Understanding the research capacity of alcohol and other drugs services in New South Wales, Australia.

INTRODUCTION: Enhancing health system research capacity can support improved quality care. This study assessed the research capacity of public local health district (LHD) and non-government organisation (NGO) alcohol and other drug (AOD) services, at the organisational, team and individual level. Research barriers and motivators were also examined. METHODS: Staff from LHD and NGO AOD treatment services in New South Wales completed an online survey using the Research Capacity and Culture (RCC) tool. Overall median research capacity scores are presented for the RCC subscales (organisational, team and individual). Comparisons were conducted by service type (LHD/NGO), geographical location (metropolitan/rural) and affiliation with a research network (yes/no). Qualitative questions explored barriers and motivators to research at individual and team levels. RESULTS: Of 242 participants, 55% were LHD-based and 45% NGO-based. Overall RCC scores indicated moderate research capacity at all levels. Organisational capacity (Med = 6.50, interquartile range [IQR] = 3.50) scored significantly higher than the team (Med = 5.00, IQR = 6.00) and individual level (Med = 5.00, IQR = 4.25). No differences in RCC scores existed between NGOs and LHDs. Metropolitan AOD services scored higher research capacity at the organisational level (Med = 7.00, IQR = 3.00) than rural services (Med = 5.00, IQR = 5.00). LHDs affiliated with a research network scored significantly higher at the organisational, team and individual level than non-affiliated LHD services. Key research barriers were inadequate time and funding. Motivators included skill development and problem-identification requiring change. DISCUSSIONS AND CONCLUSIONS: AOD services in New South Wales have moderate research capacity. Identified barriers and motivators can be used to target responses that enhance capacity and improve treatment outcomes.

Patterns and Predictors of Heroin Use, Remission, and Psychiatric Health Among People with Heroin Dependence: Key Findings from the 18-20-Year Follow-Up of the Australian Treatment Outcome Study (ATOS).

This study aimed to investigate the long-term patterns and predictors of heroin use, dependence, and psychiatric health over 18-20 years among a cohort of Australians with heroin dependence, using a prospective longitudinal cohort study conducted in Sydney, Australia. The original cohort consisted of 615 participants, who were followed up at 3 months and 1, 2, 3, 11, and 18-20 years post-baseline; 401 (65.2%) were re-interviewed at 18-20 years. The Australian Treatment Outcome Study structured interview with established psychometric properties was administered to participants at each follow-up, addressing demographics, treatment and drug use history, overdose, crime, and physical and mental health. Overall, 96.7% completed at least one follow-up interview. At 18-20 years, 109 participants (17.7%) were deceased. Past-month heroin use decreased significantly over the study period (from 98.7 to 24.4%), with one in four using heroin at 18-20 years. Just under half were receiving treatment. Reductions in heroin use were accompanied by reductions in heroin dependence, other substance use, needle sharing, injection-related health, overdose, crime, and improvements in general physical and mental health. Major depression and borderline personality disorder (BPD) were consistently associated with poorer outcome. At 18-20 years, there is strong evidence that clinically significant levels of improvement can be maintained over the long term. The mortality rate over 18-20 years was devastating, with over one in six participants deceased. More sustained and targeted efforts are needed in relation to major depression and BPD to ensure evidence-based treatments are delivered to people with heroin dependence. Supplementary Information: The online version contains supplementary material available at 10.1007/s11469-022-01006-6.

Everolimus for the Prevention of Calcineurin-Inhibitor-Induced Left Ventricular Hypertrophy After Heart Transplantation (RADTAC Study).

