Low rates of prescribing alcohol relapse prevention medicines in Australian Aboriginal Community Controlled Health Services

Introduction: Alcohol dependence is a chronic condition impacting millions of individuals worldwide. Safe and effective medicines to reduce relapse can be prescribed by general practitioners but are underutilised in the general Australian population. Prescription rates of these medicines to Aboriginal and Torres Strait Islander (First Nations) Australians in primary care are unknown. We assess these medicines in Aboriginal Community Controlled Health Services and identify factors associated with prescription. Methods: Baseline data (spanning 12 months) were used from a cluster randomised trial involving 22 Aboriginal Community Controlled Health Services. We describe the proportion of First Nations patients aged 15+ who were prescribed a relapse prevention medicine: naltrexone, acamprosate or disulfiram. We explore associations between receiving a prescription, a patient AUDIT-C score and demographics (gender, age, service remoteness) using logistic regression. Results: During the 12-month period, 52,678 patients attended the 22 services. Prescriptions were issued for 118 (0.2%) patients (acamprosate n = 62; naltrexone n = 58; disulfiram n = 2; combinations n = 4). Of the total patients, 1.6% were 'likely dependent' (AUDIT-C ≥ 9), of whom only 3.4% received prescriptions for these medicines. In contrast, 60.2% of those who received a prescription had no AUDIT-C score. In multivariate analysis, receiving a script (OR = 3.29, 95% CI 2.25-4.77) was predicted by AUDIT-C screening, male gender (OR = 2.24, 95% CI 1.55-3.29), middle age (35-54 years; OR = 14.41, 95% CI 5.99-47.31) and urban service (OR = 2.87, 95% CI 1.61-5.60).Discussion and conclusionsWork is needed to increase the prescription of relapse prevention medicines when dependence is detected. Potential barriers to prescription and appropriate ways to overcome these need to be identified.Gemma Purcell-Khodr, James H. Conigrave, K. S. Kylie Lee, Julia Vnuk, Katherine M. Conigrav

More than three times as many Indigenous Australian clients at risk from drinking could be supported if clinicians used AUDIT-C instead of unstructured assessments

Aboriginal and Torres Strait Islander ('Indigenous') Australians experience a greater burden of disease from alcohol consumption than non-Indigenous peoples. Brief interventions can help people reduce their consumption, but people drinking at risky levels must first be detected. Valid screening tools (e.g., AUDIT-C) can help clinicians identify at-risk individuals, but clinicians also make unstructured assessments. We aimed to determine how frequently clinicians make unstructured risk assessments and use AUDIT-C with Indigenous Australian clients. We also aimed to determine the accuracy of unstructured drinking risk assessments relative to AUDIT-C screening. Finally, we aimed to explore whether client demographics influence unstructured drinking risk assessments. We performed cross-sectional analysis of a large clinical dataset provided by 22 Aboriginal Community Controlled Health Services in Australia. We examined instances where clients were screened with unstructured assessments and with AUDIT-C within the same two-monthly period. This aggregated data included 9884 observations. We compared the accuracy of unstructured risk assessments against AUDIT-C using multi-level sensitivity and specificity analysis. We used multi-level logistic regression to identify demographic factors that predict risk status in unstructured assessments while controlling for AUDIT-C score. The primary variables were AUDIT-C score and unstructured drinking risk assessment; demographic covariates were client age and gender, and service remoteness. Clinicians made unstructured drinking risk assessments more frequently than they used AUDIT-C (17.11% and 10.85% of clinical sessions respectively). Where both measures were recorded within the same two-month period, AUDIT-C classified more clients as at risk from alcohol consumption than unstructured assessments. When using unstructured assessments, clinicians only identified approximately one third of clients drinking at risky levels based on their AUDIT-C score (sensitivity = 33.59% [95% CI 22.03, 47.52], specificity = 99.35% [95% CI 98.74, 99.67]). Controlling for AUDIT-C results and demographics (gender and service remoteness), clinicians using unstructured drinking risk assessments were more likely to classify older clients as being at risk from alcohol consumption than younger clients. Evidence-based screening tools like AUDIT-C can help clinicians ensure that Indigenous Australian clients (and their families and communities) who are at risk from alcohol consumption are better detected and supported.James H. Conigrave, K. S. Kylie Lee, Paul S. Haber, Julia Vnuk, Michael F. Doyle, and Katherine M. Conigrav

'Even though you hate everything that's going on, you know they are safer at home': The role of Aboriginal and Torres Strait Islander families in methamphetamine use harm reduction and their own support needs

