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Plain language review of illicit drug use among Aboriginal and Torres Strait Islander people

Preface

This plain language review of illicit drug use among Aboriginal and Torres Strait Islander people is based on the Review of illicit drug use among Aboriginal and Torres Strait Islander people (2016) by Andrea MacRae and Joanne Hoareau.

Introduction

Most Aboriginal and Torres Strait Islander people do not use illicit (illegal) drugs, but the proportion of drug use is higher among Aboriginal and Torres Strait Islander people than among non-Indigenous people [1, 2].

Cannabis is the most commonly used illicit drug among Aboriginal and Torres Strait Islander people [3, 4]. High levels of cannabis use have been reported in some Aboriginal and Torres Strait Islander communities [5-7]. Illicit drug use has a number of impacts on health and community that affect Aboriginal and Torres Strait Islander people more than non-Indigenous people. These  include a greater chance of being infected with blood-borne viruses (hep C, hep B, HIV) from injecting drug use [8], reduced social and emotional wellbeing, and an increased risk of suicide [4, 9, 10]. Illicit drug use also contributes to family disruption, harm to children, violence, crime and imprisonment [4].

Box 1: Illicit drugs

Illicit drugs are:

  • drugs that are illegal to have, such as cannabis, ice (crystal methamphetamine), cocaine and heroin

  • prescribed drugs, such as codeine and benzodiazepines, that are used for purposes different from those intended [11].

Specific information on sniffing petrol or glue (volatile substance use) is not included in this review. Detailed information on volatile substance use is available in the Review of volatile substance use among Aboriginal and Torres Strait Islander people.

For more information on categories and definitions of illicit drugs, refer to the Australian Indigenous Alcohol and Other Drugs Knowledge Centre: background information on illicit drugs.

About this review

The purpose of this plain language review is to provide an overview of the use of illicit drugs among Aboriginal and Torres Strait Islander people in Australia. It provides general information on illicit drug use in Australia and the factors relevant to Aboriginal and Torres Strait Islander people. Detailed information is provided on:

The Australian Indigenous HealthInfoNet produces a wide range of publications and reviews of specific health topics. In these publications, authors summarise and present data from other sources. It is often difficult to determine whether original sources are referring to Aboriginal people only, Torres Strait Islander people only or to both groups. When this happens the authors are ethically obliged to use the terms from the original source unless they can obtain clarification from the report authors/copyright holders. Our readers may see these terms used as well as the term ‘Indigenous’. If you have any concerns please contact the HealthInfoNet for further information.

Key facts

Level of illicit drug use among Aboriginal and Torres Strait Islander people

Health impacts

Social impacts of drug use among Aboriginal and Torres Strait Islander people

Policies and strategies

Important policies that guide governments, communities and services to reduce the harmful effects of alcohol and other drugs include:

Programs and services

Illicit drug use in Australia

The 2013 National drug strategy household survey (NDSHS) found that 15% of Australians aged 14 years and older had used illicit substances in the previous 12 months, and almost half (42%) had used an illicit substance at least once in their lifetime [1].

Illicit drug use contributes to:

and is associated with:

In 2011-2012, there were around 100,000 hospitalisations due to drug use. Almost half of these (46,000) were due to illicit drug use [14].

The cost to society of illicit drug use is very high. The total cost of legal and illegal drug use in 2004-05 was $56 billion, of which $8.2 billion (15%) was for illicit drug use [13]. Of this, $3.8 billion was for law-enforcement and cost related to crime.

What factors contribute to illicit drug use among Aboriginal and Torres Strait Islander people?

The higher level of illicit drug use among Aboriginal and Torres Strait Islander people compared with non-Indigenous people, and the harms associated with its use, are directly linked to social disadvantage [15]. These include:

Each of these will be discussed in more detail below.

Historical factors

With the arrival of Europeans in 1788, Aboriginal and Torres Strait Islander people were forcibly removed from their lands. This process resulted in the loss of culture, trade and community stability for many Aboriginal and Torres Strait Islander communities [15]. Aboriginal and Torres Strait Islander people were often separated from their country and their language groups and made to live in poor conditions in missions and settlements, where, except for the most basic roles, they were largely excluded from colonial life.

Social context

In general, Aboriginal and Torres Strait Islander people experience lower levels of education, employment, and income compared with non-Indigenous people. Patterns of problematic drug use, such as dependence (where a person has difficulty controlling their use and experiences physical withdrawal symptoms), have been closely linked with social disadvantage [16].