OBJECTIVES: This study aimed to determine the safety and efficacy of combined low-dose everolimus and low-dose tacrolimus compared with standard-dose tacrolimus in attenuating left ventricular hypertrophy (LVH) after orthotopic heart transplantation (OHT). BACKGROUND: Calcineurin inhibitors (CNIs) such as tactrolimus are important in preventing cardiac allograft rejection and reducing mortality after OHT. However CNIs are causatively linked to the development of LVH, and are associated with nephrotoxicity and vasculopathy. CNI-sparing agents such as everolimus have been hypothesized to inhibit adverse effects of CNIs. METHODS: In this prospective, randomized, open-label study, OHT recipients were randomized at 12 weeks after OHT to a combination of low-dose everolimus and tacrolimus (the RADTAC group) or standard-dose tacrolimus (the TAC group), with both groups coadministered mycophenolate and prednisolone. The primary endpoint was LVH indexed as the change in left ventricular mass (ΔLVM) by cardiovascular magnetic resonance (CMR) imaging from 12 to 52 weeks. Secondary endpoints included CMR-based myocardial performance, T1 fibrosis mapping, blood pressure, and renal function. Safety endpoints included episodes of allograft rejection and infection. RESULTS: Forty stable OHT recipients were randomized. Recipients in the RADTAC group had significantly lower tacrolimus levels compared with the TAC group (6.5 ± 3.5 µg/l vs. 8.6 ± 2.8 µg/l; p = 0.02). The mean everolimus level in the RADTAC group was 4.2 ± 1.7 µg/l. A significant reduction in LVM was observed in the RADTAC group compared with an increase in LVM in the TAC group (ΔLVM = -13.0 ± 16.8 g vs. 2.1 ± 8.4 g; p < 0.001). Significant differences were also noted in secondary endpoints measuring function and fibrosis (Δ circumferential strain = -2.9 ± 2.8 vs. 2.1 ± 2.3; p < 0.001; ΔT1 mapping values = -32.7 ± 51.3 ms vs. 26.3 ± 90.4 ms; p = 0.003). No significant differences were observed in blood pressure (Δ mean arterial pressure = 4.2 ± 18.8 mm Hg vs. 2.8 ± 13.8 mm Hg; p = 0.77), renal function (Δ creatinine = 3.1 ± 19.9 µmol/l vs. 9 ± 21.8 µmol/l; p = 0.31), frequency of rejection episodes (p = 0.69), or frequency of infections (p = 0.67) between groups. CONCLUSIONS: The combination of low-dose everolimus and tacrolimus compared with standard-dose tacrolimus safely attenuates LVH in the first year after cardiac transplantation with an observed reduction in CMR-measured fibrosis and an improvement in myocardial strain.

Randomised controlled trial of integrated trauma-focused psychotherapy for traumatic stress and substance use among adolescents: trial protocol.

INTRODUCTION: Post-traumatic stress disorder (PTSD) and substance use disorder frequently co-occur and tend to have their onset during adolescence. Although research has highlighted the importance of treating these disorders in an integrated fashion, there is a dearth of empirically validated integrated treatment options for adolescents with this comorbidity. This paper describes the study protocol for a randomised controlled trial (RCT) examining the efficacy of an integrated trauma-focused cognitive-behavioural treatment for traumatic stress and substance use among adolescents (Concurrent Treatment of PTSD and Substance Use Using Prolonged Exposure - Adolescent (COPE-A)), relative to a supportive counselling control condition (Person-Centred Therapy (PCT)). METHODS AND ANALYSIS: A two-arm, parallel, single-blind RCT with blinded follow-up at 4 and 12 months poststudy entry will be conducted in Sydney, Australia. Participants (n~100 adolescents aged 12-18 years) and their caregivers (caregiver participation is optional) will be allocated to undergo either COPE-A or PCT (allocation ratio 1:1) using minimisation. Both therapies will be delivered individually by project psychologists over a maximum of 16 sessions of 60-90 min duration and will include provision of up to four 30 min optional caregiver sessions. The primary outcome will be between-group differences in change in the severity of PTSD symptoms from baseline to 4-month follow-up, as measured by the Clinician-Administered PTSD Scale for Children and Adolescents for DSM-5. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the human research ethics committees of the Sydney Children's Hospital Network (HREC/17/SCHN/306) and the University of Sydney (HREC 2018/863). Findings will be published in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBER: ACTRN12618000785202; Pre-reults. PROTOCOL VERSION: Version 1, 31 July 2017.

The contribution of methamphetamine use to crime: Evidence from Australian longitudinal data.

