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Submission

To: the Inquiry into the supply and use of methamphetamines, particularly ‘Ice’, in Victoria

From: the Victorian Aboriginal Community Controlled Health Organisation

Date: 18 October 2013

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Contents1.Introduction ................................................................................................................. 2

2.Recommendations ....................................................................................................... 3

3.Victorian Aboriginal people and methamphetamine a snapshot ................................. 3

4.Data on Victorian Aboriginal people and methamphetamines ................................... 4

5.Victorian Aboriginal people and methamphetamine treatment .................................. 7

6.Evidence-based Drug and Alcohol Education Strategies .......................................... 11

7.Economic cost and the justice system ....................................................................... 12

1. Introduction

The Victorian Aboriginal Community Controlled Health Organisation (VACCHO)

was established in 1996 as the peak representative Aboriginal health body in Victoria.

VACCHO’s work is driven by the priorities of our members, Victoria’s Aboriginal

Community Controlled Health Organisations (ACCHOs) located across the state and

just over the border into New South Wales. By joining together under VACCHO’s

umbrella, ACCHOs gain strength, share knowledge and speak with a united voice.

VACCHO champions community control and health equality for Aboriginal

communities. We are a centre of expertise, policy advice, training, innovation and

leadership in Aboriginal health. VACCHO advocates for the health equality and

optimum health of all Aboriginal people in Victoria.

Methamphetamine issues are frequently raised by the VACCHO membership as issues

of urgent concern and VACCHO is involved in collating better evidence and

supporting member organisations in this space. Below we outline evidence collated

that focuses on Aboriginal Victorians and methamphetamines and provide associated

recommendations.

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2. Recommendations

A. Improve understanding of effectiveness of treatment processes and treatment

outcomes for Aboriginal people with methamphetamine dependence

B. Increase diversionary options from the Justice System to Drug Treatment and

Mental Health support

C. Strengthen Aboriginal Community Controlled Health Services to deliver

evidenced based harm reduction approaches suited to local community needs

D. Strengthen Aboriginal Community Controlled Health Services to provide

evidenced based methamphetamine dependence treatment suited to local

community needs

E. Improve access to drug treatments, including timeliness to detoxification and

rehabilitation that address specific needs of methamphetamine, for example,

longer detoxification periods

F. The enquiry assess sustainable and systematic service provision that meets client

need

3. Victorian Aboriginal people and methamphetamine a snapshot

• 1 in 10 young Aboriginal people use methamphetamine compared to 1 in 20 young non-Aboriginal people

• Of young Aboriginal people who use methamphetamine 1 in 2 use daily or weekly compared to 1 in 10 non Aboriginal people

• Numbers of Aboriginal people in Victorian prisons have doubled in the last 10 years, almost all have drug dependence and this worsens after imprisonment

• Health providers in Aboriginal Community Controlled health Organisations request in regard to methamphetamine treatment- professional development- improved partnerships and- more timely access to detox and rehabilitation

• Aboriginal families with methamphetamine dependent members request improved support and skills in dealing with methamphetamine dependence

• Little evidence of effectiveness of methamphetamine health education and prevention programs that work with Aboriginal people

• Little evidence about effectiveness of methamphetamine treatment with Aboriginal people

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• Concern that 'moral panic' about ICE, such as, ICE forums may further marginalise and deter methamphetamine users from help seeking behaviour. More targeted and solution focussed activities are required.

4. Data on Victorian Aboriginal people and methamphetamines

There is little information and data available about Victorian Aboriginal people and

methamphetamine use. The Victorian Aboriginal Health Service has just begun to

develop a research project planning to interview methamphetamine users. Below we

have outlined available data on Aboriginal Australians and methamphetamines.

GOANNA Survey, 2013

The GOANNA surveyi was conducted by the Kirby Institute in partnership with

VACCHO and others. The survey sample included Victorian Aboriginal young people.

Nationally the survey found that compared to the Australia Household Drug Survey ii

Both cannabis (21.3% vs 32%) and methamphetamine (5% vs 10%) use was

higher for Aboriginal young people

Higher everyday use of cannabis (11.2% vs 38%) and methamphetamine

(11.3% vs 53%) among Aboriginal young people

Similar rates of drug use to the GOANNA survey were identified in the National

Aboriginal and Torres Strait Islander Health Surveyiii (Figure 1).