Education

Having a good education affects a person’s employment opportunities and, in turn, affects their living standards. Surveys show that Aboriginal and Torres Strait Islander people are more likely to leave school at a younger age [17-19].

Employment

Employment directly affects a person’s quality of life. Unemployment may encourage drug use, and established drug use may interfere with a person’s ability to find and keep a job [20].

Figures from the 2011 Census show that, for Aboriginal and Torres Strait Islander people aged 15 years and older,  unemployment was more than three times higher (17%) than for non-Indigenous people (5.4%)  [21].

Income

Past studies have shown a clear link between income and health; that is,  people on higher incomes are healthier [16]. In 2012-13, the median weekly household income for Aboriginal and Torres Strait Islander adults was $465 compared with $869 for non-Indigenous adults.

Family and peers

Strong, healthy family relationships may decrease the likelihood of a person using illicit drugs and may help some people to overcome drug dependence [5, 22-25]. Family support and involvement has also been identified as an important factor in quitting drug use [5, 23-25].

Family support may be a protective factor, but existing drug use within the family network may be a risk factor [26].

Friends and peers may also encourage drug use. A 2009 survey of young people in prison in New South Wales (NSW) found a higher proportion of Indigenous young people (66%) than non-Indigenous young people (57%)  identified peer pressure as the main reason they tried illicit drugs [27]. Being part of a peer group that uses illicit drugs may also make it more difficult to reduce drug use or quit [28].

Community

Community relationships can protect members from drug use through positive community involvement [16, 29, 30]. Positive community support may be provided by:

How common is illicit drug use among Aboriginal and Torres Strait Islander people?

Surveys consistently show that most Aboriginal and Torres Strait Islander people do not use illicit drugs [31, 32].

According to the 2012-2013 Australian Aboriginal and Torres Strait Islander health survey (AATSIHS):

Other surveys report higher levels of recent illicit drug use (in the 12 months prior to survey) among Aboriginal and Torres Strait Islander people than among non-Indigenous people [1, 31, 32, 34]. The 2013 NDSHS found that after adjusting for age differences, almost one quarter (23%) of Aboriginal and Torres Strait Islander people aged 14 years and older had recently used an illicit drug, compared with 15% of non-Indigenous people [1].

Box 2: Age adjustment

Comparing illicit drug use by Aboriginal and Torres Strait Islander and non-Indigenous people is complicated by the fact that the Aboriginal and Torres Strait Islander population is younger overall than the non-Indigenous population. A statistical procedure known as age-standardisation adjusts health measures (such as prevalence and rates) to minimise the effects of differences in age structures of the two populations, so that these different populations can be compared [33]. These measures are called age adjusted or age standardised comparisons.

According to the 2012-2013 AATSIHS, when comparing between Aboriginal and Torres Strait Islander males and females:

When comparing different age groups:

Table 1: Proportions (%) of illicit drug use among Aboriginal and Torres Strait Islander people aged 15 years and older, by age-group and frequency of use, Australia, 2012-2013

 

Used illicit drug in the previous 12 months

Used illicit drug but not in the last 12 months

Age-group (years)

Proportion of persons (%)

 

 

Proportion of persons (%)

 

 

15-24

28

 

 

15

 

 

25-34

27

 

 

30

 

 

35-44

23

 

 

27

 

 

45-54

19

 

 

29

 

 

55+

7

 

 

14

 

 

All ages

22

 

 

23

 

 

Source: ABS, 2013 [31]

The 2008 Australian secondary students alcohol and drug survey (ASSAD) found that one in five (19%) Indigenous participants aged 12-15 years had used an illicit drug in the previous year compared with 9% for all respondents [35].

Remote vs non-remote:

What are the commonly used illicit drugs?

Cannabis is the most common illicit drug used in Australia for both the Aboriginal and Torres Strait Islander population and the total population [1, 2]. Other illicit drugs used by Aboriginal and Torres Strait Islander people include analgesics (painkillers and sedatives for non-medical use) and amphetamines (ice or speed) [3]. Levels of illicit drug use vary according to the type of drug used as shown in Figure 1.

Figure 1. Proportions (%) of recent illicit drug use among Aboriginal and Torres Strait Islander people aged 15 years and older, by type of illicit drug, Australia, 2012-13

 

Source: ABS, 2013 [3]

Notes:

  1. ‘Recent use’ refers to use in the 12 months prior to survey
  2. ‘Other’ includes heroin, cocaine, petrol, LSD/synthetic hallucinogens, ecstasy/designer drugs, methadone and other inhalants

Cannabis

What is the level of cannabis use according to surveys?