BACKGROUND: To quantify the extent to which methamphetamine use is associated with increases in crime net of any premorbid risk of criminality among people who use the drug. METHODS: Four one-month data panels from 469 participants dependent on methamphetamine were drawn from the MATES cohort (N = 501). Odds ratios for within-person effects were extracted from a random intercept logistic regression model for crime during periods of methamphetamine use compared to no use. Effects were adjusted for time-varying measures of age, other substance use, and socio-economic disadvantage (income, unemployment and unstable accommodation). Involvement in crime (property crime, drug dealing, fraud, violent crime) and days of methamphetamine in the past month were assessed using the Opiate Treatment Index. RESULTS: Crime was more likely during months when participants used methamphetamine compared to when they did not (OR 13.2 95% CI 8.5-20.6; AOR 4.7 95% CI 2.8-8.0), this reflecting more property crime (OR 10.6 95% CI 6.3-18.0; AOR 5.5 95% CI 2.8-10.8), violent crime (OR 8.2 95% CI 4.2-15.9; AOR 3.4 95% CI 1.5-8.0), fraud (OR 3.4, 95% CI 2.0-5.8; AOR 1.7 95% CI 0.8-3.3) and dealing drugs (OR 18.2 95% CI 10.2-32.5; AOR 5.9 95% CI 3.0-11.9), although the adjusted relationship for fraud was not significant. Effects were dose related. CONCLUSIONS: The use of methamphetamine was associated with significant increases in crime beyond premorbid risk for criminality. Crime is a likely social consequence of methamphetamine use and efforts are needed to reduce this impact.

Australian treatment outcome study: protocol for the 18-20-year follow-up of a prospective longitudinal cohort examining the natural history of heroin dependence and associated mortality, psychiatric and physical health, and health service use.

INTRODUCTION: Opioid dependence is a global health priority, currently making the biggest contribution to drug-related deaths. The chronic, long-term persistence of heroin dependence over the life course requires investigation in prospective longitudinal studies, to better understand patterns and predictors of remission and relapse, as well as the impact of changes in substance use on a range of physical and mental health outcomes. Such knowledge is critical in order to identify modifiable risk factors that can be targeted for intervention. Crucial unanswered questions include the following: What are the long-term rates of mortality? What are the long-term patterns and predictors of heroin use, remission, psychiatric health and health service use? What are the long-term physical health consequences of heroin use? METHODS AND ANALYSIS: The 18-20-year follow-up of the Australian Treatment Outcome Study (ATOS) cohort will examine the natural history of heroin dependence of an existing cohort of 615 people with heroin dependence, who were recruited into the study in 2001-2002. Five waves of follow-up interviews have since been completed, at 3-month, 1-year, 2-year, 3-year and 10-11-year post-baseline. At the 18-20-year follow-up, the ATOS cohort is (on average) approaching their 50s and an average of 30 years have passed since they first used heroin. The 18-20-year follow-up will consist of: (1) a structured interview; (2) physical health assessment; and (3) data linkage. The results of this follow-up will improve our understanding and management of age-related disorders in this population, which if not addressed in the immediate future, has the capacity to overwhelm treatment centres and aged care facilities. ETHICS AND DISSEMINATION: Ethical approval has been granted for the study (Sydney Local Health District Royal Prince Alfred Zone, Human Research Ethics Committee X18-0512 & HREC/18/RPAH/733). The results of the study will be disseminated through published manuscripts, bulletins and technical reports, as well as conference, seminars, webinar and workshop presentations.

Modelling Long-Term Joint Trajectories of Heroin Use and Treatment Utilisation: Findings from the Australian Treatment Outcome Study.

BACKGROUND: Heroin is currently contributing to the worst drug addiction epidemic in United States history; recent rates of use, dependence and death have also increased dramatically in parts of Europe. An improved understanding of the long-term relationship between heroin use and treatment utilisation is essential to inform both clinical and public health responses. We aimed to identify i) joint trajectories of heroin use and treatment utilisation, ii) predictors of joint group membership, and iii) outcomes associated with joint group membership; over 10-11 years among a cohort of Australians with heroin dependence. METHODS: A total of 615 people with heroin dependence were recruited as part of a prospective longitudinal cohort study between 2001 and 02. This analysis focuses on 428 participants (70.1% of the original cohort) for whom complete data were available over 10-11 years. FINDINGS: Five joint trajectory groups were identified: i) 'long-term stable' (17%: decrease in probability of heroin use alongside high treatment utilisation); ii) 'long-term success' (13%: decrease in heroin use alongside decreased treatment utilisation, until there was maintained abstinence from heroin with no treatment utilisation); iii) 'treatment failure' (12%: no decrease in heroin use alongside high treatment utilisation); iv) 'late success' (9%: gradual decrease in heroin use alongside increased treatment utilisation); and v) 'relapsed' (9%: relapse in heroin use alongside an increase and decrease in treatment utilisation). Few variables were found to predict joint group membership, but group membership was predictive of demographic, substance use and physical and mental health outcomes at 10-11 years. INTERPRETATION: The role of treatment in recovery from heroin dependence is undeniable; however, a considerable proportion of people are able achieve and maintain abstinence without the need for ongoing treatment. An equally significant proportion will continue to use heroin despite being in long-term treatment. FUNDING: Australian National Health and Medical Research Council.

