New Zealand Women's Experience of Intimacy Within Heterosexual Relationships: Influence of Partners' Perceived Pornography Use.

The association between women's levels of relationship intimacy and how frequently their partner viewed pornography was examined in a community sample of 136 NZ heterosexual women. Controlling for age, ethnicity and education, partner use of pornography was significantly negatively correlated with emotional, sexual, intellectual and recreational intimacy, but not social intimacy. Women's attitudes toward pornography did not mediate any of these associations. However, significant moderation effects were found: women with more negative attitudes toward pornography reported lower rates of emotional and social intimacy when their partner was believed to be viewing pornography weekly or more, but not when this frequency was less. No association was found for women with less negative attitudes toward pornography. These findings indicate that pornography may be detrimental to relationship intimacy for women with strongly negative attitudes toward it.

Readiness and recovery: Transferring between methadone and buprenorphine/naloxone for the treatment of opioid use disorder.

Long-acting opioids are prescribed as part of treatment for opioid use disorders; methadone and buprenorphine are well researched and commonly prescribed for the treatment of opioid use disorder. Meta-analysis suggests that buprenorphine has a slightly poorer retention rate in treatment as compared to methadone. Benefits of buprenorphine/naloxone include greater ease in ceasing treatment and less use of illicit opioids while in treatment as compared to methadone. There are a number of qualitative and mixed-method studies that ask patients about their experiences of methadone maintenance and buprenorphine maintenance treatment. This research aimed to understand perspectives of receiving buprenorphine/naloxone for the treatment of opioid use disorder. A qualitative descriptive approach was used. Seven participants with a current diagnosis of opioid use disorder treated with buprenorphine/naloxone were interviewed. Thematic analysis extracted four themes: drivers for opioid substitution treatment change; readiness for buprenorphine/naloxone substitution treatment; absence of effect from buprenorphine/naloxone; and an increased sense of citizenship on buprenorphine/naloxone. This study identified a number of factors influencing participants' decision-making in transferring between methadone and buprenorphine/naloxone for the treatment of their opioid use disorder. Methadone was preferred by those seeking sedation and wishing to continue using other opioids, and buprenorphine/naloxone was most effective for participants no longer wishing to experience sedation and seeing opioid abstinence as an end point in their recovery. Changing treatment expectations are important to consider when determining medication selection and highlight the importance of quality information when determining the most suitable medication for the treatment of opioid use disorder.

Therapeutic alliance predicts mood but not alcohol outcome in a comorbid treatment setting.

INTRODUCTION: The pan-theoretical variable of alliance has been consistently reported to have a moderate yet robust effect on psychotherapy treatment outcome. However, the relationship is less clear in the addiction field where there is more limited research. The current study investigated the relationship between alliance and treatment outcome in an alcohol dependent and depressed population. METHOD: The Treatment Evaluation of Alcohol and Mood (TEAM) study was a randomized controlled pharmacotherapy trial with supportive clinical case management. Therapist and client alliance ratings were assessed using the Working Alliance Inventory (WAI) for 123 client-therapist dyads at 3 weeks. Outcome data was obtained at 3 and 12 weeks (end of treatment). Drinking-related measures included Percent Days Abstinent (PDA) and Drinks per Drinking Day (DDD). Mood outcomes were scores on the Montgomery Asberg Depression Rating Scale (MADRS). RESULTS: Clients rated alliance significantly higher than did therapists and client and therapist ratings were not associated with each other. Baseline motivation was the only pre-treatment client variable associated with alliance, the higher the client's Readiness to Change Questionnaire-Treatment Version (RCQ-TV) score, the higher the therapist-rated alliance. Higher therapists' ratings of alliance were significantly associated with improved mood outcomes at the end of treatment but, with one minor exception, were not related to drinking outcomes. Therapist alliance was also significantly associated with treatment completion. In contrast, client-rated alliance was not related to mood or drinking outcomes, possibly due to a ceiling effect. Subscale analysis found that of the different components that comprise the alliance concept, the task component was most important for drinking outcomes whereas the task and goal components were equally important for mood outcomes. Controlling for early symptom change did not meaningfully alter associations between therapist alliance and mood. In contrast, the strength of associations between therapist alliance and drinking outcomes was reduced for PDA and DDD 12-week change scores, whereas the association between the therapist alliance and 12-week PDA became significant when previously this had not been the case. CONCLUSIONS: Therapeutic alliance was associated with improved mood outcomes, which is consistent with other research. However, alliance, as measured by the WAI, and drinking outcomes, were not related. Findings from these investigations signal the need to re-examine the concept and measurement of alliance in substance-using treatment populations, particularly with regard to drinking outcomes. Within this re-examination, findings support a greater focus on the therapists' role in the alliance-outcome relationship.

