Hepatitis C (HCV) Reinfection and Risk Factors among Clients of a Low-Threshold Primary Healthcare Service for People Who Inject Drugs in Sydney, Australia.

Hepatitis C (HCV) reinfection studies have not focused on primary healthcare services in Australia, where priority populations including people who inject drugs (PWID) typically engage in healthcare. We aimed to describe the incidence of HCV reinfection and associated risk factors in a cohort of people most at risk of reinfection in a real-world community setting. We conducted a secondary analysis of routinely collected HCV testing and treatment data from treatment episodes initiated with direct-acting antiviral (DAA) therapy between October 2015 and June 2021. The overall proportion of clients (N = 413) reinfected was 9% (N = 37), and the overall incidence rate of HCV reinfection was 9.5/100PY (95% CI: 6.3-14.3). Reinfection incidence rates varied by sub-group and were highest for Aboriginal and/or Torres Strait Islander people (20.4/100PY; 95% CI: 12.1-34.4). Among PWID (N= 321), only Aboriginality was significantly associated with reinfection (AOR: 2.73, 95% CI: 1.33-5.60, p = 0.006). High rates of HCV reinfection in populations with multiple vulnerabilities and continued drug use, especially among Aboriginal and Torres Strait Islander people, highlight the need for ongoing regular HCV testing and retreatment in order to achieve HCV elimination. A priority is resourcing testing and treatment for Aboriginal and/or Torres Strait Islander people. Our findings support the need for novel and holistic healthcare strategies for PWID and the upscaling of Indigenous cultural approaches and interventions.

Substances injected at the Sydney supervised injecting facility: A chemical analysis of used injecting equipment and comparison with self-reported drug type.

Providing information about substances injected can reduce the negative impact of illicit drug consumption and support people who inject drugs to make informed decisions. In Australia, information about drugs injected relies largely on periodic self-report surveys. For the first time, the analysis of the residual content of used injecting equipment was conducted in a supervised injecting facility (SIF) located in Sydney, Australia. The aim was to gain a better understanding of the substances injected by clients through: (1) chemical analyses of the content of used syringes; (2) comparison of these results with clients' self-reported drug use; and (3) assessing the usefulness of analysing other injecting equipment to detect substances used. During one week in February 2019, syringes and other injecting equipment were collected at the Sydney SIF. Their residual content was analysed by gas-chromatography/mass-spectrometry. Heroin was the most commonly detected substance (present in 51% of syringes), followed by methamphetamine (22%) and oxycodone (10%). In addition to the main psychoactive substance, cutting agents reported in the literature were also detected in used syringes. The main psychoactive substance identified by laboratory analysis reliably corresponded with users' self-reported drug type. Analytical confirmation of substances injected allows for the provision of better targeted harm reduction messaging based on timely and objective data. The approach used is amenable to clients and feasible in the Australian SIF context. Upscaling and wider implementation could be done through Needle and Syringe Programs, and would support the early detection of harmful substances entering drug markets and better inform harm reduction strategies.

"Beyond Safer Injecting"-Health and Social Needs and Acceptance of Support among Clients of a Supervised Injecting Facility.

Health and social issues in aging populations of people who inject drugs (PWID) tend to aggregate, despite risky injecting practices decreasing with age. Identifying needs and avenues of support is becoming increasingly important. We described the health and social situation among clients of a long-running supervised injecting facility (SIF) in Sydney, Australia. An interviewer-administered survey (n = 182) assessed current housing status, employment, physical and mental health, incarceration history, drug use, engagement in drug treatment, health service utilization, and willingness to accept support. Results were compared to the information provided at initial visit. Up to half of the participants transitioned between lower- and higher-risk health and social indicators over time. Willingness to accept support was greatest amongst those with higher self-perceived need. Support for mental health was a low priority, despite the high self-reporting of mental health issues. SIF clients are open to support for health and social issues, despite ongoing active drug use. Lower-threshold services such as SIFs are well-positioned to recognize and respond to deteriorating health and social issues for PWID. Facilitating care and treatment remains a challenge when the services to which people are being referred are higher-threshold with a more rigid approach.

