What’s the evidence, what’s working, what’s not and what are the issues and opportunities for the future?
About Poche Centres for Indigenous Health
Poche Centres for Indigenous Health are an example of the power of partnership in achieving real change and genuinely contributing to closing the gap in life expectancy.
Established and funded by philanthropist Greg Poche AO, Poche Centres seek to leverage the best of the best in Universities with communities and governments to seek solutions to address complex health problems faced by Aboriginal people.
Mr Poche has gifted more than $40m to Aboriginal health in the past six years and intends to gift a further $10m this year.
The Poche model is unique. Located within universities, Poche Centres work with leading researchers, alumni, faculty and students to bring their knowledge together with communities to find sustainable, workable, affordable solutions to health issues including oral health, specialist medical, Foetal Alcohol Spectrum Disorders, allied health, social and emotional well-being, chronic disease, workforce development, leadership and health promotion.
The facts about alcohol, tobacco and other drug use and Aboriginal and Torres Strait Islander health
Just as Aboriginal and Torres Strait Islander (Indigenous) Australians have a higher burden of physical disease, they also are more likely to experience mental health and alcohol and other drug use disorders than are non-Indigenous Australians. Indigenous Australians are hospitalised or die because of alcohol-related conditions four times as often.1 Alcohol or other drug (AOD) problems are also a key factor in the appallingly high imprisonment rates of Indigenous Australians. For example, more than two out of every three Indigenous prisoners in NSW report being intoxicated at the time of their offence,2 with just under half male inmates in surveys in both QLD and NSW reporting evidence of dependence on alcohol.2 3 Indigenous Australians also carry a greater burden of smoking-related disease, and are twice as likely to be smokers (with pockets of far higher smoking prevalence in remote communities).1 Alcohol and tobacco are also each risk factors for a
range of common chronic diseases including heart disease, diabetes, cancer and brain damage, so addressing these issues will be key to closing the health gap.
While illicit drug use is less common than alcohol or tobacco, some communities report major problems related to cannabis, including dependence, mental health concerns, and sometimes, marked agitation or even violence when the drug is not available.4 There is growing concern in many Indigenous communities about a rise in stimulant use, and the violence that can be associated with
‘ice’. As for all Australians, injecting drug use is less common than use of licit drugs or cannabis, but poses particular concern around transmission of viruses, including Hepatitis C and HIV.
Sadly, jail can be the place where indigenous Australians are introduced both to injecting and sharing of injecting equipment. Petrol sniffing has become less common in isolated communities, which have been supported to switch over non-sniffable (OPAL) fuel, but remains a concern in other regions.
￼￼￼￼Indigenous Australians are at an increased risk of AOD disorders because of ongoing marginalisation, disempowerment and stress. Indigenous Australians are far more likely to suffer from recurrent stress and trauma than the remainder of the population.5 And in any population relative disempowerment, lower educational opportunity, and a lack of a sense of connectedness with community or society are risk factors for risky drinking and for smoking. Childhood separation from parents or childhood emotional trauma, are additional well recognised risk factors for later
substance use and mental health disorders. Indeed, early or recurrent life stress may lead to permanent changes in the way the brain reacts to alcohol or other drugs6 and leave a person vulnerable to AOD disorders.
While the social determinants of substance misuse are well recognized, a vicious cycle can be set up, where an adult’s substance use can then create a stressful fetal or childhood environment, and so increase the risk of substance use in the next generation. In this way trans-generational transmission of alcohol or drug problems occurs. For all these reasons,
￼state-of-the-art treatment for adults, and effective prevention measures for whole communities (and to the whole country) are vital.
What’s working and what’s not?
Prevention and community-wide measures: In preventing AOD problems, many of the strategies used by Indigenous communities align well with the evidence base. For example, increasing connectedness and opportunities for young people through sport, culture, music, education and training is in keeping with the demonstrated importance of promoting connectedness and resilience to reduce substance misuse.7 8 Furthermore, reducing access to alcohol, such as by liquor licensing arrangements, fits well with the strong evidence-base for supply control.
Successful calls from Indigenous communities (e.g. in remote or regional communities) to reduce access to alcohol have often greatly reduced harms from alcohol. However it can be very challenging for community representatives to achieve reduced density or opening hours of licensed premises, or reduced availability of cheap alcohol, against the wishes of the alcohol industry.
Where Indigenous communities have themselves sought reduction of the supply of alcohol this has often had strong positive effects. However there are real concerns that where supply control is forced on communities or individuals on the basis of race, rather than on the basis of evidence of harms, these measures may increase the very disempowerment, which drives substance misuse.