Postgraduate Alcohol and Other Drug Practitioner Training in New Zealand: Significant Influences.

OBJECTIVE: The purpose of this article is to present a case study of the evolution of postgraduate-level training programs for alcohol and other drug (AOD) practitioners provided by two universities in New Zealand. METHOD: The case study compiles details on relevant treatment contexts and systems in New Zealand and key milestones and significant developments in postgraduate AOD practitioner programs in two locations over a 30-year period. The details were compiled by the authors, all of whom were closely involved with the development of the training programs. RESULTS: The key ingredients for success that were identified included a focus on specialized learning overlaying generic undergraduate professional training; a core commitment to practice oriented teaching; investment in the training by government bodies; and the parallel emergence of professional bodies, registration systems, and collaborative relationships across agencies. In a small country, the two programs have enabled 345 students to obtain specialist postgraduate qualifications in AOD practice over a 10-year period. CONCLUSIONS: Little could have been achieved without ongoing cooperation between education providers, government agencies, and AOD services. This history may be of interest to those in other locations attempting to establish nation- or statewide approaches to AOD practitioner training.

Psychosocial enhancement of the Green Prescription for obesity recovery: a randomised controlled trial.

AIMS: Kia Akina is a low-cost obesity recovery network providing ongoing addiction-orientated psychosocial support. This study explored the impact of Kia Akina when added to the Green Prescription, a key government-funded health promotion programme in New Zealand. METHODS: A randomised controlled trial (ACTRN12613001160729) involving 108 participants recruited from primary care compared Green Prescription plus Kia Akina (KA/GRx) with Green Prescription alone (GRx) over 12 months. The primary a priori outcome measure was achieving 5% loss of weight from baseline. RESULTS: KA/GRx participants lost more weight overall than GRx (3.6kg vs 0.7kg, p=0.03), while 39% of the GRx group gained weight compared with 21% of KA/GRx (p=0.04). However, KA/GRx and GRx had similar proportions with weight loss of 5% or greater (20% vs 17%, p=0.62). KA/GRx participants had greater changes in confidence about recovery (p=0.02), and quality of life measures (p=0.03) and greater overall satisfaction with assistance received (p<0.001) compared with GRx participants. CONCLUSIONS: Psychosocial support provided through Kia Akina enhanced treatment outcomes for people with obesity at 12 months when added to GRx, although weight-loss outcomes were modest. Before Kia Akina is expanded, improved weight-loss outcomes are required, which may be achieved through individualised assessment and targeted dietary assistance.

A randomized trial of combined citalopram and naltrexone for nonabstinent outpatients with co-occurring alcohol dependence and major depression.

Despite the high rate of co-occurrence of major depression and alcohol dependence, the role of pharmacotherapy in their treatment remains unclear. In the new era of naltrexone for alcohol dependence, it is notable that only 1 study to date has examined the efficacy of antidepressant medication prescribed concurrently with naltrexone. We aimed to determine whether combining naltrexone with citalopram produced better treatment outcomes than naltrexone alone in patients with co-occurring alcohol dependence and depression, and to investigate whether either sex or depression type (independent or substance-induced depression) moderated treatment response. Participants were 138 depressed alcohol-dependent adults who were not required to be abstinent at the commencement of the trial. They were randomized to 12 weeks of citalopram or placebo, plus naltrexone and clinical case management. Treatment was well attended, and medications were reasonably well tolerated with high adherence rates. Substantial improvements in both mood and drinking occurred in both groups, with no significant differences between groups on any of the mood or drinking outcome measures, whether or not other variables were controlled for. No interaction effect was found for independent/substance-induced depression status, whereas there was a marginal effect found by sex, with greater improvement in 1 drinking outcome measure (percent days abstinent) in women taking citalopram. These findings suggest that citalopram is not a clinically useful addition to naltrexone and clinical case management in this treatment population. Independent/substance-induced depression status did not predict treatment response. Findings for sex were equivocal.

Opioid substitution treatment in New Zealand: a 40 year perspective.