Rumination and problematic substance use among individuals with a long-term history of illicit drug use.

BACKGROUND: Rumination is a cognitive process that is implicated in the development and maintenance of various forms of psychopathology, including problematic substance use. Most studies on the role of rumination in substance use have been conducted among community samples or individuals with alcohol use disorders and have predominately focused on overall rumination rather than differentiating between its subtypes, ruminative brooding and ruminative reflection. The current study therefore aimed to investigate i) whether rumination subtypes are associated with problematic substance use among people with a long-term history of illicit drug use independently of related psychological disorders (depression and post-traumatic stress disorder [PTSD]), and ii) whether gender moderates these relationships. METHODS: This cross-sectional study used data from the Australian Treatment Outcome Study (ATOS); a naturalistic prospective cohort study of people with heroin dependence. At the 11-year follow-up of ATOS, a total of 380 participants completed measures of rumination, depression, PTSD, and indices of problematic substance use. RESULTS: Hierarchical logistic regression analyses indicated that higher brooding scores were associated with current heroin dependence (OR = 1.11, CI: 1.01-1.22), polydrug use (OR = 1.16, CI: 1.06-1.28) and experience of injection related health problems (OR = 1.08, CI: 1.00-1.17), independently of depression, PTSD, and other covariates. Reflection was not related to any of the substance use measures. These results were not moderated by gender. CONCLUSIONS: Findings indicate that ruminative brooding is related to a poorer substance use profile among people with long-term illicit drug use and highlight the potential benefits of targeting brooding during substance use treatment.

Prevalence and correlates of low self-reported physical health status among prisoners in New South Wales, Australia.

PURPOSE: The purpose of this paper is to examine the prevalence and predictors of low self-reported physical health status among NSW prison inmates. DESIGN/METHODOLOGY/APPROACH: Cross-sectional random sample of 1,098 adult male and female prisoners, interviewed as part of the 2015 Justice Health and Forensic Mental Health Network Patient Health Survey. FINDINGS: Almost a quarter of participants had "low self-reported physical health status". Independent predictors of "low health status" were having been in out of home care before the age of 16 years, being illiterate, smoking 20 or more cigarettes a day, not eating more than one serve of fruit a day, not being physically active in the 12 months before incarceration, higher body mass index score and low self-reported mental health status. Many of these predictors are modifiable risk factors for chronic disease, which could be targeted during incarceration. ORIGINALITY/VALUE: This paper demonstrates the utility of a using a single item measure of self-reported physical health status among Australian prisoners, and helps to characterise those prisoners in greatest need of intervention for issues relating to their health.

Native T1 Mapping in the Diagnosis of Cardiac Allograft Rejection: A Prospective Histologically Validated Study.

OBJECTIVES: This study aimed to determine the role of T1 mapping in identifying cardiac allograft rejection. BACKGROUND: Endomyocardial biopsy (EMBx), the current gold standard to diagnose cardiac allograft rejection, is associated with potentially serious complications. Cardiac magnetic resonance (CMR)-based T1 mapping detects interstitial edema and fibrosis, which are important markers of acute and chronic rejection. Therefore, T1 mapping can potentially diagnose cardiac allograft rejection noninvasively. METHODS: Patients underwent CMR within 24 h of EMBx. T1 maps were acquired at 1.5-T. EMBx-determined rejection was graded according to International Society of Heart and Lung Transplant (ISHLT) criteria. RESULTS: Of 112 biopsies with simultaneous CMR, 60 were classified as group 0 (ISHLT grade 0), 35 as group 1 (ISHLT grade 1R), and 17 as group 2 (2R, 3R, clinically diagnosed rejection, antibody-mediated rejection). Native T1 values in patients with grade 0 biopsies and left ventricular ejection fraction >60% (983 ± 42 ms; 95% confidence interval: 972 to 994 ms) were comparable to values in nontransplant healthy control subjects (974 ± 45 ms; 95% confidence interval: 962 to 987 ms). T1 values were significantly higher in group 2 (1,066 ± 78 ms) versus group 0 (984 ± 42 ms; p = 0.0001) and versus group 1 (1,001 ± 54 ms; p = 0.001). After excluding patients with an estimated glomerular filtration rate <50 ml/min/m2, there was a moderate correlation of log-transformed native T1 with high-sensitivity troponin T (r = 0.54, p < 0.0001) and pro-B-type natriuretic peptide (r = 0.67, p < 0.0001). Using a T1 cutoff value of 1,029 ms, the sensitivity, specificity, and negative predictive value were 93%, 79%, and 99%, respectively. CONCLUSIONS: Myocardial tissue characterization with T1 mapping displays excellent negative predictive capacity for the noninvasive detection of cardiac allograft rejection and holds promise to reduce substantially the EMBx requirement in cardiac transplant rejection surveillance.