Figure 1: Illicit substance use among Indigenous people aged 15 years and over

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Notes: 1) Pain-killers/analgesics are for non-medicinal use.2) Estimate for LSD or synthetic hallucinogens in last 12 months has a relative standard error of between 25 and 50% and should be used with caution.

Source: Australian Government. National Aboriginal and Torres Strait Islander Health Survey, 2008

Qualitative study

A qualitative study with Aboriginal methamphetamine users in Sydney found that

most participants had reduced or were planning to reduce their drug use, or "at least

have it under control". Motivators for seeking treatment were to "keep out of jail",

"keep children", and because of a genuine desire to make positive changes in their

life. Some did not want their children to know of their drug use, or to become

involved with drugs themselves. Around half had tried residential rehabilitation in the

past and found it beneficial, all had relapsed.

Barriers to accessing treatment services focused on the rules and lack of freedom that

these services offer.

"I don't want to have to follow their rules."

"No freedom."

"I feel the program is judging me, as in preaching"iv.

VACCHO Ice forums

“Please don't produce any more resources it's a waste of money!!The mainstream and existing information is efficient”

In 2013 VACCHO ran three forums with Aboriginal Community Controlled Health

Organisations. Participants were a mixture of service providers and Aboriginal

community members and audience size varied from over 100 to 15. Participants were

asked to fill in evaluations with one question asking ‘what would you like more

information about’. Participants’ responses are grouped into themes in Table 1. In

particular, health staff requested professional development in methamphetamine

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treatment and families wanted support to deal with methamphetamine dependent

family members and their behaviours. Rather than promoting ICE forums VACCHO

now recommends more targeted solution based workshops. There are also concerns

that 'ICE Forums' create moral panic and marginalise ICE users further potentially

deterring them from help seeking behaviour.

Table 1: Ice forum participant responses to the question, ‘What would you like more information about?’

Prevention

Participants thought early intervention for young at risk clients,

providing self-care, and holistic programs for young people were

important interventions.

Treatment

Participants wanted clarity on what harm reduction and treatment

options should be implemented for clients. More places in detox and

rehabilitation were needed. Family

support

Participants asked for better support and advice about how they can

make a difference with supporting loved ones.

Service accessMaking sure mainstream services were culturally safe and running

support programs for drug users and their families.

Sharing

information

Participants wanted to know more about helpful strategies that work

with Ice users and sharing of best practice models. Participants also

wanted more information about what Ice users need for their journey

to improved health.

Workers’ perspectives on the Victorian alcohol and drug treatment system

In November 2012 VACCHO facilitated a discussion of the proposed Victorian

government AOD treatment system reforms with a combined group of Aboriginal

AOD, mental health and social and emotional wellbeing (SEWB) workersv. The

focus of this discussion was barriers and enablers to effective treatment for Aboriginal

clients. Key themes drawn from this discussion were:

Complexity and breadth of responsibilities – The complexity of the work

required of AOD workers is not well understood or acknowledged

Staff turnover, lack of workforce stability – Participants perceived heavy

workloads and inadequate support for workers dealing with complex issues as

major causes of staff turnover

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Regional/rural inequity – Disparities in treatment experienced by clients in

rural areas, compared to those living in metropolitan areas, including lack of

treatment facilities and lack of choice in service providers (e.g. the only GP in

town lacks knowledge of drug treatment). The requirement to move clients

from their families, off country to access treatment services was also

considered to be a consequence of the inequitable resourcing of rural/regional

communities

The first two dot points are compounded by a lack of training and supervision.

VACCHO’s most recent AOD and SEWB worker skills survey prepared for the

government identifies an undertrained and unsupported workforce. Among workers

surveyed, less than half (43%) had formal Diploma or Certificate IV level

qualifications in AOD. While 25% were undertaking training (mostly at a Cert IV

level), 32% did not have or were not completing AOD qualifications. In another

VACCHO survey only 20 of 47 AOD workers had an AOD qualification at Certificate

IV-level or higher. Workers also reported low levels of supervision with only 10

workers receiving regular supervision compared to 27 that did not receive supervision

or received inadequate supervision (10 workers were not on site to answer).

