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Australia Experience of HR in Drug Free Settings

Australia Experience of HR in Drug Free Settings

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1. Australian National Council on Drugs & the National Drug Strategy

2.„The Australian experience of substitution treatment, needle and syringe programs (NSP) and harm reduction initiatives in drug free settings‟

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These Presentations Will Cover:
• Australian National Drug Strategy - highlights • Harm Reduction in Australia
– Needle & Syringe Access Program – Substitution Treatment – Harm Minimisation Initiatives within a drug free service

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Advisory Structures for the Australian National Drug Strategy
PRIME MINISTER MINISTERIAL COUNCIL ON DRUG STRATEGY

AUSTRALIAN NATIONAL COUNCIL ON DRUGS

ANCD/IGCD JOINT EXECUTIVE

INTERGOVERNMENTAL COMMITTEE ON DRUGS

ASIA PACIFIC DRUG ISSUES COMMITTEE

OF SUBSTANCE

NATIONAL INDIGENOUS DRUG AND ALCOHOL COMMITTEE

NATIONAL EXPERT ADVISORY PANEL

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Australian National Drug Strategy 2004-2009
Mission • To improve health, social and economic outcomes by preventing the uptake of harmful drug use and reducing the harmful effects of licit and illicit drugs in Australian society.

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Australia‟s National Drug Strategy
Harm Minimisation

Supply

Demand

Harm

Reduction

Reduction

Reduction

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Three Major Approaches Used to Control Drug Use/Dependence
1. Supply reduction Refers to a range of legal and law enforcement measures which are used by all countries to try to control or eliminate drug availability 2. Demand reduction Refers to educating the community about drug use, persuading young people not to use drugs and encouraging current drug users to control, reduce or stop drug use by creating provision of a range of drug treatment options

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3. Harm reduction An approach where the goal is to decrease the risks and harmful health and social consequences of drug use without necessarily reducing drug use

e.g. Random breath testing of drivers;
Nicotine patches/gum for cigarette smokers;

Methadone maintenance for opioid dependent users;
Sterile needles & syringes for injecting drug users

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Australian National Drug Strategy 2004 – 2009 Priority Areas:
• • • • • • • Prevention Supply reduction Reduction of drug use and related harms Improved access to quality treatment Development of the workforce, organisations, & systems Strengthened partnerships Implementation of the National Drug Strategy Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003 – 2006 • Identification and response to emerging trends

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Why did we rethink our Drug Strategy?
• Mid-1960‟s heroin first came into Australia
– By 1997 estimated 74,000 dependent users – 10% of all 25–34 year old deaths due to heroin overdose – annual cost of heroin related crime $0.5 to $1.6 billion – only 36% of dependent-heroin users in treatment

• Relying on supply reduction alone was proving expensive (and)

• Drug use was increasing
• Realised that you could not control blood-borne virus transmission with supply reduction alone: • HIV had emerged as the major threat related to injecting drug use for individuals and communities (USA experience)

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Challenges around Implementation of the 3rd Pillar: Harm Reduction
• Public and political concerns
– Is it sending wrong message?
– Concern about treatment services in the community – Does it encourage/normalise drug use?

• Negative media • Diversion of methadone onto the illegal market Twenty years later there is evidence to satisfy these concerns

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Australia‟s Drug Budget 2002/03 (All Govt‟s)
Source: DPMP Monograph Series #1

14% Law Enforcement Interdiction 42% 23% Prevention Treatment Harm Reduction Other 1%3% 17%
http://www.turningpoint.org.au /research/dpmp_bulletin

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Needle and Syringe Program (NSP)

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Are Needle and Syringe Programs Safe?
• No evidence of increase in number of injecting drug users • No evidence of increase in frequency of injecting drug use • No increase in used, discarded injecting equipment • No case of blood-borne virus infection reported as a result of disposal
Source: Five US government funded reviews + NIH Consensus Development Conference (1997)

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Are Needle and Syringe Programs effective?
• Internationally: data on HIV from 103 cities world wide shows: - 36 cities with NSP had an 18.6 % mean annual decrease in HIV seroprevalence - 67 cities without NSP had an 8.1% mean annual increase in HIV seroprevalence
• Australia: from 1991-2000 - NSP prevented 25,000 HIV infections - NSP prevented 21,000 hepatitis C infections - NSP cost US$85.4 million - NSP saved US$1,681 million
Source: Return on Investment in Needle and Syringe programs in Australia, Commonwealth of Australia 2002