The long-term impact of post traumatic stress disorder on recovery from heroin dependence.

The high prevalence of post traumatic stress disorder (PTSD) among people with heroin dependence and its impact on short term outcomes has been well established. The impact of PTSD on long-term recovery is, however, unknown. This paper examines the impact of current and lifetime PTSD on long-term recovery from heroin dependence among participants who took part in the 11-year follow-up of the Australian Treatment Outcome Study (ATOS), a prospective naturalistic longitudinal study of 615 people with heroin dependence recruited from Sydney, Australia, in 2001-2002. Seventy-one percent of the cohort (n = 431) were re-interviewed 11-years post study entry. Outcomes examined included heroin and other drug use, dependence, general physical and mental health, depression, PTSD, employment, and the incidence of trauma exposure, overdose, imprisonment, and attempted suicide over the 11- year follow-up. Despite having a poorer profile at baseline, individuals with current PTSD or a history of PTSD at baseline demonstrated similar levels of improvement to those without a history of PTSD in all outcome domains across the 11-year follow-up, PTSD was associated with consistently higher levels of major depression, and attempted suicide, subsequent trauma exposure, and poorer occupational functioning across the 11-year follow-up. These findings highlight the importance of interventions aimed at occupational rehabilitation, reducing the likelihood of retraumatisation, and addressing PTSD and associated comorbidities among people with heroin dependence.

The relationship between methamphetamine use and heterosexual behaviour: evidence from a prospective longitudinal study.

AIMS: To estimate the extent to which specific sexual behaviours (being sexually active, having multiple sex partners, casual sex, condomless casual sex, anal sex and condomless anal sex) change during periods of methamphetamine use. DESIGN: Within-person estimates for the relationship between methamphetamine use and sexual behaviour were derived from longitudinal panel data from the Methamphetamine Treatment Evaluation Study (MATES) cohort (2006-10). SETTING: Sydney and Brisbane, Australia. PARTICIPANTS: Participants (n = 319) were recruited through treatment and other health services, self-identified as heterosexual, were aged 17-51 years, 74% were male and all were dependent on methamphetamine on study entry. MEASUREMENTS: Days of methamphetamine use in the past month and sexual behaviour in the past month were both assessed using the Opiate Treatment Index. FINDINGS: When using methamphetamine, participants had double the odds of being sexually active compared with when they were not using, after adjustment for demographics and other substance use [adjusted odds ratio (aOR) = 1.9, P = 0.010]. When participants were sexually active, they were more likely to have multiple sex partners (aOR = 3.3, P = 0.001), casual sex partners (aOR = 3.9, P < 0.001) and condomless casual sex (aOR = 2.6, P = 0.012) when using methamphetamine than when they were not using. During months when participants had a casual sex partner, there was no significant reduction in their likelihood of condom use when they were using methamphetamine. There was no significant change in the likelihood of having anal sex or condomless anal sex during months of methamphetamine use. CONCLUSIONS: Methamphetamine use is associated with an increase in being sexually active, having multiple sex partners and casual sex partners and having condomless sex with casual partners, but it is not associated with a change in condom use per se.

Predicting abstinence from methamphetamine use after residential rehabilitation: Findings from the Methamphetamine Treatment Evaluation Study.