5. Victorian Aboriginal people and methamphetamine treatment

Aboriginal-specific programs for healing, detoxification and rehabilitation have

proven effective, with services including:

Wulgunggo Ngalu Learning Place, Gippsland – a 'learning place' for

Indigenous men undertaking community-based orders. A live-in program,

accommodates up to 20 men at one time

Bunjilwarra youth healing service, Hastings – currently closed

Baroona Healing Centre, Echuca – youth focused

Wulgunggo Ngalu Learning Place in Gippsland for Aboriginal men on community

based orders has achieved excellent results that continue to improve. The centre has

been open since 2008, however 66.7% of those referred in 2010/11 successfully

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completed the program, a figure increasing to 76.6% in 2011/12 and 97.1% in the 11

months to May 2013vi.

The 2011 Bunjilwarra Healing Service evaluation found that young people required

repeated attempts at rehabilitation. Case studies demonstrated the complexities of

each young person’s background and a lack of structures and supports in their early

years. Turning lives around cannot happen in the immediate term. Participating in a

healing framework is only part of this process, but had the potential to be the

important and significant first step. The average length of stay was 69 days, with

some staying a few weeks and others longer. It was common for a young person to

stay for a short period followed by a longer period when they re-entered. The young

people were found to have complex issues and high levels of social disadvantage,

meaning the Healing Service addressed more than just substance abuse by

concurrently addressing broader health and wellbeing issues. The author found a

strength of Bunjilwarra was fostering an environment holding Indigenous culture in

high regard with young people frequently reporting that living in the house helped

them to be proud of their cultural background. For some this was a new experience

and others knew very little about their Indigenous background. The study author

suggests services and programs providing youth residential treatment or youth

detention are ineffective without appropriate aftercarevii.

A NSW study examining the outcomes of Aboriginal and non-Aboriginal people in an

Aboriginal-specific residential substance abuse rehabilitation centre found significant

improvements among participants completing treatment. Outcomes included reduced

psychological distress and increased refusal self-efficacy and empowerment.

Aboriginal people rated cultural components of treatment slightly more helpful than

non-Aboriginal participantsviii.

There is little data on success rates and treatment length in mainstream services.

Aboriginal people also use mainstream services, however their cultural safety has not

been assessed. A study assessing the acceptability and accessibility of mainstream

services for Aboriginal Australians with alcohol or drug use disorders found

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Aboriginal people were well represented in an urban Area Health Service analysed by

the authors. Representative attendance was attributed to relationships between the

local hospital and the Aboriginal Medical Service (AMS), particularly in

pharmacotherapy dosing and outreach by Aboriginal staff members with the hospital’s

Drugs in Pregnancy Unit. An existing collaboration between the treatment service and

the AMS, including priority appointments for new Aboriginal clients, was also

identified as an influencing factor. Interviews identified increased flexibility of

services, increased outreach services and holistic and human care as the areas needing

improvement, and the importance of Aboriginal staffing was emphasised by clients

and staff membersix.

Evidence from meta-reviews of methamphetamine treatment options show few

proven treatments are availablex,xi,xii,xiii. Evidence from behavioural treatments have led

to reduced methamphetamine dependence, while pharmacotherapy-based treatments

are yet to demonstrate effectiveness in large randomised controlled trials. Behavioural

interventions demonstrating effectiveness include cognitive behavioural therapy

(CBT) and contingency management. Contingency management offers incentives

during treatment such as prizes and money to encourage abstinence. CBT-

Contingency management hybrids such as the Matrix Model have also demonstrated

improved outcomes although it is unclear if improvements are sustained over a longer

periodxiv,xv,xvi.