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HIV prevalence in injecting drug users

90 80 70
HIV prevalence, %

Myanmar

60 50 40 30 20 10 0 1983

Edinburgh
Bangkok

Manipur & Yunnan Lithuania

Ho Chi Minh City Odessa

Jakarta

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

Year

Source: We Health Organization- Western Pacific Region

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Return on Investment for NSP’s
Investment on NSP’s (1990-2000) = $149.9 million
Estimated Number of HIV cases avoided (1990-200) =25,000 Estimated Number of HCV cases avoided (1990-2000) = 21,000 Estimated Number of HIV related deaths (by 2010) = 4,500 Estimated Number of HCV related deaths (by 2010) = 650

Based on costs for treatment, quality of life, productivity loss etc, it is estimated that the return for the investment on NSP’s is between NSP’

$2.4 billion and $7.7 billion. billion
Source: Commonwealth Department of Health & Ageing (to be released)

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Program Issues:
“Aim & Objectives” Aim • To minimise HIV transmission across the whole population of injecting drug users Behavioural Objective • New (sterile) needle and syringe for every injection

Operational Objectives • Achieve maximum contact with injecting drug users • Fully meet demand for needles and syringes

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Achieving Coverage:
Key factors • • • The injecting drug user population is highly diverse Risk behaviour is determined by a range of individual, social and environmental factors Injecting drug users have a range of needs, of which HIV may not be of most significance to them There may be significant barriers which discourage injecting drug users from accessing needle syringe programs

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Achieving Coverage:
Key Responses • Establish trust and rapport with injecting drug users – by developing a relationship based on respect and non-judgemental attitude

• Consult with injecting drug users about their needs and preferences and modify services accordingly – role of peer based organisations • Provide needles and syringes through multiple sources, to attract different populations
• Supply needles and syringes with minimal conditions • Develop innovative services including outreach

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Achieving Coverage:
Key Responses Develop links with relevant services and make appropriate referrals, in particular:

• Provide access to a range of drug treatment services, based on evidence of effectiveness
• Provide access to primary health care

• Provide access to testing and treatment for blood borne and sexually transmissible infections

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Achieving Coverage:
Key Responses (Continued)
• Identify and remove/reduce barriers to access • Develop agreements with local police • Consult with local community interests and identify concerns, in particular: - do not operate near children - collect and reduce discarded needles • Monitor and evaluate program performance through data collection and research

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Cooperation: Health and Police
• Develop common understanding and mutual respect

• Develop policies and procedures that are supportive and complementary
• Develop relationships at all levels, including policy, command and operational levels • Pragmatic and supportive policing • Health work which is respectful of police role

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Cooperation: Health and Police
E.g. of an Australian State Police Policy: • “Without restricting their day to day duties and obligations, police should be mindful not to carry out unwarranted patrols in the vicinity of needle and syringe programs that might discourage injecting drug users from attending them.”

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HIV Outcomes
• Less than 2% of injecting drug users infected with HIV in Australia • Fewer than 20 new HIV cases among injecting drug users per year (out of a total of 380 per year) • Very few secondary infections to women and children • Small heterosexual epidemic • HIV epidemic largely confined to homosexual and bisexual men

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Substitution Treatment

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Major Challenge:
Reduce Public Health Burden of Heroin Dependence • Distinguish between drug users and drug dependent users • Deliver safe, effective maintenance treatment to as many drug dependent users as possible • Develop treatments that are more attractive • Increase community acceptability • Achieve a balance between over-regulation and laissezfaire provision • Monitor impact of treatment • Developing less expensive and more efficient ways of delivering treatment

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Is Substitution Treatment Effective?
Studies examining the effectiveness of substitution therapy…

• Review of 33 studies from peer-reviewed journals 19881999, with an aggregate of 17,771 subjects, concluded:
‘there is clear evidence that methadone maintenance treatment does reduce HIV risk behaviours, particularly drug injecting‟ • Similar observations for other substitution therapies, e.g. buprenorphine etc.