INTRODUCTION AND AIMS: We previously found that residential rehabilitation increased continuous abstinence from methamphetamine use 1 year after treatment. We examine what client and treatment characteristics predict this outcome. DESIGN AND METHODS: Participants (n = 176) were dependent on methamphetamine and entering residential rehabilitation for methamphetamine use. Simultaneous logistic regression was used to identify independent predictors of continuous abstinence from methamphetamine use at 1 year follow-up. Measures included demographics, drug use, psychiatric comorbidity (Diagnostic and Statistical Manual of Mental Disorders, major depression, social phobia, panic disorder, schizophrenia, mania and conduct disorder), symptoms of psychosis and hostility, readiness to change, motivations for treatment and treatment characteristics (duration, rapport, group and individual counselling). RESULTS: Participants stayed in treatment for a median of 8 weeks; 23% remained abstinent at 1 year. The only independent predictors of abstinence were more weeks in treatment [adjusted odds ratio (AOR) 1.2, P < 0.001], better rapport with treatment providers (AOR 2.4, P = 0.049) and receipt of individual counselling (AOR 3.7, P = 0.013), whereas injecting methamphetamine predicted not achieving abstinence (AOR = 0.25, P = 0.002). Individual counselling and good rapport increased abstinence to 45%; for injectors, longer stays in treatment (13+ weeks) were additionally needed to produce similar abstinence rates (43%). DISCUSSIONS AND CONCLUSIONS: Abstinence from methamphetamine use following residential rehabilitation could be significantly increased by providing individual counselling, maintaining good rapport with clients and ensuring longer stays for people who inject the drug. [McKetin R, Kothe A, Baker AL, Lee NK, Ross J, Lubman DI. Predicting abstinence from methamphetamine use after residential rehabilitation: Findings from the Methamphetamine Treatment Evaluation Study. Drug Alcohol Rev 2018;37:70-78].

Trajectories of heroin use: 10-11-year findings from the Australian Treatment Outcome Study.

AIMS: To identify trajectories of heroin use in Australia, predictors of trajectory group membership and subsequent outcomes among people with heroin dependence over 10-11 years. DESIGN: Longitudinal cohort study. SETTING: Sydney, Australia. PARTICIPANTS: A total of 615 participants were recruited between 2001 and 2002 as part of the Australian Treatment Outcome Study (66.2% male; mean age 29 years). The predominance of the cohort (87.0%) was recruited upon entry to treatment (maintenance therapies, detoxification and residential rehabilitation), and the remainder from non-treatment settings (e.g. needle and syringe programmes). This analysis focused upon 428 participants for whom data on heroin use were available over 10-11 years following study entry. MEASUREMENTS: Structured interviews assessed demographics, treatment history, heroin and other drug use, overdose, criminal involvement, physical health and psychopathology. Group-based trajectory modelling was used to: (i) identify trajectory groups based on use of heroin in each year, (ii) examine predictors of group membership and (iii) examine associations between trajectory group membership and 10-11-year outcomes. FINDINGS: Six trajectory groups were identified [Bayesian Information Criterion (BIC) = -1927.44 (n = 4708); -1901.07 (n = 428)]. One in five (22.1%) were classified as having 'no decrease' in heroin use, with the probability of using remaining high during the 10-11 years (> 0.98 probability of use in each year). One in six (16.1%) were classified as demonstrating a 'rapid decrease to maintained abstinence'. The probability of heroin use among this group declined steeply in the first 2-3 years and continued to be low (< 0.01). The remaining trajectories represented other fluctuating patterns of use. Few baseline variables were found to predict trajectory group membership, but group membership was predictive of demographic, substance use and physical and mental health outcomes at 10-11 years. CONCLUSIONS: Long-term trajectories of heroin use in Australia appear to show considerable heterogeneity during a decade of follow-up, with few risk factors predicting group membership. Just more than a fifth continued to use at high levels, while fewer than a fifth become abstinent early on and remained abstinent. The remainder showed fluctuating patterns.

Substance use disorders comorbid with mood and anxiety disorders in the Australian general population.