Outcomes from a Stimulant Treatment Program in NSW where participants received a

stepped-care approach including a median six counselling sessions over a three month

period achieved a reduction in methamphetamine use. While there was no change in

other drug use, crime or HIV risk behaviour, methamphetamine use in the preceding

month fell from 79% at entry to 53% and 55% at three month and six month follow

up. Reduction in use was more common among younger participants, people with no

history of drug treatment, and people without concurrent heroin use. Psychotic

symptoms, hostility and disability associated with poor mental health also reducedxvii.

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Another NSW study on amphetamine treatment across NSW found regional and rural

areas are disproportionately affected and clients often presented with concurrent

cannabis and/or alcohol problems. Clients were overwhelmingly injecting drug users

with poor socio-demographic characteristics. Counselling was the most common

treatment service provided, followed by detoxification and residential rehabilitation.

Detoxification was usually provided in an in-patient setting, particularly within

metropolitan NSW. Compliance with residential rehabilitation was notably poor. The

authors concluded that interventions for amphetamine use need to consider the

majority of treatment clients will be based in a regional or rural setting, and treatment

for amphetamine users often involves concurrent cannabis and alcohol problemsxviii.

A study analysing barriers to methamphetamine withdrawal treatment in Australia

found current treatment practices are diverse and uncertain and a broad spectrum of

barriers identified. 24 AOD workers (managerial, clinical leadership, and

practitioners) were interviewed across Australia. The authors suggest that AOD

service providers are not clear about the best way to respond to clients seeking

methamphetamine withdrawal treatment and identified general pessimism about

withdrawal treatment for this group. The authors concluded that treatment services

should consider improving withdrawal protocols, educating clinicians and

reconsidering entry criteria to better respond to methamphetamine users who have

made the important first step into withdrawal treatmentxix.

Based on systematic reviews of interventions, the World Health Organization (WHO)

recommends the following related to methamphetamine use:

Dexamphetamine should not be offered for the treatment of stimulant use

disorders in non-specialized settingsxx

Brief interventions, based on motivational principles, should be offered for the

treatment of stimulant use disorders in non-specialist settingsxxi

Patients with stimulant use disorders who do not respond to short duration

psychological treatment may be referred for treatment in a specialist setting, when

availableibid

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Individuals using cannabis and psychostimulants should be offered brief

intervention, when they are detected in non-specialized health care settings. Brief

intervention should comprise a single session of 5-30 minutes duration,

incorporating individualised feedback and advice on reducing or stopping

cannabis / psychostimulant consumption, and the offer of follow-upxxii

People with ongoing problems related to their cannabis or psychostimulant drug

use who does not respond to brief interventions should be considered for referral

for specialist assessmentibid

An analysis of relapse factors after methamphetamine treatment among people in the

United States found longer time in treatment resulted in improved outcomes. The

analysis also found no difference in relapse between residential and outpatient

treatment. People who had previously been enrolled in methamphetamine treatment

programs were found to have poorer outcomesxxiii.

6. Evidence-based Drug and Alcohol Education Strategies

Knowledge and awareness are generally ineffective for prevention of use of illicit

drugsxxiv. A Cochrane review of non-school based interventions including education

and skills training interventions, family interventions, and multi-component

community interventions found a lack of evidence proving their effectiveness in

preventing or reducing drug use by young peoplexxv. While some studies suggest some

interventions may be effective, small sample sizes, high loss to follow up and other

factors meant the authors could not draw firm conclusions. Similar conclusions were

drawn in a systematic review of primary prevention of cannabis usexxvi.

In a large, systematic review of tobacco and substance abuse prevention programs

interactive programs were found to be more effective than non-interactive programs,

with the latter described at best only marginally effective. Specifically, interactive

programs more effectively reduced, prevented and delayed drug use among

adolescents for tobacco, alcohol, and cannabis. Effectiveness was also linked to

smaller numbers of participantsxxvii.

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Family-based drug prevention programs have only proven effective when

comprehensively implemented across life-spans and addressed multiple risk factors.

The programs also require content based on proven prevention theory and research,

material that is developmentally appropriate, sensitive to culture and community, of

sufficient length and regularly followed up, interactively taught, includes training for

prevention program providers, and evaluated to understand the effect on

behaviourxxviii. Developing and coordinating such a program state-wide would require

significant and sustained financial and human resources.