We provide an overview of the history and philosophy of the treatment for opioid dependence, which has been dominated by methadone substitution treatment for the past 40 years in New Zealand. Although changes in approach have occurred over this time, influenced by various sociopolitical events and changing ideologies, opioid substitution treatment has still "not come of age". It remains undermined by stigma and risk concerns associated with methadone and has struggled to be accessible and attractive to illicit opioid drug users, comprehensive and integrated into mainstream health care. However, the introduction in 2012 of Pharmac-subsidised buprenorphine combined with naloxone (Suboxone) in the context of an emerging trend towards a broader recovery and well-being orientation could signal a new era in treatment. The availability of buprenorphine-naloxone may also facilitate a further shift in treatment from primarily siloed specialist addiction services to integrated primary care services. This shift will help reduce stigma, promote patient self-management and community integration and align opioid substitution treatment with treatment for other chronic health conditions such as diabetes and asthma.

Clients' perceptions of opioid substitution treatment: an input to improving the quality of treatment.

Despite the emphasis on providing high quality mental health and addiction treatment, there has been relatively little consideration given to examining clients' perceptions of addiction treatment (consumer satisfaction) as a quality improvement strategy. The present article reports on a survey of a representative sample of 93 clients receiving opioid substitution treatment (OST). Employed participants reported higher treatment satisfaction and a pattern of positive associations was found between satisfaction and general health, mental health, social functioning, lower methadone doses, and participants' ratings of their treatment progress. Lower satisfaction was associated with higher frequency of benzodiazepine use, and, for women, longer treatment duration. Maori participants rated their treatment progress as lower than that of non-Maori. Results strongly endorse recording participants' comments to provide a deeper understanding of survey item ratings. The study findings highlight the need for a research focus on the roles of mental health and other registered nurses who work with people receiving OST in specialist service and primary care settings, and endorse a partnership approach to future research in this area. The pattern of findings arising from this study suggests key strategies for improving the flexibility and client responsiveness of OST.

Could an advance practice nurse improve detection of alcohol misuse in the emergency department?

Alcohol misuse is a prevalent problem in New Zealand society, and one that exacts a considerable cost in terms of health, social cohesion, and economic productivity. Despite the burden of alcohol misuse, screening, brief assessment, and interventions for alcohol problems are frequently poorly performed within general health services. In this paper we explore the response to alcohol problems in a New Zealand emergency department and discuss difficulties encountered in improving rates of detection by emergency department personnel. We report the results of a clinical audit of alcohol screening and brief assessment and a staff education programme designed to improve practice in this area, but which met with limited success. The potential role for an advanced practice nurse providing a clinical consultation and liaison service to the emergency department staff is explored. We argue that such a role has potential to reduce the health and social costs of alcohol misuse, and to meet the national policy objective of providing a treatment response to people with alcohol-related problems in contact with health services.

An estimation of the prevalence of opioid dependence in New Zealand.

BACKGROUND: An accurate prevalence estimate for opioid dependence in New Zealand, and hence the extent of unmet treatment need, is lacking. METHODS: Opioid users were recruited via snowball sampling, with participants initially recruited from opioid substitution treatment (OST) services and dedicated needle exchanges in Auckland, Tauranga and Christchurch. Participants estimated the number of people they knew personally who were receiving OST and who were not receiving OST, but were using opioids daily or almost daily. From these estimates a multiplier of the ratio between these two groups was derived and applied to the known number receiving OST in New Zealand to arrive at the total population estimate. RESULTS: The mean multiplier estimate, weighted for treatment site, for 84 recruited participants was 2.015. The multiplier was higher for Christchurch. Initial recruitment source did not influence the value of the multiplier estimate. When the multiplier was applied to the known size of the New Zealand OST treatment population the total opioid dependent population was estimated to be 9142 (95% CI: 8248-10036), of whom half were not receiving OST. CONCLUSION: This figure was lower than for previous less robust estimates, but still represents a substantial level of unmet need. Greater effort needs to be made to close this treatment gap.

Implementing and maintaining nurse-led healthy living programs in forensic inpatient settings: an illustrative case study.

BACKGROUND: Healthy living programs (HLPs) within the context of mental health units are an applied response to the concerns of metabolic syndrome and the associated physical illnesses to which people with serious mental illness are susceptible. OBJECTIVE: To illustrate how nurses, with other health professionals and service users, have established and maintained HLPs in two locked forensic mental health units in New Zealand. DESIGN: This illustrative case study adopts a multimodal approach to data collection and analysis. Across two programs, interviews were undertaken with service users (n = 15) and staff (n = 17), minutes of meetings were analyzed for major decision points, and clinical notes were reviewed to identify which service-user health status measures (body mass index, glucose tolerance test results, blood pressure, and medication use) were recorded. RESULTS: Similarities were identified in the way the HLPs were implemented and maintained by champions who advocated for change, challenged staff attitudes, secured funding, and established new systems and protocols. Successful implementation depended on involvement of the multidisciplinary team. Each program operated within a different physical environment and adopted its own philosophical approach that shaped the style of the program. The HLPs had an impact on nurses, other staff, and on the culture of the institutions. The programs raised dilemmas about restrictions and risk versus autonomy and self-management. CONCLUSION: Understanding the effects of the clinical and philosophical contexts in which HLPs are established and the way challenges and benefits are affected by context has practical significance for the future development of health programs in forensic settings, prisons, and general mental health units.

Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness.

In New Zealand approximately 4600 people receive opioid substitution treatment (OST) for opioid dependence, primarily methadone maintenance treatment. This study explored ways in which OST could be improved, given the significant waiting times for treatment. Two parallel surveys were conducted: 1) peer interviews with 85 regular daily or almost daily opioid drug users (51.8% receiving OST, 18.8% not currently receiving OST, and 29.4% never received OST) and; 2) a census of all 18 specialist OST service providers. When asked how OST might be improved, the four categories most commonly cited by the opioid users were 'better treatment by staff', 'more flexibility', 'better takeaway arrangements', and 'decreased waiting time'. Both opioid users and specialist services rated 'restricted takeaways' and 'having to go on a waiting list' in the top three perceived barriers to OST. Almost all services reported significant resource issues and barriers to the transfer of stable clients from specialist services to continuing treatment in primary care. The findings from this study indicate how OST can be made more accessible and attractive and thus achieve better uptake and retention.

Retention of adolescents with substance dependence and coexisting mental health disorders in outpatient alcohol and drug group therapy.

The aim of this study was to investigate characteristics that might enhance retention among adolescents attending outpatient alcohol and drug group therapy within a youth mental health setting. An important goal was to provide information for nurses and other clinicians who work with adolescents with coexisting substance use and mental health disorders. A retrospective file audit reviewed the files of 64 adolescents who attended a weekly alcohol and drug group between 2002 and 2004. Five characteristics were shown to have a significant impact on enhancing participant group retention. These were Maori and Pacific Island ethnicity, past or current legal charges, youth drug court (YDC) involvement, having a diagnosis of cannabis dependence, and a diagnosis of conduct disorder. Logistic regression found that YDC involvement on its own significantly predicted treatment retention. In an area of limited research, the findings from this study expand the literature on enhancing treatment retention for a vulnerable and hard-to-engage adolescent group with complex treatment needs, and highlight the need for further investigation of the potential role of the YDC. From a practice perspective, the findings support group therapy interventions as a cost-effective treatment modality for assisting adolescents with coexisting substance use and mental health issues, including those with conduct disorder and YDC involvement.

Youth retention: factors associated with treatment drop-out from youth alcohol and other drug treatment.

INTRODUCTION AND AIMS: This study examined factors associated with treatment drop-out among young people aged 13-19 years attending alcohol and other drug (AOD) treatment. DESIGN AND METHODS: Data were gathered from structured interviews (n = 79) and a clinical file search of 184 randomly selected young people who had attended youth specific AOD treatment services in Aotearoa, New Zealand during 2003 or 2004. RESULTS: The median length of stay was 2.7 months for those attending day/residential services (n = 42) and 4.0 sessions for those attending outpatient services (n = 37) 16.7% of participants from day/residential services dropped out of treatment early (within the first month) and 32.4% of participants from outpatient treatment services dropped out of treatment early (before the third session). Fixed client characteristics, such as age, sex, ethnicity, substance use and mental health diagnoses were not found to be associated with treatment retention. Dynamic client characteristics, such as motivation to attend treatment and expectations about treatment outcomes and program characteristics, such as positive experiences with treatment staff and feeling involved in the treatment process were found to be associated with treatment retention. DISCUSSION AND CONCLUSIONS: The findings of this study support previous research indicating that fixed client characteristics are not sufficient to explain youth retention in AOD treatment. Of more use are dynamic client characteristics and program variables. These findings stress the potential for improving treatment retention by creating more youth appropriate services.

Profile of young people attending alcohol and other drug treatment services in Aotearoa, New Zealand: clinical file search.

