine, as its human metabolite benzoylecgonine; methamphetamine; and 3,4-methylendioxymethamphetamine (MDMA)). A total of 112 daily composite wastewater samples were collected from 14 wastewater treatment plants across four states and two territories. These covered approximately 40% of the Australian population. We identified and quantified illicit drug residues using liquid chromatography coupled with tandem mass spectrometry. There were distinctive spatial patterns of illicit stimulant use in Australia. Multivariate analyses showed that consumption of cocaine and MDMA was higher in the large cities than in rural areas. Also, cocaine consumption differed significantly between different jurisdictions. Methamphetamine consumption was more similar between urban and rural locations. Only a few cities had elevated levels of use. Extrapolation of the WBE estimates suggested that the annual consumption was 3tonnes for cocaine and 9tonnes combined for methamphetamine and MDMA, which outweighed the annual seizure amount by 25 times and 45 times, respectively. These ratios imply the difficulty of detecting the trafficking of these stimulants in Australia, possibly more so for methamphetamine than cocaine. The obtained spatial pattern of use was compared with that in the most recent national household survey. Together both WBE and survey methods provide a more comprehensive evaluation of drug use that can assist governments in developing policies to reduce drug use and harm in the communities.

Pre-Drinking Behavior of Young Heavy Drinkers.

BACKGROUND: Pre-drinking has been linked to subsequent heavy drinking and the engagement in multiple risky behaviors. OBJECTIVES: The present study examined a group of adolescents who recently had a "big night out" to determine whether there were differences in their pre-drinking behavior based on age, gender, geographic location, and social setting. METHODS: Participants (n = 351, aged 16-19) representing the heaviest 20-25% of drinkers in their age group were recruited using nonrandom sampling from metropolitan (Melbourne, Sydney, Perth) or regional (Bunbury) locations across Australia and administered a survey by a trained interviewer. RESULTS: Almost half the sample pre-drank (n = 149), most commonly at a friend's house. Those aged 18-19 were more likely to pre-drink, and did so at higher quantities compared to their younger counterparts. Males and females reported similar pre-drinking duration, quantity and amount spent on alcohol. Compared to those in cities, regional participants consumed greater quantities over longer periods of time. Two-thirds of participants consumed alcohol in excess of national guidelines during their pre-drinking session. These participants were more likely to nominate price as a motivation to pre-drink and were less likely to report that someone else provided them alcohol. CONCLUSIONS: This study sheds light on the pre-drinking habits of a population of young risky drinkers, and highlights the need for policy makers to address this form of drinking to reduce alcohol-related harm among young people.

Temporal changes in alcohol-related mortality and morbidity in Australia.

BACKGROUND AND AIMS: Alcohol consumption is an avoidable risk factor for morbidity and mortality. Studies have examined relative risks and outcomes of alcohol-related harms in Australia at discrete times, limiting the ability to examine changes across time. This paper examined alcohol consumption and its contribution to deaths, illness and injury at two time-points, 2001 and 2010. DESIGN: Alcohol consumption was modelled based on the 2001 and 2010 National Drug Strategy Household Survey, upshifted to reflect alcohol sales data. SETTING: All data reported are from Australian sources. MEASUREMENTS: Based on relative risk estimates obtained from meta-analysis, alcohol-attributable fractions were estimated for 42 disease and injury categories in 2001 and 2010 separately for conditions that were not 100% alcohol-attributable. Deaths and hospital separations attributable to alcohol were calculated in 2001 and 2010. FINDINGS: There was a relatively stable per capita consumption of alcohol across time, with males reporting higher levels of consumption compared with females. While there were increases in the number of abstainers from alcohol across time, the proportion of heavy alcohol consumers also increased. This corresponded with an observed increase in alcohol-attributable burden. For example, alcohol-attributable deaths increased from 4957 [95% confidence interval (CI) = 2867-8770] to 5610 (95% CI = 3398-9408) during the study period. CONCLUSION: The findings demonstrate that there has been an increase in alcohol-attributable harms between 2001 and 2010 in Australia without a corresponding increase in per capita consumption.