Does adolescent heavier alcohol use predict young adult aggression and delinquency? Parallel analyses from four Australasian cohort studies.

While the association between heavy alcohol consumption and aggression has been well documented, the causal direction of this association, particularly at a population level, is disputed. A number of causal sequences have been proposed. First, that aggression leads to heavy alcohol use. Second, that heavy alcohol use leads to aggression. Third, that the association between alcohol use and aggression is due to confounding by (a) sociodemographic variables or (b) delinquency. We report here data from four Australasian prospective longitudinal studies of adolescents, to assess the temporal sequence of heavy drinking and aggression over the period from adolescence to young adulthood. The four cohort studies provide a total sample of 6,706 persons (Australian Temperament Project, n = 1701; Christchurch Health and Development Study, n = 931; Mater-University of Queensland Study of Pregnancy, n = 2437; Victorian Adolescent Health Cohort Study, n = 1637). We use multinomial logistic regression to determine whether early adolescent aggression predicts subsequent age of onset of heavy episodic drinking (HED), after adjustment for concurrent sociodemographic factors and delinquency. We then consider whether HED predicts subsequent aggression, after adjusting for past aggression, concurrent delinquency, and a range of confounders. There are broadly consistent findings across the four cohort studies. Early aggression strongly predicts subsequent HED. HED predicts later aggression after adjustment for prior aggression and other confounders. Policies that alter population levels of alcohol consumption are likely to impact on levels of aggression in societies where HED linked to aggression is more common.

Alcohol and parenthood: An integrative analysis of the effects of transition to parenthood in three Australasian cohorts.

AIMS: To determine the extent to which the transition to parenthood protects against heavy and problematic alcohol consumption in young men and women. DESIGN: Integrated participant-level data analysis from three population-based prospective Australasian cohort studies. SETTING: General community; participants from the Australian Temperament Study, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. MEASUREMENTS: Recent binge drinking, alcohol abuse/dependence and number of standard drinks consumed per occasion. FINDINGS: 4015 participants (2151 females; 54%) were assessed on four occasions between ages 21 and 35. Compared to women with children aged <12 months, women who had not transitioned to parenthood were more likely to meet the criteria for alcohol abuse/dependence (fully adjusted risk ratio [RR] 3.5; 95% CI 1.5-7.9) and to report recent binge drinking (RR 3.0; 95% CI 2.1-4.3). The proportion of women meeting the criteria for alcohol abuse/dependence and/or binge drinking increased with the age of participants' youngest child, as did the mean number of standard drinks consumed on each occasion (1.8 if the youngest child was <1 year of age vs. 3.6 for 5+ years of age). Associations between parenthood and male drinking behaviour were considerably weaker. CONCLUSIONS: For most women in their twenties and thirties, parenting a child <1 year of age was associated with reduced alcohol consumption. However, this protective effect diminished after 12 months with drinking levels close to pre-parenthood levels after five years. There was little change in male drinking with the transition to parenthood.

Adverse adult consequences of different alcohol use patterns in adolescence: an integrative analysis of data to age 30 years from four Australasian cohorts.