INTRODUCTION AND AIMS: Substance use disorders (SUDs) are common and frequently co-occur with mood and anxiety disorders. This paper provides a detailed analysis of patterns, prevalence and correlates of mood and anxiety disorders among those with a (i) pure SUD; (ii) SUD plus a mood or anxiety disorder (SUDs + 1); and (iii) SUD plus a mood and anxiety disorder (SUDs + 2). DESIGN AND METHODS: Data came from the 2007 National Survey of Mental Health and Wellbeing; a nationally representative household survey of 8841 Australians aged 16-85 years. RESULTS: The 12-month prevalence of SUDs was 5.1%. Of those with a 12-month SUD, 65% met the criteria for pure SUDs, 19% for SUDs + 1 and 16% for SUDs + 2. Major depression was the most common mood disorder in both comorbid groups. One-third of SUDs + 1 experienced social phobia, while over half of SUDs + 2 experienced generalised anxiety disorder. Compared with pure SUDs, SUDs + 1 experienced two times more and SUDs + 2 experienced over four times more days out of role in the preceding 30 days. Both comorbid groups were more likely to experience severe levels of impairment. SUDs + 2 were over 18 times more likely to experience suicidal thoughts in the same year. SUDs + 1 were over three times and SUDs + 2 were over 10 times more likely to have had one or more consultations with a health professional in the previous year. DISCUSSIONS AND CONCLUSIONS: These findings highlight the complexities inherent with responding to and treating multiple comorbidities among substance users and emphasise the need for coordinated, cohesive responses from drug and alcohol treatment services.[Prior K, Mills K, Ross J, Teesson M. Substance use disorders comorbid with mood and anxiety disorders in the Australian general population. Drug Alcohol Rev 2017;36:317-324].

The efficacy of behavioural activation treatment for co-occurring depression and substance use disorder (the activate study): a randomized controlled trial.

BACKGROUND: Epidemiological studies suggest that compared with the general population, mood disorders are up to 4.7 times more prevalent in substance dependent samples. Comorbid substance use disorder (SUD) and depression has been associated with a more severe and protracted illness course and poorer treatment outcomes. Despite this, the development and assessment of behavioural interventions for treating depression among individuals with SUDs have received little empirical attention. Behavioural Activation Treatment for Depression (BATD-R) is an empirically supported treatment for depression that has shown some efficacy among substance users. This paper describes the study protocol of a parallel, single blind, randomised controlled trial to determine the efficacy and feasibility of a modified version of the BATD-R (Activate) in reducing symptoms of depression and substance dependence among individuals in residential rehabilitation (RR) and opioid substitution therapy (OST). METHODS/DESIGN: A sample of approximately 200 individuals with depressive symptomatology in treatment for SUD will be recruited from RR and OST services in New South Wales, Australia. Dynamic random allocation following minimisation methodology will be used to assign participants to one of two groups. The control group will receive treatment as usual (TAU), which will be the model of care provided in accordance with standard practice at participating RR and OST services. The intervention group will receive Activate, comprising 10 individual 60-min therapy sessions with a psychologist employed on the research team, in addition to TAU. Data collection will occur at baseline (pre-intervention), and 3-months and 12-months post baseline. DISCUSSION: The association between depression and substance dependence has been well documented, yet practical and effective treatments are scarce. The findings of the present study will contribute significantly to understanding the types of programs that are effective in treating this comorbidity. TRIAL REGISTRATION: This trial is registered with the Australian and New Zealand Clinical Trials registry, ACTRN12613000876796 . Registered on 7 August, 2013.

Years of potential life lost amongst heroin users in the Australian Treatment Outcome Study cohort, 2001-2015.

BACKGROUND: Heroin use carries the highest burden of disease of any drug of dependence. The study aimed to determine mortality rates of the Australian Treatment Outcome Study cohort over the period 2001-2015, and the years of potential life lost (YPLL). METHODS: The cohort consisted of 615 heroin users. Crude mortality rates per 1000 person years (PY) and Standardised Mortality Ratios (SMR) were calculated. YPLL were calculated using two criteria: years lost prior to age 65, and years lost prior to average life expectancy. RESULTS: The cohort was followed for 7,790.9 PY. At 2015, 72 (11.7%) of the cohort were deceased, with a crude mortality rate of 9.2 per 1000 PYs. Neither age nor gender associated with mortality. The SMR was 10.2 (males 7.3, females 17.2), matched for age, gender and year of death. The most common mortality cause was opioid overdose (52.8%). Using the<65 years criterion, there were 1988.3 YPLL, with a mean of 27.6 (males 27.6, females 27.7). Using the average life expectancy criterion, there were 3135.1 YPLL, with a mean of 43.5 (males 41.9, females 46.3). Accidental overdose (<65 yr 63.0%, average life expectancy 63.7%) and suicide (<65 yr 12.8%, average life expectancy 13.3%) accounted for three quarters of YPLL where cause of death was known. CONCLUSIONS: YPLL associated with heroin use was a quarter of a century, or close to half a century, depending on the criteria used. Given the prominent role of overdose and suicide, the majority of these fatalities, and the associated YPLL, appear preventable.