2013 NDSHS [1]:

2012-2013 AATSIHS [3]:

2008 ASSAD [35]:

Figure 2: Proportions (%) of cannabis use among students aged 12-15 years, by Aboriginal and Torres Strait Islander status and frequency of use, Australia, 2008

 

Source: Smith G, White V, 2010 [35]

Note: Due to rounding, percentages totals may be higher than 100%

Cannabis use in Aboriginal and Torres Strait Islander communities

National surveys do not provide information on illicit drug use in specific locations or communities. Therefore we have to find information from smaller studies. Some studies have reported very high levels of cannabis use among Aboriginal and Torres Strait Islander people living in some remote communities. This high level of cannabis use is known to have negative effects on social and emotional wellbeing [36]. The following studies provide data from remote communities.

Analgesics and sedatives

What is the level of use for analgesics (pain killers) and sedatives according to surveys?

2013 NDSHS [1]:

2012-2013 AATSIHS [3]:

Amphetamines

Since 2007, the use of methamphetamine has been relatively steady for the total Australian population [39].  Reports show:

What is the level of amphetamine use according to surveys?

2013 NDSHS [1]:

2012-2013 AATSIHS [3]:

2008 ASSAD [35]:

Ecstasy and other designer drugs

What is the level of use for ecstasy and designer drugs according to surveys?

2013 NDSHS [1]:

2008 NATSISS [32]:

2008 ASSAD [35]:

Kava

What is the level of kava use according to surveys?

2012-2013 AATSIHS [3]:

2008 NATSISS [32]:

There has been a decline in use of kava in very remote areas since 2002, which reflects the impact of restrictions that have been placed on kava during this time [41, 42]. For details, please see the Review of the use of kava among Indigenous people .

Table 2. Proportions (%) of recent kava use among Aboriginal and Torres Strait Islander people aged 18 years and older, by area of residence, Australia, 2002 and 2008

 

Major cities

Inner regional

Outer regional

Total non-remote

Remote

Very remote

Total remote

2002

0.7

1.1

0.4

0.7

0.7

4.3

3.2

2008

1.4

1.8

0.4

1.2

n.p.

1.8

1.2

Source: Steering Committee for the Review of Government Service Provision, 2011 [40]

Notes:

  1. ‘n.p.’ means ‘not provided’
  2. Data for remote areas should be viewed with caution because relative standard errors exceed 25%

How common is injecting drug use?

Experts suggest that studies and surveys about injecting drug use (as for other illicit drugs) may not be very accurate for several reasons:

Very few surveys and studies provide national information on injecting drug use among Aboriginal and Torres Strait Islander people [24].

The goanna survey (2011-2013), asked survey participants about behaviour such as illicit drug use and injecting drug use [43]. Of the 3,000 participants:

According to data from Alcohol and other drug treatment services in Australia 2013-14 [44]:

In a study involving clients of needle and syringe programs (NSPs) across Australia in 1998-2008 [45]:

Figure 3: Duration of injecting drug use for participants attending NSPs, by Aboriginal and Torres Strait Islander status and characteristics, Australia, 1998-2008

 

Source: Ward J, Topp L, Iversen J, Wand H, Akre S, Kaldor J, Maher L, 2011 [45

Figure 4: Drug last injected by proportion (%) of Aboriginal and Torres Strait Islander participants attending NSPs, Australia, 1998-2008

 

Source: Ward J, Topp L, Iversen J, Wand H, Akre S, Kaldor J, Maher L, 2011 [45

Figure 5: Drug last injected by proportion (%) of non-Indigenous participants attending NSPs, Australia, 1998-2008

 

Source: Ward J, Topp L, Iversen J, Wand H, Akre S, Kaldor J, Maher L, 2011 [45]

 

Some Australian studies provide valuable information about Aboriginal and Torres Strait Islander injecting drug use in specific locations.

Poly-drug use

Poly-drug use refers to using more than one drug at the same time (concurrent use) or replacing one drug with another when the preferred one is not available [15, 48].

How common is poly-drug use according to surveys?