First published: 31 May 2022Introduction: First Nations people who use methamphetamine are over represented in regional and remote Australia and more likely to turn to family for support. This can place strain on families. The support needs of family members of individuals using methamphetamine are poorly understood.Methods:We conducted 19 focus groups and seven interviews with mostly First Nations community, family members and service providers. In total, 147 participants across six sites participated as part of a larger study investigating First Nations perspectives of how to address methamphetamine use and associated harms. We applied a social and emotional wellbeing framework to examine sup-port needs and role of family in mitigating methamphetamine harms.Results:Findings highlighted the importance of families in providing support to people using methamphetamine and in reducing associated harms, often without external support. The support provided encompassed practical, social, emotional,financial, access to services and maintaining cultural connection. Providing sup-port took a toll on family and negatively impacted their own social and emotional wellbeing.Discussion and Conclusions:First Nations families play an important and under recognised role in reducing methamphetamine-related harms and greater efforts are required to support them. Professional resources are needed to deal with impacts of methamphetamine on families; these should be pragmatic, accessible, targeted and culturally appropriate. Support for families and communities should be developed using the social and emotional well being framework that recognises wellbeing and healing as intrinsically connected to holistic health, kin-ship, community, culture and ancestry, and socioeconomic and historical influences on peoples’ lives.Sandra Gendera, Carla Treloar, Rachel Reilly, Katherine M. Conigrave, Julia Butt, Yvette Roe, James War

Effects of service-wide support on regularity of alcohol screening of clients in Australian Aboriginal and Torres Strait Islander Community Controlled Health Services: a cluster randomised trial

Background: We have previously shown that service-wide support can increase the odds of alcohol screening in any 2-month period in a cluster randomized trial of service-wide support to Aboriginal and Torres Strait Islander Community Controlled Health Services (ACCHS). Here we report an exploratory analysis on whether the resulting pattern of screening was appropriate. Aim: we assess whether that increase in screening was associated with: (i) increased frst-time screening, (ii) increased annual screening, (iii) whether frequently screened clients fell into one of four risk categories as defned by national guidelines. Methods: Setting and participants: 22 ACCHS; randomized to receive the support model in the treatment (‘earlysupport’) arm over 24-months or to the waitlist control arm. Intervention: eight-component support, including training, sharing of experience, audit-and-feedback and resource support. Analysis: records of clients with visits before and after start of implementation were included. Multilevel logistic modelling was used to compare (i) the odds of previously unscreened clients receiving an AUDIT-C screen, (ii) odds of clients being screened with AUDIT-C at least once annually. We describe the characteristics of a sub-cohort of clients who received four or more screens annually, including if they were in a high-risk category. Results: Of the original trial sample, 43,054 met inclusion criteria, accounting for 81.7% of the screening events in the overall trial. The support did not signifcantly increase the odds of frst-time screening (OR =1.33, 95% CI 0.81–2.18, p =0.25) or of annual screening (OR =0.99, 95% CI 0.42–2.37, p=0.98). Screening more than once annually occurred in 6240 clients. Of the 841 clients with four or more screens annually, over 50% did not fall into a high-risk category. Females were overrepresented. More males than females fell into high-risk categories. Conclusion: The signifcant increase in odds of screening observed in the main trial did not translate to signifcant improvement in frst-time or annual screening following implementation of support. This appeared to be due to some clients being screened more frequently than annually, while more than half remained unscreened. Further strategies to improve alcohol screening should focus on appropriate screening regularity as well as overall rates, to ensure clinically useful information about alcohol consumption. Trial Registration ACTRN12618001892202, retrospectively registered 16 November 2018 https://anzctr.org.au/Trial/ Registration/TrialReview.aspx?ACTRN=12618001892202.Monika Dzidowska, Jacques E. Raubenheimer, Timothy A. Dobbins, K. S. Kylie Lee, Noel Hayman, Julia Vnuk, Paul Haber, and Katherine M. Conigrav

‘The Drug Survey App’: a protocol for developing and validating an interactive population survey tool for drug use among Aboriginal and Torres Strait Islander Australians

Background: Disadvantage and transgenerational trauma contribute to Aboriginal and Torres Strait Islander (Indigenous) Australians being more likely to experience adverse health consequences from alcohol and other drug use than non-Indigenous peoples. Addressing these health inequities requires local monitoring of alcohol and other drug use. While culturally appropriate methods for measuring drinking patterns among Indigenous Australians have been established, no similar methods are available for measuring other drug use patterns (amount and frequency of consumption). This paper describes a protocol for creating and validating a tablet-based survey for alcohol and other drugs (“The Drug Survey App”). Methods: The Drug Survey App will be co-designed with stakeholders including Indigenous Australian health professionals, addiction specialists, community leaders, and researchers. The App will allow participants to describe their drug use flexibly with an interactive, visual interface. The validity of estimated consumption patterns, and risk assessments will be tested against those made in clinical interviews conducted by Indigenous Australian health professionals. We will then trial the App as a population survey tool by using the App to determine the prevalence of substance use in two Indigenous communities. Discussion: The App could empower Indigenous Australian communities to conduct independent research that informs local prevention and treatment efforts.James H. Conigrave, Scott Wilson, Katherine M. Conigrave, Tanya Chikritzhs, Noel Hayman, Angela Dawson, Robert Ali, Jimmy Perry, Michelle S. Fitts, Louisa Degenhardt, Michael Doyle, Sonya Egert, Tim Slade, Nadine Ezard, Monika Dzidowska, and K. S. Kylie Le

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