BACKGROUND AND AIMS: Studies have linked adolescent alcohol use with adverse consequences in adulthood, yet it is unclear how strong the associations are and to what extent they may be due to confounding. Our aim was to estimate the strength of association between different patterns of adolescent drinking and longer-term psychosocial harms taking into account individual, family and peer factors. DESIGN: Participant-level data were integrated from four long-running longitudinal studies: Australian Temperament Project, Christchurch Health and Development Study, Mater Hospital and University of Queensland Study of Pregnancy and Victorian Adolescent Health Cohort Study. SETTING: Australia and New Zealand. PARTICIPANTS: Participants were assessed on multiple occasions between ages 13 and 30 years (from 1991 to 2012). Number of participants varied (up to n = 9453) by analysis. MEASUREMENTS: Three patterns of alcohol use (frequent, heavy episodic and problem drinking) were assessed prior to age 17. Thirty outcomes were assessed to age 30 spanning substance use and related problems, antisocial behaviour, sexual risk-taking, accidents, socio-economic functioning, mental health and partner relationships. FINDINGS: After covariate adjustment, weekly drinking prior to age 17 was associated with a two- to threefold increase in the odds of binge drinking [odds ratio (OR) = 2.14; 95% confidence interval (CI) = 1.57-2.90], drink driving (OR = 2.78; 95% CI = 1.84-4.19), alcohol-related problems (OR = 3.04; 95% CI = 1.90-4.84) and alcohol dependence (OR = 3.30; 95% CI = 1.69-6.47) in adulthood. Frequency of drinking accounted for a greater proportion of the rate of most adverse outcomes than the other measures of alcohol use. Associations between frequent, heavy episodic and problem drinking in adolescence and most non-alcohol outcomes were largely explained by shared risk factors for adolescent alcohol use and poor psychosocial functioning. CONCLUSIONS: Frequency of adolescent drinking predicts substance use problems in adulthood as much as, and possibly more than, heavy episodic and problem drinking independent of individual, family and peer predictors of those outcomes.

Uptake of wheel-filtration among clients of a supervised injecting facility: Can structured education work?

INTRODUCTION AND AIMS: Wheel-filtration of pharmaceutical opioid tablets is a recognised harm reduction strategy, but uptake of the practice among people who inject drugs is low. The study aimed to: (i) examine perceptions of filtration practices; (ii) provide structured education on wheel-filtration; and (iii) assess uptake of the practice. DESIGN AND METHODS: Frequent opioid tablet injectors (n = 30) attending a supervised injecting facility in Sydney, Australia, received hands-on instruction on wheel-filtration based on recommended practice. Pre-education, post-education and follow-up questionnaires were administered. RESULTS: Wheel-filtration was generally regarded as better than cotton-filtration (the typical method) in terms of perceived effects on health, ease of use and overall drug effect. Sixty-eight percent of those who said they would try wheel-filtration after the education had actually done so. Of those who usually used cotton-filtration, over half (60%) had used wheel-filtration two weeks later. DISCUSSION AND CONCLUSIONS: Uptake of safer preparation methods for pharmaceutical opioid tablets increases after structured education in wheel-filtration. Findings suggest that SIFs are an effective site for this kind of education. Supervised injecting facility workers are uniquely positioned to provide harm reduction education at the time of injection. [Steele M, Silins E, Flaherty I, Hiley S, van Breda N, Jauncey M. Uptake of wheel-filtration among clients of a supervised injecting facility: Can structured education work? Drug Alcohol Rev 2018;37:116-120].

A prospective study of the substance use and mental health outcomes of young adult former and current cannabis users.

INTRODUCTION AND AIMS: The extent to which young adult former cannabis users fare better than infrequent users is unclear. We investigated the association between cannabis use status at age 23 and substance use and mental health outcomes at age 27. DESIGN AND METHODS: Data were from the 20+ year cohort of the PATH Through Life Study. Lifetime cannabis users (n = 1410) at age 23 were classified as former/occasional/regular users. Multivariable logistic regression was used to estimate the association between cannabis use status at age 23 and six outcomes assessed at age 27. RESULTS: Compared with occasional cannabis users: (i) former users had odds of subsequent tobacco use [odds ratio (OR) = 0.67, 95% confidence interval (CI) 0.52-0.85], illicit drug use (cannabis, OR = 0.22, 95% CI 0.17-0.28; other illicit drugs, OR = 0.29, 95% CI 0.22-0.39) and mental health impairment (OR = 0.71, 95% CI 0.55-0.92) that were 29-78% lower; and (ii) regular users had odds of subsequent frequent alcohol use (OR = 2.34, 95% CI 0.67-1.34), tobacco use (OR = 3.67, 95% CI 2.54-5.30), cannabis use (OR = 11.73, 95% CI 6.81-20.21) and dependence symptoms (OR = 12.60, 95% CI 8.38-18.94), and other illicit drug use (OR = 2.95, 95% CI 2.07-4.21) that were 2-13 times greater. Associations attenuated after covariate adjustment, and most remained significant. DISCUSSION AND CONCLUSIONS: Clear associations exist between cannabis use status in young adulthood and subsequent mental health and substance use. While early intervention remains important to prevent regular cannabis use and the associated harms, experimentation with cannabis use in the years leading into young adulthood may not necessarily determine an immutable pathway to mental health problems and illicit substance use. [Silins E, Swift W, Slade T, Toson B, Rodgers B, Hutchinson DM. A prospective study of the substance use and mental health outcomes of young adult former and current cannabis users. Drug Alcohol Rev 2017;00:000-000].