2008 NATSISS [32]:

2008 ASSAD [35]:

Table 3. Proportion (%) of ASSAD participants aged 12-15 years who engaged in concurrent substance use in the 12 months prior to interview, by Aboriginal and Torres Strait Islander status and type of substance, Australia, 2008

Type of substance

Concurrent use with cannabis

Concurrent use with amphetamines

Concurrent use with ecstasy

 

Aboriginal and

Torres Strait

Islander

All ASSAD

Aboriginal and

Torres Strait

Islander

All ASSAD

Aboriginal and

Torres Strait

Islander

All ASSAD

Alcohol

58

58

52

48

55

61

Tobacco

42

43

35

34

36

42

Cannabis

-

-

40

32

54

39

Hallucinogens

6.6

4.9

17

10

14

15

Amphetamines

3.6

5.8

-

-

24

14

Ecstasy

13

8.8

26

15

-

-

Analgesics

12

9.4

19

7.3

10

9.7

No other substances used

29

29

21

29

12

19

Source: Smith G, White V, 2010 [35]

Some small studies provide information on poly-drug use among Aboriginal and Torres Strait Islander people (which is not available from national surveys).

What is known about the health impacts of drug use among Aboriginal and Torres Strait Islander people?

Health issues associated with cannabis use

Cannabis use has been linked with many social and emotional wellbeing problems among Aboriginal and Torres Strait Islander people. These include [7, 9, 49, 51-54]:

Evidence also suggests that cannabis use may be linked to thinking about and planning for suicide [55]. A WA study reviewing the state’s coronial records for suicides among people aged 15-24 years in 1986-1998 found that cannabis was the illicit drug most commonly detected during suicide postmortems, being detected in 20% of males and 11% of females [56].

Health issues associated with injecting drug use

People who inject drugs are more likely to become infected with blood borne viruses such as hepatitis C and HIV, if they share injecting equipment [57]. Many Aboriginal and Torres Strait Islander people who inject drugs do not use new injecting equipment from needle and syringe programs (NSPs) and other services due to feelings of shame and discrimination [24, 46, 58].

A study conducted at NSPs across Australia in 1998-2008 found that [45]:

Health issues associated with hepatitis C

Almost all (around 80-90%) of Australia’s hepatitis C infections are caused by injecting drug use [45, 59]. Studies between 1996 and 2004 have found that half the injecting drug users were diagnosed with hepatitis C [59].

Aboriginal and Torres Strait Islander people have higher rates of hepatitis C infection than non-Indigenous people [60].

Treatment for hepatitis C is currently available, but people who inject drugs do not tend to seek treatment [61].

Health issues associated with HIV

As with hepatitis C, HIV infections can result from the sharing of injecting equipment. Infection with HIV through injecting drug use is much more common among Aboriginal and Torres Strait Islander people than among non-Indigenous people [60]. In 2009-2013, four times as many Aboriginal and Torres Strait Islander people as non-Indigenous people were newly diagnosed with HIV due to injecting drug use (12% compared with 3%).

Rates of diagnosis for HIV [60]:

Other harms associated with injecting drug use

In addition to hepatitis C and HIV infection, injecting drug use can cause [62]:

Several of these symptoms occur during withdrawal, while others are ongoing health issues (Table 4).

Table 4. Proportion (%) of Aboriginal and Torres Strait Islander participants reporting physical reactions and injecting-related health problems from injecting drug use, SA, 2001

Physical reactions

Proportion of participants

Injecting-related health problems

Proportion of participants

Poor appetite

82

Track marks

81

Hot or cold flushes

80

Shaking or shivering

66

Lack energy

79

Nausea

55

Aching muscles or joints

76

Headache due to hit

54

Headache

69

Vein problems

52

Nausea

65

Hurt self while intoxicated

41

Teeth

51

Dirty hit

27

Breathing problems

49

Virus from injecting

22

Stomach problems

48

 

 

Liver problems

39

 

 

Skin problems

33

 

 

Virus

25

 

 

Heart problems

17

 

 

Source: Holly C, Shoobridge J, 2004 [62]

Overdose

Overdose is a serious risk that injecting drug users face [63]. The 2012 IDRS (with 16% Aboriginal or Torres Strait Islander participants) found:

Impacts on social and emotional wellbeing according to surveys

Surveys show that illicit drug use can have a negative effect on a person’s social and emotional wellbeing.

2012-2013 AATSIHS [64]:

2008 NATSISS [19]:

Hospitalisation

Detailed national information on hospitalisation due to illicit drug use for Aboriginal and Torres Strait Islander people is available for the period 2012-13 [11].