Coping with problematic drug use in the family: An evaluation of the Stepping Stones program.

INTRODUCTION AND AIMS: Problematic substance use by an individual is often highly destructive to their family, creating emotional turmoil and destroying healthy family functioning. The aim of this study was to evaluate the impact of participation in the Stepping Stones family support program on the coping capacity of family members affected by another's substance use. DESIGN AND METHODS: A pre and post study of the Stepping Stones intervention for families was conducted, involving 108 participants recruited from March 2013 to March 2014. RESULTS: Significant improvement in coping across all domains was observed post course and at follow up on both outcome measures (Coping Questionnaire and the Family Drug Support Questionnaire). Improvements for participants were either increased or sustained at 3 months follow up. Participants recorded high satisfaction ratings. DISCUSSION AND CONCLUSIONS: The findings from this study demonstrate that participation in the Stepping Stones program assists family members to cope better with problematic substance use of a family member, as indicated by reductions in negative coping strategies, such as over-engagement, making excuses for the drug user or hopelessly tolerating the problem, and improvements in positive coping strategies such as self-care and engagement with their own activities and interests. [Gethin A, Trimingham T, Chang T, Farrell M, Ross J. Coping with problematic drug use in the family: An evaluation of the Stepping Stones program. Drug Alcohol Rev 2016;35:470-476].

Therapist tips for the brief behavioural activation therapy for depression - revised (BATD-R) treatment manual practical wisdom and clinical nuance.

OBJECTIVE: This article aims to provide supportive guidance for clinicians using the brief behavioral activation treatment for depression - revised (BATD-R) manual. Expanding upon key points less explicitly addressed in the treatment manual, the goal is to convey practical wisdom and clinical nuance beyond that available in the manual, thereby enhancing therapist comfort with the approach and improving treatment delivery. METHODS: In preparation for a randomised control trial of behavioural activation treatment for depression among substance users (the Activate Study), Professor Carl Lejuez, an author on the manual, provided training to our research team. This occurred over four days in May 2013 at the National Drug and Alcohol Research Centre in Sydney, Australia and involved in-depth discussion about treatment delivery, often addressing important issues implied but not addressed in-depth in the manual. Reflections were discussed throughout training and subsequently collated into key themes. RESULTS: Intricacies associated with treatment delivery were identified. Seven key themes emerged, covering: provision of the treatment rationale; therapeutic alliance and self-disclosure; behaviour monitoring; values; angles and steps; contracts; and drawing from other therapeutic approaches. A detailed discussion of how to approach these themes in treatment forms the basis of this article. CONCLUSIONS: The current article seeks to guide therapists and provide a supplement to the BATD-R manual that will enhance the flexibility and accessibility for therapists utilising this treatment. The suggestions made are useful for straightforward cases of depression and more complicated comorbid presentations, serving as a useful complement for therapists using the manual.

Patterns and Correlates of Sustained Heroin Abstinence: Findings From the 11-Year Follow-Up of the Australian Treatment Outcome Study.

OBJECTIVE: We report on patterns and correlates of sustained abstinence at the 11-year follow-up of the Australian Treatment Outcome Study cohort. METHOD: This report is a longitudinal cohort analysis of patterns of recent and sustained abstinence. RESULTS: A total of 431 (70.1%) of the original 615 participants were interviewed, and 10.2% were deceased. The mean elapsed time since heroin initiation was 20.4 years (SD = 7.2). At the 11-year follow-up, heroin abstinence over the preceding month was reported by 75.2%. A period of at least 1 month's abstinence across the follow-up was reported by 97.7% and at least 1 year by 89.9%, whereas 52.2% reported an abstinence period of 5 or more consecutive years. Sustained abstinence across the entire follow-up period was reported by 5.6%. Independent correlates of 5 or more consecutive years of heroin abstinence were female gender (odds ratio [OR] = 1.73), not being currently enrolled in a drug treatment program (OR = 2.16), and fewer treatment episodes across the follow-up (OR = 0.90, 95% CI [0.85, 0.96]). CONCLUSIONS: The clinical profile of the cohort at the 11-year follow-up was encouraging, with the majority currently heroin abstinent, a proportion that has increased across time. Although only a small minority maintained abstinence over the entire period, half had sustained abstinence for at least 5 consecutive years. With the exception of gender, baseline characteristics made poor predictors of long-term abstinence. Treatment stability, however, appears crucial in maintaining abstinence.