Adolescent substance use and educational attainment: An integrative data analysis comparing cannabis and alcohol from three Australasian cohorts.

BACKGROUND: The relative contributions of cannabis and alcohol use to educational outcomes are unclear. We examined the extent to which adolescent cannabis or alcohol use predicts educational attainment in emerging adulthood. METHODS: Participant-level data were integrated from three longitudinal studies from Australia and New Zealand (Australian Temperament Project, Christchurch Health and Development Study, and Victorian Adolescent Health Cohort Study). The number of participants varied by analysis (N=2179-3678) and were assessed on multiple occasions between ages 13 and 25. We described the association between frequency of cannabis or alcohol use prior to age 17 and high school non-completion, university non-enrolment, and degree non-attainment by age 25. Two other measures of alcohol use in adolescence were also examined. RESULTS: After covariate adjustment using a propensity score approach, adolescent cannabis use (weekly+) was associated with 1½ to two-fold increases in the odds of high school non-completion (OR=1.60, 95% CI=1.09-2.35), university non-enrolment (OR=1.51, 95% CI=1.06-2.13), and degree non-attainment (OR=1.96, 95% CI=1.36-2.81). In contrast, adjusted associations for all measures of adolescent alcohol use were inconsistent and weaker. Attributable risk estimates indicated adolescent cannabis use accounted for a greater proportion of the overall rate of non-progression with formal education than adolescent alcohol use. CONCLUSIONS: Findings are important to the debate about the relative harms of cannabis and alcohol use. Adolescent cannabis use is a better marker of lower educational attainment than adolescent alcohol use and identifies an important target population for preventive intervention.

Young adult sequelae of adolescent cannabis use: an integrative analysis.

BACKGROUND: Debate continues about the consequences of adolescent cannabis use. Existing data are limited in statistical power to examine rarer outcomes and less common, heavier patterns of cannabis use than those already investigated; furthermore, evidence has a piecemeal approach to reporting of young adult sequelae. We aimed to provide a broad picture of the psychosocial sequelae of adolescent cannabis use. METHODS: We integrated participant-level data from three large, long-running longitudinal studies from Australia and New Zealand: the Australian Temperament Project, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. We investigated the association between the maximum frequency of cannabis use before age 17 years (never, less than monthly, monthly or more, weekly or more, or daily) and seven developmental outcomes assessed up to age 30 years (high-school completion, attainment of university degree, cannabis dependence, use of other illicit drugs, suicide attempt, depression, and welfare dependence). The number of participants varied by outcome (N=2537 to N=3765). FINDINGS: We recorded clear and consistent associations and dose-response relations between the frequency of adolescent cannabis use and all adverse young adult outcomes. After covariate adjustment, compared with individuals who had never used cannabis, those who were daily users before age 17 years had clear reductions in the odds of high-school completion (adjusted odds ratio 0·37, 95% CI 0·20-0·66) and degree attainment (0·38, 0·22-0·66), and substantially increased odds of later cannabis dependence (17·95, 9·44-34·12), use of other illicit drugs (7·80, 4·46-13·63), and suicide attempt (6·83, 2·04-22·90). INTERPRETATION: Adverse sequelae of adolescent cannabis use are wide ranging and extend into young adulthood. Prevention or delay of cannabis use in adolescence is likely to have broad health and social benefits. Efforts to reform cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent potentially adverse developmental effects. FUNDING: Australian Government National Health and Medical Research Council.