Figure 6: Hospitalisation relating to drug use, by Aboriginal and Torres Strait Islander status and principal diagnosis, Australia 2012-13

 

Source: AIHW, 2014 [11]

Notes:  Rates are per 100,000 population; age-standardised using the Australian 2001 standard population

Figure 7: Hospitalisation for mental/behavioural disorders relating to drug use by Aboriginal and Torres Strait Islander status and principal diagnosis, Australia 2012-13

 

Source: AIHW, 2014 [11]

Notes:

  1. Rates are per 100,000 population; age-standardised using the Australian 2001 standard population
  2. ICD code F15 hospitalisation from use of other stimulants includes amphetamine-related disorders and caffeine but not cocaine.
  3. See original source for other relevant ICD codes

Deaths due to drug use

In 2008-2012, the number of deaths due to drug use was 1.5 times higher for Aboriginal and Torres Strait Islander people living in NSW, Qld, WA, SA and the NT than for non-Indigenous people [11]. This rate was highest in SA (3.3 times), followed by NSW (2.0 times). In WA and Qld the rates for Aboriginal and Torres Strait Islander people and non-Indigenous people were almost the same (1.2 and 1.1 respectively).

Suicide

Drug use has been identified as a risk factor for suicide among Aboriginal and Torres Strait Islander people [9, 10], particularly for impulsive suicide (where a person is more likely to do things without thinking them through) [56]. The effects of longer term use on a person’s social and emotional wellbeing can also lead to an increased chance that a person may decide to take their own life. In general, drug use can make any existing mental health disorder worse [56, 65, 66]. Cannabis use, in particular, has been associated with suicide attempts [55].

In 2012, the death rate due to suicide for Aboriginal and Torres Strait Islander people living in NSW, Qld, WA, SA, and the NT in 2012 was 2.0 times the rate reported for non-Indigenous people [67]. It was the fifth leading cause of death among Aboriginal and Torres Strait Islander people.

What are the social impacts of drug use among Aboriginal and Torres Strait Islander people?

As well as affecting health, the use of illicit drugs is associated with a number of social harms including:

Child and family harm

Illicit drug use can be damaging to families, in particular children. Harmful alcohol and other drug use can contribute to unsafe environments for children including [68-70]:

There is a recognised association between drug use, family violence and conflict within the community  [70, 71]. Children who experience family violence and neglect may be more likely to use violent behaviour themselves [72].

Illicit drug use can also lead to tension within families. A study in Vic of Aboriginal and Torres Strait Islander people who inject drugs found that clients were most worried about their family’s negative reaction towards their injecting drug use behaviour [46]. They reported fears of shaming and stigma from their family and community and the risk of physical violence towards them if the family learned of their habit. Because of these fears, many clients were unwilling to collect clean injecting equipment from Aboriginal and Torres Strait Islander community-controlled health services.  They preferred to use mainstream services that were more anonymous, and where they wouldn’t be recognised by anyone from their community.

Community harm and violence according to surveys

Illicit drug use can have a negative effect on the whole community.

NATSISS (2008) [32, 40, 73]:

Other studies:

Crime and imprisonment rates according to surveys

Imprisonment rates for Aboriginal and Torres Strait Islander people are much higher than those for non-Indigenous people [75]. In 2013 the imprisonment rate for Aboriginal and Torres Strait Islander people was 15 times higher than that for non-Indigenous people. The relationship between crime, imprisonment, and illicit drug use is complex [76-79]:

Policies that address illicit drug use among Aboriginal and Torres Strait Islander people

National drug strategy 2010-2015

Australia’s National drug strategy (NDS) is based on the three pillars of harm minimisation: demand reduction, supply reduction and harm reduction. The strategy provides a collection of actions that can be used to minimise the harm from drug use [82].

Demand reduction

Demand reduction strategies aim to [82, 83]:

Demand reduction includes a wide range of strategies including health promotion, treatment and ongoing care.

Supply reduction

Supply reduction strategies aim to [82, 83]:

Harm reduction

Harm reduction strategies aim to [82, 83]:

One of the main harm reduction strategies in Australia is through NSPs.

National drug strategy Aboriginal and Torres Strait Islander Peoples complementary action plan 2003-2009

The National drug strategy Aboriginal and Torres Strait Islander peoples complementary action plan (CAP) was developed to address the specific needs of Indigenous people affected by alcohol and drugs [84, 85].

A review of CAP in 2009 found it [84]:

Recommendations were made to develop the CAP further and introduce improved ways of collecting information on the effectiveness of alcohol and drug programs and strategies.