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Cost-effectiveness: Maintenance
• Methadone Maintenance is the most cost-effective treatment currently available • Naltrexone treatment is the least cost-effective

• Treatment in GP (shared-care) setting is more costeffective than in specialist clinics

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Cost-effectiveness: Maintenance cost-drivers
Buprenorphine - relatively expensive medication, but - induction can be streamlined - dispensing/dosing process can be less expensive Methadone - inexpensive medication, quick to dispense - further cost-efficiencies unlikely Naltrexone - relatively expensive medication - further cost-efficiencies unlikely

Distribution of Dosing Site in Australia June 2002
Private clinic 9% Prison 7% Other 6%

Public clinic 15%

Pharmacy 63%

2/7/2011

34,210 clients

30

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http://www.nationaldrugstrategy.gov.au/resources/publist.htm

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Steps in Developing Valid Usable Guidelines
• Systematic review of evidence • Multidisciplinary expert group to translate evidence into clinically helpful guidelines • Sufficient resources, both human and financial to do task

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E.g. of „harm reduction‟ initiatives in a

residential „drug free‟ organisation
since the outbreak of HIV

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1986 - What was available?
• • Methadone maintenance „conditions applied‟ Detox clinics, providing abstinence only services


• •

Government D&A services, mainly 9am-5pm
Non Government residential drug rehabilitation services “abstinence only” General practitioners

In summary: help limited in quantity and quality

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What happened to consider a change from a Traditional Drug Free Rehab?
1986 • Evidence of users presenting with HIV


• • •

International concerns re HIV transmission
Drug overdose on the increase IV drug use on the increase My organisation (an NGO) was in a process of physically moving from a rural traditional TC to an inner city TC.(1986)

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Internal Challenges
• • • • • • “Abstinence Only” issues to be resolved Dilemma: moral or reality based approach? Does NSP equipment pose a threat to clients recovery? “Treatment episode” redefined - Abstinence Only Elimination of „success / failure‟ thinking Therapists feeling a loss of control Health gains

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External Challenges
• Other D&A services at the time challenged our new direction • Tension over the term “Harm Reduction” • Contradictions emerging: help or service to clients? • Conflict: “user services” vs rehabs/TCs

• Competition for funding $s influenced polarisation for a while

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Strategic Response
• • Commenced gathering and analysing data Key decision makers consulted (Senior staff, Management and Board of Directors) Our organisation started thinking outside historical thinking Newly established „user advocacy groups‟ were consulted Notion of risk management info for users (past, present and future) as a priority in new service plans

• • •

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Processes
• Partnerships paramount, synergy of resources

• Consulted clients in treatment at the time
• Interviewed ex-clients irrespective of using status • Reviewed initial “internal” organisational challenges • Consulted external stakeholders

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Partnerships & Agreements
• Consensus with staff and board of management • Current and ex-clients support with new direction • Funding Agreement was varied to include Harm Reduction • New positions - HIV/Infectious disease workers hired • Partnerships with Research Institutions e.g OD info • Staff join “user group” management committees • NSP support with supplies (ie syringes,condoms etc)

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Outcome
• Been providing well integrated Harm Reduction (HR) services in our drug free services for past 19 years


Enjoyed funding for HR workers for past 17 years
HR project now integrated across our 7 TC sites

Provision of NSP supplies did not affect clients retention or drug use within facilities
HR manager equal line management with clinical mgrs

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Finally
• Continue to promote a “common sense” approach to drug treatment based soundly on evidence • Are Harm Reduction and Abstinence Based Treatment irreconcilable opposites? Our experience demonstrates much common ground

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Summary
 Successive Australian National Strategies have maintained the commitment to a balanced approach addressing supply, demand and harm reduction: called „Harm Minimisation‟  They have included health, law enforcement and the community (including drug users themselves)  Together, clean needle programs and substitution treatment for opioid users have helped Australia maintain low levels of HIV and reduce other BBV

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Conclusion
 Faced with an increasing illicit drug use problem, Governments have to make a decision:
 Develop programs based on the evidence and which address the twin epidemics of illicit drug use and HIV/other BBV  Face the possibility of HIV/AIDS and other BBV epidemics driven by the reuse of contaminated needles & syringes

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