In a study of health behaviour modification, the most effective interventions across a

range of health behaviours included physician advice or individual counselling, and

workplace and school-based activitiesxxix. Other interventions to prevent drug use such

as public service announcements on radio, television, print and the Internet have

proven ineffectivexxx,xxxi.

7. Economic cost and the justice system

There has been considerable debate about the cost effectiveness of policies that target

activities to reduce drug supply. A recent review of policies aiming to reduce drug

supply, including those in Australia, found that over the time these policies had been

implemented drugs had become cheaper and of higher quality. The study concluded

that the policies had been ineffective in reducing drug supplyxxxii.

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The number of Aboriginal prisoners in Victoria has increased 82% since 2006, almost

double the rate of non-Aboriginal prisoners. Aboriginal prisoners account for 7.4% of

Victoria’s prison populationxxxiii,xxxiv. The Koori Prisoner Mental Health and Cognitive

Functioning Study – conducted in a partnership between the Department of Justice,

VACCHO and Monash University – found very high levels of substance abuse

disorders (inclusive of methamphetamines) and mental illness among Victorian

Aboriginal and Torres Strait Islander prisoners. These rates were considerably higher

than for non-Aboriginal prisoners, contributing to increased contact with the justice

systemxxxv.

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Figure 2: Lifetime prevalence of mental illness among Koori prisoners by gender

Notes: White bars indicate levels found among non-Aboriginal prison population

Source: Ogloff et al. Koori Prisoner Mental Health and Cognitive Function Study. Victorian Department of Justice. 2013

In the five years to September 2012 the number of Aboriginal people in Victorian prisons rose

by 144 peoplexxxvi. This represents an increase in prison expenditure of $45,360 per day in just

five years, or $16.6 million per annum. These figures do not price the consequent economic

costs of imprisonment (e.g. increased health and mental health services as well as losses in

productivity through inability to work) nor the social costs. Using recidivism rates among

Aboriginal prisoners as a yardstick for the effectiveness of imprisonment and prisoner

rehabilitation, the significant increase in prison expenditure has failed: more than half return

to prison within two years, rates are consistently 15 – 20 per cent higher among Aboriginal

prisoners, and despite some variability rates have actually worsened xxxvii.

Drug use is known to become more regular and more dependent once a person has entered

into the justice system.

“…in general, the lifetime drug using and offending career began with the

onset of offending, followed by the onset of illegal drug use, persisting into

regular offending, and finally regular illegal drug use. The first offence was

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most likely to be minor property offending such as stealing without break-in or

vandalism, and the drug first used was most likely to be cannabis.”

Drugs and crime: a study of incarcerated male offenders,

Australian Institute of Criminology, 2003

The impact of imprisonment extends beyond prison expenditure. Prisoners are more likely to

die or be hospitalised, especially Aboriginal prisoners xxxviii xxxix. Hospitalisation costs (based

on bed days) of Aboriginal prisoners in the first year of release has been costed at $5.4 million

in Western Australia alone, driven predominantly by mental and behavioural disorders and

injuries xl. More than a third of Aboriginal women released from prison were hospitalised xli.

This is just one area of the health system, in one jurisdiction, over a relatively short period.

Aboriginal people are also much more likely to die after they are released from prison, most

commonly through suicide, motor vehicle accidents, circulatory system diseases and drug-

related deaths xlii xliii . These outcomes remain elevated throughout the first year of releasexliv

xlv. Aboriginal prisoners also experience poorer health, with much higher rates of sexually

transmitted infections, blood borne viruses, high blood sugar and diabetes, liver-disease

markers, asthma and more xlvi. These afflictions lead to poor quality of life and premature

death, and engender grief, loss, and trauma among family, friends, and communities.

These imprisonment costs bear a significant economic burden and an unquantifiable social

cost. The period following release from prison represents a significant opportunity to reduce

very high rates of morbidity and mortality and work alongside people to reduce rates of

recidivism. Significant investment at the transition period between prison and the community

could substantially reduce economic and social costs associated with health, mental health,

and re-imprisonment, and has proven effective at significantly improving health service

utilisation in Australia and overseasxlvii,xlviii,xlix,l..

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