National Aboriginal and Torres Strait Islander peoples drug strategy 2014-2019

The National Aboriginal and Torres Strait Islander peoples’ drug strategy 2014-2019 is a sub strategy of the NDS and builds upon the strengths of the CAP to identify four priority areas [86]:

  1. Build capacity and capability of the alcohol and other drug service system, particularly Aboriginal and Torres Strait IslanderÔÇÉcontrolled services and their workforce.
  2. Increase access to a full range of culturally responsive and appropriate programs.
  3. Strengthen partnerships based on respect both within and between Aboriginal and Torres Strait Islander peoples, government and mainstream service providers.
  4. Establish effective ways of measuring whether alcohol and other drugs programs and strategies are working [86].

In relation to illicit drug use, these priorities are directed toward reducing:

Policies for specific types of illicit drugs

There are a number of national policies that focus on specific types of illicit drugs or the way they are used. Many of these policies identify Aboriginal and Torres Strait Islander people as a priority population. 

Injecting drug use related policies

Policies relating to injecting drug use include:

These policies all promote harm reduction through [87-91]:

Cannabis related policy

The National cannabis strategy 2006-2009, developed by the Ministerial Council on Drug Strategy aimed to reduce cannabis use and the associated harms [54]. This policy identified Aboriginal and Torres Strait Islander people as a priority population and outlined four priority areas:

  1. community cannabis education
  2. preventing the use of cannabis
  3. preventing problems associated with cannabis
  4. responding to problems associated with cannabis.

The Strategy specified the need to create and use specific resources for Aboriginal and Torres Strait Islander people, developed in partnership with communities, as well as increasing the workforce capacity of Aboriginal and Torres Strait Islander Health Workers.

Amphetamine related policy

In 2015 the National ice action strategy was developed in response to the issues surrounding the drug crystal methamphetamine (ice) [92].  

Six areas for action were identified in the interim report [92]:

  1. target primary prevention
  2. improve access to early intervention, treatment and support services
  3. support local communities to respond
  4. improve tools for front line workers
  5. focus law enforcement actions
  6. improve and consolidate research and data.

The final report includes a recommendation that all levels of government should work towards improving access to services for Aboriginal and Torres Strait Islander people that are [93]:

Services

Current alcohol and other drug services aim to reduce the harms from drug use in three ways [15]:

Table 5 (below) outlines how services addressing Aboriginal and Torres Strait Islander drug use fit within the three pillars of harm minimisation and the three levels of prevention (note that this list may not be exhaustive).

Table 5. Services by pillar of harm minimisation and type of prevention

 

Demand reduction

Supply reduction             

Harm reduction

Primary prevention

(preventing the uptake of drugs)

  • Addressing social determinants
  • Recreational activities
  • Education
  • Health promotion campaigns
  • Law enforcement
 

Secondary prevention

(minimising the harms of short-term use; preventing drug dependency)

  • Brief interventions
  • Diversion of offenders
  • Education
  • Health promotion campaigns
  • Primary health care
  • Community-based treatment
  • Counselling and support services
  • Law enforcement
  • Night patrols
  • Sobering-up shelters
  • Needle and syringe programs

Tertiary prevention

(reducing harms from chronic use; rehabilitation)

  • Primary health care
  • Community-based treatment
  • Residential treatment
  • Counselling and support services
 
  • Sobering-up shelters
  • Needle and syringe programs

Sources: Gray et al, 2008 [15], Gray et al, 2010 [30]

Notes:

  1. Services may fit in multiple categories
  2. Services exclude those for alcohol exclusively (notably supply control of alcohol)

Primary prevention

Primary prevention aims to minimise the risk of harmful drug use by addressing social determinants and educating the public, in the hope of decreasing or delaying use [15].

Social determinants

The social determinants of health are the circumstances in which people are born, live and age [94]. Factors such as inadequate housing, leaving school early, not being able to get a job and racism, contribute to the cycle of social disadvantage. Disadvantage contributes to behaviours associated with harmful drug use [95]. The social determinants of harmful drug use for Aboriginal and Torres Strait Islander people include not only the current disadvantage they may be experiencing, but also the past disadvantage of colonisation, which includes loss of land, loss of culture, and past practices of forcible removal of children (Stolen Generations) [96, 97]. This history of trauma continues to impact on Aboriginal and Torres Strait Islander people today [98, 99].

Recreational activities

Organised recreational activities may prevent drug use by providing alternative entertainment, positive role models and peers, and a safe place for community members [16, 100-102]. Recreational activities can take a number of forms such as sport, cultural activities, art, and music. Providing recreational facilities and services for young people is an important part of reducing demand and allowing communities to guide young people away from drug use [100, p.21].