Factors associated with variability and stability of cannabis use in young adulthood.

BACKGROUND: This study investigated the factors associated with initiating cannabis use, reverting to cannabis use and remaining a cannabis user in young adulthood. This is an important area of research as the risk for cannabis initiation is extending beyond adolescence and opportunities to influence cannabis use pathways can emerge throughout the life-course. METHODS: A large, community-based sample was followed prospectively. Data from two successive waves (mean age 23 years and 27 years respectively) of the Path Through Life Study (PATH) were analysed (n=2045). The longitudinal design enabled change in cannabis use in young adulthood to be predicted based on factors assessed approximately four years prior. RESULTS: An environment of licit drug use was strongly associated with initiating cannabis use (tobacco: OR=4.98, 95%CI: 2.31-10.76) and reverting to cannabis use in young adulthood (alcohol: OR=2.13, 95%CI: 1.42-3.19). Greater fun seeking was found to orientate people towards initiating cannabis use in young adulthood (OR=1.17, 95%CI: 1.04-1.30). Higher psychoticism increased the odds of remaining a cannabis user (OR=1.19, 95%CI: 1.07-1.33). Religious involvement was protective of cannabis initiation (OR=0.89, 95%CI: 0.83-0.95). Early childhood factors did not influence the pattern of cannabis use in young adulthood. CONCLUSIONS: The findings make an important contribution to the development of prevention and intervention strategies for young adults by drawing attention to specific areas of risk and protection.

Cannabis and depression: an integrative data analysis of four Australasian cohorts.

BACKGROUND: This study presents an integrative data analysis of the association between frequency of cannabis use and severity of depressive symptoms using data from four Australasian cohort studies. The integrated data comprised observations on over 6900 individuals studied on up to seven occasions between adolescence and mature adulthood. METHODS: Repeated measures data on frequency of cannabis use (not used/

Cannabis use and educational achievement: findings from three Australasian cohort studies.

BACKGROUND: The associations between age of onset of cannabis use and educational achievement were examined using data from three Australasian cohort studies involving over 6000 participants. The research aims were to compare findings across studies and obtain pooled estimates of association using meta-analytic methods. METHODS: Data on age of onset of cannabis use (<15, 15-17, never before age 18) and three educational outcomes (high school completion, university enrolment, degree attainment) were common to all studies. Each study also assessed a broad range of confounding factors. RESULTS: There were significant (p<.001) associations between age of onset of cannabis use and all outcomes such that rates of attainment were highest for those who had not used cannabis by age 18 and lowest for those who first used cannabis before age 15. These findings were evident for each study and for the pooled data, and persisted after control for confounding. There was no consistent trend for cannabis use to have greater effect on the academic achievement of males but there was a significant gender by age of onset interaction for university enrolment. This interaction suggested that cannabis use by males had a greater detrimental effect on university participation than for females. Pooled estimates suggested that early use of cannabis may contribute up to 17% of the rate of failure to obtain the educational milestones of high school completion, university enrolment and degree attainment. CONCLUSIONS: Findings suggest the presence of a robust association between age of onset of cannabis use and subsequent educational achievement.

Assessing evidence for a causal link between cannabis and psychosis: a review of cohort studies.