Education about the risks of drugs or alcohol on its own has limited effectiveness in preventing alcohol or other drug misuse in Indigenous (or non-Indigenous) Australians. However education can be successfully combined with measures to increase empowerment or connectedness or to reduce access to problem substances.8
Detecting problems earlier: The past 40 years, has seen a rise in the awareness of the importance of early detection and assistance for those with AOD problems. For example, Indigenous community- controlled health services have increasingly been working to increase systematic screening for alcohol and tobacco use, so as to offer help earlier.
Treatment: Internationally there has been a rapid expansion in knowledge in what works in treating alcohol, tobacco and other drug dependence. This has included the availability of medicines to reduce craving for alcohol, tobacco and opioids. However anecdotally, Indigenous Australians may face challenges in accessing such treatments. Also there are major gaps in availability of residential treatment services for alcohol and other drug problems, with some people having to travel many hours to access care, and facing long waiting lists. There are also challenges finding withdrawal management, which is often a necessary first step before entering a rehabilitation service. Anecdotally some rural hospitals refuse to admit patients for management of alcohol withdrawal, even when there is a past history of withdrawal seizures that can be life threatening.
AOD problems are very often accompanied by physical and mental health problems (comorbidity). However funding and staffing of many AOD residential services limits their ability to accept clients with complex issues. Accordingly, individuals with polydrug dependence or with physical or mental comorbidity can find it difficult to access care. Furthermore, despite the importance of mental health conditions in leading to (or perpetuating) substance use, there is a nation-wide shortage of mental health care. Also, while AOD dependence typically behaves like a chronic disease with periods of remission and relapses, opportunities for continuing care after a period of residential treatment can be limited.
Impact of imprisonment: Currently far too many Indigenous Australians with AOD problems end up in prison and Indigenous Australians make up more than a quarter (27%) of the total prison population. Yet, prison is more expensive and less effective compared with voluntary treatment in helping individuals stop dependent AOD use. It is also results in a reduced chance of later employment and has a disruptive effect on family and community. There has been a range of promising initiatives to reduce imprisonment including by diverting individuals into treatment and with the use of circle sentencing. However availability of such programs is still limited, and in NSW for example, most regions do not offer diversion programs for offenders with charges related alcohol use.
￼￼￼￼Impact of fetal alcohol spectrum disorders (FASD): There has been a growing awareness of the prevalence of FASD. However further efforts are needed on grass roots education, warning labels, and more alcohol treatment services that are capable of assisting pregnant women. Role of Indigenous AOD workers: There can be stigma and challenges in seeking AOD treatment, and Indigenous AOD workers have a unique role in increasing accessability and appropriateness of treatment. In keeping with rapid changes to the field, the Indigenous AOD workforce has actively pursued opportunities for upskilling. A range of training, including certificate level and university courses are available to workers, and professional networks have been formed to support workers
in this stressful field. However, Indigenous AOD workers often face lack of job security and lack of career development opportunities. This can result in high job turnover and loss of skills.
What are the issues and opportunities for the future?
A collaborative and strategic approach: Stop-start (or non-recurrent) funding of short-term initiatives has impeded progress in tackling AOD problems. There is a pressing need for a sustained, integrated and strategic approach to prevent and treat AOD misuse. This should be a collaborative and evidence-based approach and should cut across political and departmental boundaries. Addressing the social determinants of alcohol, tobacco and other drug problems will underpin these efforts.
Reducing the influence of alcohol industry lobby groups: In reducing tobacco-related harms, it has been necessary to curtail the influence of the tobacco companies on government decision making. Similarly to reduce the harms of alcohol, the influence of the alcohol industry must be recognised and reduced. Transparency in political donations is one way to help achieve this. Currently there is broad agreement among health professionals of the importance of pricing alcohol according to the number of standard drinks, increasing the minimum price of an alcoholic drink, and reducing promotion and availability. This would help all Australians, including Indigenous Australians.
Other specific opportunities: Other approaches to reduce the negative effects of alcohol, tobacco and other drugs on Indigenous Australians include:
- Drawing on community and cultural strengths: increasing integration between successful prevention and treatment models that have been developed by Indigenous Australians with the best of ‘Western’ health care. Adequate funding for evaluation and quality improvement with realistic time frames will facilitate this.
- Supporting Indigenous AOD workers to build their expertise and pathways for career development: this also requires health service funding to be sufficient to release workers for training and for salaries that recognise skills, training and experience.