Evidence suggests that these programs are valued but may suffer from lack of funding [103, 104]. Recreational and cultural activities are often provided with one-off funding with no commitment to supporting these activities into the future [83, p.5].

A study by the Centre for Remote Health and the Central Australian Youth Link-Up Service (CAYLUS) to explore what works when providing services for young people found that programs need to [102]:

Education and health promotion campaigns

Aboriginal and Torres Strait Islander-specific education and health promotion campaigns aim to provide culturally relevant information about drug use to Aboriginal and Torres Strait Islander people, and are the most frequent services provided for drug use [15, 105]. Some health promotion activities are based on the belief that harmful drug use results from a lack of knowledge about drugs, which can be addressed through education and public awareness campaigns. The effectiveness of education and health promotion campaigns has not been proven [105-108].

In 2011-12, the majority of Commonwealth-funded alcohol and other drug services (84%) provided community education and activities and 54% provided school-based education [109].

Law enforcement

Australian governments’ expenditure on law enforcement is much greater than their expenditure on treatment services (demand and harm reduction) [110].

In 2009-10, an analysis of the Australian federal and state governments’ direct (proactive) spending on illicit drug policy was approximately $1.7 billion [111]. Approximately 64% of the illicit drug budget was spent on law enforcement, 23% on treatment, 10% on prevention, and 2% on harm reduction. This analysis found that, between 2002-03 and 2009-10, there had been little change in the balance of spending across the four policy areas (prevention, treatment, harm reduction and law enforcement). Overall spending had increased by a small amount but harm reduction was one area where spending had reduced.

Evidence suggests that law enforcement should focus its efforts on the suppliers of illicit drugs, rather than on the users of drugs – who are better managed through education and treatment services rather than the criminal justice system [48]. In 2009-10, around 80% of all arrests were of drug users in Australia; cannabis-related crimes accounted for 67% of arrests [112].

Secondary prevention

Secondary prevention aims to prevent risky drug use and stop occasional use from progressing to problematic use or dependence [15].

Brief interventions

Brief intervention refers to prevention activities offered in health care settings such as a general practitioner’s (GP’s) offices or community counselling [113].  

Brief intervention activities relevant to drug use include  [15, 113]:

The advice given in a brief intervention is tailored to each person and may include a referral to a specialist, if required.

Research has found that training in brief intervention techniques at Aboriginal Community-Controlled Health Services (ACCHS) gives staff the confidence to use brief intervention approaches with Aboriginal and Torres Strait Islander clients [114].  Workshop materials developed for GPs can also be adapted for health care providers in ACCHS. Brief interventions provided by GPs can provide Aboriginal and Torres Strait Islander patients with clear advice that is culturally appropriate, particularly if an Aboriginal and Torres Strait Islander Health Worker is involved [115].

Barriers to the use of brief interventions for drug use include [114, 116-118]:

One Aboriginal and Torres Strait Islander-specific project that aimed to address cannabis use and included brief intervention was Could it be the gunja? The project was developed in partnership with six Aboriginal and Torres Strait Islander communities and included [119]:

As a result of the project, the percentage of clinic staff who talked to clients about cannabis rose from 20% to around 60%.

Night patrols

Night patrols are community-based initiatives that aim to improve overall safety in Aboriginal communities [120]. They involve teams of local people who patrol communities at night, either by car or on foot, and assist people who may be at risk of causing harm or being harmed.

Night patrols began in the NT in remote communities but now operate in urban, regional, and remote areas across Australia [120-122]. They have been found to be an effective way of reducing alcohol and drug-related harm and the number of police lock-ups [122]. Night patrols are highly valued by the community in providing a culturally appropriate mobile service that can respond quickly to problems in the community [123, 124].

Sobering-up shelters

Sobering-up shelters provide a safe place where people can get sober, avoid harming themselves and others, and avoid being locked up by the police [105, 125]. Shelters offer practical care, provide opportunities for brief interventions and referral, and offer basics, like food.

In 2013-14, there were nine Aboriginal and Torres Strait Islander alcohol and other drug services that provided sobering-up, residential respite and short-term client care to around 5,000 people [126]. A 2010 review of alcohol and other drug services reported 36 sobering-up shelters nationally, but noted a shortage of sobering-up shelters in many parts of Australia [30]. Sobering-up shelters have been shown to have strong community and police support [103, 105, 125].