OBJECTIVE: The aim of the present study was to provide a profile of young people attending alcohol and other drug (AOD) treatment services in Aotearoa, New Zealand. METHOD: Data were gathered from a clinical file search of 184 randomly selected young people aged 13-19 years who had attended one of eight youth AOD treatment services in New Zealand during 2003 or 2004. These services represented eight of the 11 youth-specific AOD services available to youth in New Zealand. RESULTS: Young people who attend youth-specific AOD services in New Zealand present with a range of complex needs including substance use and mental health issues, criminality, family conflict and disengagement from school. A total of 62.0% were male, 56.4% had criminal convictions, 40.6% had spent some time in Child, Youth and Family Services care and 53.8% were reported to have a coexisting substance use and mental health disorder. Low rates of reporting of substance use and mental health diagnoses in treatment files suggest that substance use and mental health disorders among this population are likely to be higher than those reported. CONCLUSIONS: This paper provides a unique profile of young people attending youth-specific AOD treatments in New Zealand. Such information is useful in informing treatment planning and funding and ensuring that service development occurs to specifically meet the complex needs of this patient group.

Development of a brief treatment instrument for routine clinical use with methadone maintenance treatment clients: the methadone treatment index.

Routine measurement of treatment outcome between clinician and client in alcohol and drug user treatment services is an important quality improvement initiative. It is particularly important for clients receiving long-term treatment such as methadone maintenance treatment, as fluctuations in substance use, functioning, and health are to be expected. Although there are a number of standardized alcohol and drug user treatment outcome instruments available for research and clinical use, a key challenge is to develop clinical instruments that will actually be used routinely in busy practice settings by a range of staff. Such instruments need to be brief, acceptable to staff and clients, easy to use, provide immediate feedback, and meet adequate psychometric requirements. This report describes development work undertaken in three studies of the Methadone Treatment Index (MTI). The MTI is a brief instrument comprising measures of recent substance use, aspects of social and behavioral functioning, and physical and psychological health. The MTI was designed in consultation with clinicians and clients for use in monitoring treatment progress with clients receiving methadone maintenance treatment. Key findings were that the MTI was acceptable to clients, produced clinically relevant information, and has satisfactory psychometric properties, although it was not used to measure change in this study. Further evaluation of the MTI on a longitudinal basis is supported.

Alcohol and drug treatment population profile: a comparison of 1998 and 2004 data in New Zealand.

AIMS: To describe the profile of clients attending dedicated alcohol and other drug (AOD) treatment services in New Zealand, and to compare this profile with data from a 1998 survey. METHODS: 288 randomly selected AOD treatment workers in New Zealand were interviewed by telephone regarding their most recent assessment and follow-up clients, yielding a randomly selected sample of 383 clients. Workers were asked to identify the age, gender, ethnicity, main substance use problem, and geographical location of clients. RESULTS: 65% of clients were male; 32% were Maori. The mean age was 34 years and the largest group of clients were seen for alcohol-related issues (47%), followed by cannabis (24%) and opioids (15%). Amphetamines had risen as the main substance used--from near zero (in 1998) to 10% of the sample (in 2004). In 2004, surveyed clients were older and less likely to be Caucasian (European ethnicity), and were more likely to be seen in district health board (DHB) and non-residential settings. Compared to clients attending assessment appointments, those attending for follow-up were older, less likely to be female or Maori, and more likely to use opioids. Overall, Maori clients were younger, used cannabis more, and were less likely to live in a large city. Amphetamine users were younger and almost exclusively living in the North Island. CONCLUSIONS: Several substantial changes have occurred in the profile of AOD clients over the 6 years (1998-2004). Although the traditional substances of alcohol, cannabis, and opioids continue to predominate, the rise in amphetamine use in the community is reflected in a corresponding rise in amphetamine presentations to AOD services, particularly amongst younger clients and those in the North Island. While other observed changes might have been predicted from broader demographic trends and service reconfiguration, the emergence of a substantial disparity in treatment follow-up rates between Maori and non-Maori is not so easily explained.

Health status of clients receiving methadone maintenance treatment using the SF-36 health survey questionnaire.

This study investigated the health status of a representative sample of clients (35 Maori, 72 non-Maori) receiving methadone maintenance treatment in New Zealand, using the SF-36 health survey. The publication of New Zealand norms in 1999 enabled comparisons of the health of the Methadone Treatment Programme study participants with that of the New Zealand population. Although over 50% of participants rated their health as good, very good or excellent, 44% rated their health as fair or poor and compared with population norms, the health of the study participants was significantly poorer on all eight SF-36 scales. Male and female participants rated their health similarly to male and female clients attending another New Zealand Methadone Treatment Programme. Results highlighted the impact of a chronic disorder and co-existing health-related problems on the health and well-being and day-to-day functioning of this client group. Higher frequency of benzodiazepine use was associated with poorer social functioning, mental health and role functioning and higher frequency of cannabis use was associated with poorer role functioning due to emotional problems. Findings support routine monitoring of health status with clients receiving methadone maintenance treatment as a guide to preventative and treatment interventions and health maintenance strategies.