- Increasing access to new medicines to reduce craving for alcohol: from overseas research, these can significantly improve outcomes for dependent drinkers, and also have potential for individuals leaving rehabilitation units or prison.
- Increasing availability of mental health care particularly for individuals with substance use disorders: this includes those who have faced childhood physical or sexual abuse.
- Supporting communities to address heavy drinking: Efforts to challenge alcohol supply can be challenging (and sometimes risky) in heavy drinking communities. Even in an urban setting it can be hard for community organisations to take on lawyers of ‘big alcohol companies’ to challenge an application for a licensed premise. Supporting communities to address alcohol’s harms is a good investment.
- Reducing imprisonment for AOD problems: we need to see an expansion of services to divert Indigenous Australians with AOD problems away from prison and into treatment. For those who do end up in jail, correctional initiatives need to offer quality treatment and build resilience. Given the social determinants of substance misuse, and the increased prevalence of FASD among offenders, it is important that we avoid punishing victims.
- Increasing the availability of treatment for AOD disorders in primary care: currently many
- Indigenous community controlled services are working to achieve this.
- Including AOD dependence on the chronic disease agenda: we know that AOD dependence typically follows a chronic pattern, with remissions and relapses. A more realistic understanding of prognosis and of the social determinants of use is needed.
Questions to assist the discussion on the day
1. How easy is it for Indigenous Australians who are dependent on alcohol or other drugs to access AOD treatment services?
2. What are the barriers to primary health, ‘rehab’ or prison health services offering Indigenous Australians who are dependent on alcohol access to the newer medicines to help stay dry?
3. If a person lives in a regional centre and is addicted to heroin or strong pain killers, how easy is it for them to get access to methadone or ‘bupe’ (buprenorphine) treatment?
4. How can we reduce the large numbers of individuals with AOD problems and mental health disorders ending up in jail?
5. What factors have been responsible for the recent reduction in smoking cessation rates among Indigenous Australians, and how can these gains be maintained.
￼￼6. How can communities be better supported to reduce harmful use of alcohol, for example, if they wish to challenge new or existing licensed premises?
7. How can we increase transparency over influence of the alcohol industry on government decisions relating to alcohol pricing and licensing?
8. How can we achieve ‘a more coordinated’ and long-term approach to fund services to prevent and treat AOD problems?
9. Are palliative care services available for those who find it impossible to stop drinking or using other drugs, and for those who have developed alcohol-related brain damage?
10. How can we change the culture of blaming those who are dependent on alcohol, tobacco and other drugs, rather than acknowledging a shared local and national responsibility to reduce the risk factors for dependence?
1. Australian Institute of Health and Welfare. Substance use among Aboriginal and Torres Strait Islander people. Canberra: Australian Institute of Health and Welfare, 2011. Available at: http://www.aihw.gov.au/publication-detail/?id=10737418268 [accessed 1/3/14]
2. Indig D, McEntyre E, Page J, Ross B. 2009 NSW Inmate Health Survey: Aboriginal health report. Sydney: Justice Health,2010. Available at file:///C:/Users/conigk/Documents/references%20electronic/aboriginal,%20TI%20&%20 indigenous/prison/2009%20inmat e-health-survey-aboriginal-health-report%20nsw.pdf [Accessed June 4, 2014]
3. Kinner SA, Dietze PM, Gouillou M, Alati R. Prevalence and correlates of alcohol dependence in adult prisoners vary according to Indigenous status. Australian and New Zealand Journal of Public Health 2012;36(4):329-34.
4. Lee KSK, Conigrave KM, Patton G, Clough A. Cannabis: endemic yet neglected in remote Indigenous Australia [editorial]. Med J Aust 2009;190(5):228-29.
5. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples: an overview 2011. Canberra: ABS, 2011.
6. Enoch MA. The role of early life stress as a predictor for alcohol and drug dependence. Psychopharmacology 2011;214(1):17-31.
7. Bond L, Butler H, Thomas L, Carlin J, Glover S, Bowes G, et al. Social and school connectedness in early secondary school as predictors of late teenage substance use, mental health, and academic outcomes. Journal of Adolescent Health 2007;40(4):357. e9-57. e18.
8. Lee KSK, Jagtenberg M, Ellis CM, Conigrave KM. Pressing need for more evidence to guide efforts to address substance use among young Indigenous Australians. Health Promotion Journal of Australia 2013;24(2):87-97.
Details of the Key Thinkers’ Forum
Date: 11 July 2014
Venue: Charles Darwin University (Room TBA)
Chair: Dr Tom Calma AO