Over the past five years, the release of cohort studies assessing the link between cannabis and psychosis has increased attention on this relationship. Existing reviews generally conclude that these cohort studies show cannabis has a causal relationship to psychosis, or at least that one cannot be excluded. Few studies have evaluated the relative strengths and limitations of these methodologically heterogeneous cohort studies, and how their relative merits and weaknesses might influence the way the link between cannabis use and psychosis is interpreted. This paper reviews the methodological strengths and limitations of major cohort studies which have looked at the link between cannabis and psychosis, and considers research findings against criteria for causal inference. Cohort studies that assessed the link between cannabis and psychosis were identified through literature searches using relevant search terms and MEDline, PsycINFO and EMBASE. Reference lists of reviews and key studies were hand searched. Only prospective studies of general population cohorts were included. Findings were synthesised narratively. A total of 10 key studies from seven general population cohorts were identified by the search. Limitations were evident in the measurement of psychosis, consideration of the short-term effects of cannabis intoxication, control of potential confounders and the measurement of drug use during the follow-up period. Pre-existing vulnerability to psychosis emerged as an important factor that influences the link between cannabis use and psychosis. Whilst the criteria for causal association between cannabis and psychosis are supported by the studies reviewed, the contentious issue of whether cannabis use can cause serious psychotic disorders that would not otherwise have occurred cannot be answered from the existing data. Further methodologically robust cohort research is proposed and the implications of how evidence informs policy in the case of uncertainty is discussed.

Patterns and harms of pharmaceutical drug use among ecstasy users in Australia.

BACKGROUND: There has been a significant incursion of prescription drugs in to the club scene worldwide. The concomitant use of ecstasy and pharmaceutical drugs is associated with potentially serious health-related harms. This has ramifications for people who deliberately combine pharmaceutical drugs with ecstasy to achieve a specific effect and for people legitimately using pharmaceutical drugs for a health condition who may incidentally use ecstasy. This exploratory study had the broad aim to investigate the patterns and harms of concomitant use of pharmaceutical drugs and ecstasy, and to explore participants' experiences when visiting a General Practitioner (GP). METHODS: In-depth interviews were conducted with 30 ecstasy/pharmaceutical drug users. RESULTS: Users reported deliberately combining stimulants (dexamphetamine, methylphenidate (e.g. Ritalin), antidepressants and sildenafil (e.g. Viagra) for non-medical purposes with ecstasy. A wide range of effects were reported. Several clear relationships emerged between the use of pharmaceutical drugs and ecstasy, and the distinctions between these in terms of motivations for use and consequences are discussed. The attitudes of GPs were professional and non-judgemental and there was little reluctance among participants to disclose illicit drug use. Screening for illicit drug use was limited. IMPLICATIONS: Findings have important implications for clubbers in regard to harm reduction strategies and highlight a number of areas for future research.

Pautas y problemas derivados del consumo de fármacos entre los consumidores de éxtasis en Australia / Patterns and harms of pharmaceutical drug use among ecstasy users in Australia

Antecedentes: en el ambiente de las discotecas de todo el mundo existe un aumento significativo del uso de medicamentos con receta. El consumo conjunto de éxtasis y fármacos se asocia con daños potencialmente graves para la salud. Esto tiene ramificaciones en el caso de personas que combinan de forma deliberada los fármacos con el éxtasis para lograr un determinado efecto y en quienes toman legalmente fármacos por problemas de salud y de vez en cuando consumen éxtasis. Este estudio exploratorio se propone investigar los hábitos y daños del consumo concomitante de fármacos y éxtasis y explorar las experiencias de los participantes cuando visitan al médico de cabecera (MC). Método: se entrevistó a fondo a 30 consumidores de éxtasis/fármacos. Resultados: los consumidores admitieron la combinación deliberada de estimulantes (dexanfetamina, metilfenidato [p.e. Ritalín]), antidepresivos y sildenafil (p.e. Viagra®) con éxtasis por motivos no médicos. Se descubrió una amplia gama de efectos. Aparecieron claras relaciones entre el consumo de fármacos y éxtasis, y se analizaron las distinciones entre ellos en términos de motivaciones para el consumo y consecuencias del mismo. Las actitudes de los MC fueron profesionales y sin prejuicios, y los participantes mostraron escasa resistencia a reconocer el consumo de drogas ilegales. Se limitó el cribado de drogas ilegales. Consecuencias: Los resultados tienen importantes repercusiones para el público de las discotecas en lo referente a estrategias de reducción del daño y en el descubrimiento de una serie de ámbitos para futuras investigaciones (AU)

Background: There has been a significant incursion of prescription drugs in to the club scene worldwide. The concomitant use of ecstasy and pharmaceutical drugs is associated with potentially serious health related harms. This has ramifications for people who deliberately combine pharmaceutical drugs with ecstasy to achieve a specific effect and for people legitimately using pharmaceutical drugs for a health condition who may incidentally use ecstasy. This exploratory study had the broad aim to investigate the patterns and harms of concomitant use of pharmaceutical drugs and ecstasy, and to explore participants’ experiences when visiting a General Practitioner (GP). Methods: In-depth interviews were conducted with 30 ecstasy/pharmaceutical drug users. Results: Users reported deliberately combining stimulants (dexamphetamine, methylphenidate (e.g. Ritalin®)), antidepressants and sildenafil (e.g. Viagra®) for non-medical purposes with ecstasy. A wide range of effects were reported. Several clear relationships emerged between the use of pharmaceutical drugs and ecstasy, and the distinctions between these in terms of motivations for use andconsequences are discussed. The attitudes of GPs were professional and non-judgemental and there was little reluctance among participants to disclose illicit drug use. Screening for illicit drug use was limited. Implications: Findings have important implications for clubbers in regard to harm reduction strategies and highlight a number of areas for future research (AU)

Residential detoxification: essential for marginalised, severely alcohol- and drug-dependent individuals.

INTRODUCTION AND AIMS: In an era of health care rationalisation, residential detoxification services catering for drug- and alcohol-dependent homeless people are being closed. The principal findings of a recent evaluation of a non-medicated residential detoxification service are presented. The aims were to describe the characteristics of residents, their experience of admission, rates of withdrawal completion, referral patterns, staff and key informant perceptions of the service and its role within the wider treatment system. DESIGN AND METHODS: A process evaluation was utilised incorporating interviews with residents (n = 80) and key informants (n = 13); a survey of all service staff (n = 10); and demographic and clinical data for all residents (n = 392) admitted over one calendar year. Results. Residents were heavily substance-dependent and marginalised, with many exhibiting substantial mental and physical health impairments. Polydrug use and frequent prior engagement with drug and alcohol services were common. The majority completed withdrawal and were referred to further treatment. Residents who presented for heroin and other opiate withdrawal were more likely than other residents to leave before completing treatment (odds ratio 2.47, 95% confidence interval 1.48 - 4.15). Information from key informants, service staff and residents converged in underscoring the important role performed by the service. DISCUSSION AND CONCLUSION: Out-patient detoxification for homeless and severely drug- and alcohol-dependent populations is unrealistic. For this group, access to residential detoxification is vital as it provides an environment where potentially serious medical and psychological complications can be managed. There continues to be a clear role for supervised withdrawal in such a setting.

Evaluation of a community-driven preventive youth initiative in Arnhem Land, Northern Territory, Australia.

INTRODUCTION AND AIMS: We evaluated a community-driven initiative established to prevent substance misuse and increase respect for culture and their elders among young people in a group of remote Aboriginal communities in Arnhem Land, Northern Territory (NT), Australia. The Youth Development Unit provided a range of training, recreational and cultural activities within a community development framework to all young people in the community. DESIGN AND METHODS: Methods of operation, community acceptability, perceived impact and likely ability to meet goals were assessed. Data included community, staff and stakeholder interviews and observation. School attendance, youth apprehension rates and information on levels of substance use were compared 2 years before and after the initiative was implemented. RESULTS: Interviewees reported increased youth training and recreational opportunities, increased communication between local agencies, overall satisfaction with programme delivery and optimism that it could achieve its goals. Suggested improvements included even more training, cultural programmes and other activities and employment of more community-based Indigenous staff. The importance of key staff, involvement of a respected Indigenous staff member and community engagement were noted as probable contributors to its success. DISCUSSION AND CONCLUSIONS: Indigenous young people in Australia remain one of the most disadvantaged and vulnerable groups. Community-driven preventive initiatives offer enhanced youth resilience and connectedness in remote Aboriginal communities and alternatives to substance use.