Needle and syringe programs

Needle and syringe programs (NSPs) provide sterile needles, syringes, and other injecting equipment. These items may be free of charge, on an exchange basis, or for sale. They also provide information and counselling and referral services for people who inject drugs [91]. NSPs aim to reduce the sharing of injecting equipment and provide education to users, both of which aim to lower the risks associated with injecting drug use.

NSPs are delivered:

NSPs form a part of the harm minimisation approach outlined by the NDS, with more than 3,000 programs established across the country [45].

The NSP program has been described as a key strategy that is relatively low cost and effective in reducing harms related to injecting drug use [91]. A 2009 evaluation of NSPs in Australia found that they had directly prevented around 32,050 HIV infections and 96,667 hepatitis C infections during 2000-2009 [127].

A Victorian study into injecting drug use among Aboriginal and Torres Strait Islander people suggests that Aboriginal and Torres Strait Islander clients may feel more comfortable visiting mainstream NSPs or vending machines because they provide greater privacy [46].

Diversion

Diversion programs aim to [79]:

Diversion programs mainly target young people and offenders with crimes relating to drug use. Examples of Aboriginal and Torres Strait Islander diversion programs are [79, 128]:

The MERIT program has been shown to reduce re-offending and to lead to improved health in participants [128, 129]. A study  of  the MERIT program found that those people who completed the program were less likely to re-offend than those who did not complete the program (a 30% reduction in risk) [129].

Some studies found that Aboriginal clients were less likely to complete the MERIT program than non-Indigenous participants [130, 131]. However when the program was adapted to meet the needs of the Aboriginal participants, there was a significant increase in the number of Aboriginal clients who completed the MERIT program (33% compared to 7% for services that were not adapted to meet Aboriginal participant needs) [132].

Diversion programs also aim to provide relevant health services for offenders. For example, establishing NSPs or methadone programs in prisons can potentially reduce the harm associated with injecting drug use among inmates [133-135].

Tertiary prevention

Tertiary prevention aims to reduce health and social harm among problem users, and help them to reduce or quit drug use [15]. This prevention includes:

Tertiary prevention also seeks to prevent harm from drug use affecting other people, including family members and the wider community.

Many of the primary health care services provided by ACCHSs provide comprehensive care that includes treatment and support for alcohol and other drug users [109, 136].

In 2013-14, there were 203 federally funded Aboriginal and Torres Strait Islander primary health care services (Figure 8) [126].

Figure 8: Proportion (%) of Aboriginal and Torres Strait Islander primary health care services, by remoteness level, Australia, 2013-14

 

Source: AIHW, (2015) [126]

 

These primary health care organisations reported that the most common drug use issues were [126]:

The most common services offered by these organisations were [126]:

Community-based treatment

Community-based treatment provides specialised and ongoing support for Aboriginal and Torres Strait Islander people in the community [15]. Treatment may include:

In 2013-14, 95% of Commonwealth-funded alcohol and other drug services for Aboriginal and Torres Strait Islander people were for non-residential services [126]. There were around 353,000 episodes of non-residential, follow-up, and after-care reported and on average each client received 11 episodes of care. This is a large increase from 2011-12 when there were 61,000 episodes of non-residential care [109].

According to the 2013-14 AIHW report on alcohol and other drug treatment services in Australia, around one in seven (14%) clients receiving treatment for drug use were Aboriginal and Torres Islander people.

Residential rehabilitation

Residential rehabilitation provides a service where clients are able to live away from the environment where they usually use drugs [15]. This provides an opportunity for intensive interventions (e.g. counselling, life-skills, cultural activities) to change drug use behaviours. It also helps the client to regain their health. Some services include the involvement of family members.

In 2013-14, nearly half (46%) of Commonwealth funded alcohol and other drug services for Aboriginal and Torres Strait Islander people provided residential treatment [126]. Through the 21 organisations providing residential rehabilitation, 2,300 clients were provided services with around 2,400 episodes of care. Three quarters (76%) of these organisations had waiting lists.

Evaluation of residential rehabilitation services for Aboriginal and Torres Strait Islander people shows both positive and negative results [137, 138].

Positive aspects of residential services are that they:

Negative aspects include:

Other studies have found that residential rehabilitation is beneficial when [139, 140]:

Residential rehabilitation is best suited to those people with moderate-to-severe levels of drug dependence and less social stability (e.g. they may not have a secure place to live) [140].

What works in alcohol and other drug services?

The following factors are important in providing effective alcohol and drug services to Aboriginal and Torres Strait Islander people.

Community originated and controlled services

Alcohol and other drug services that are led and controlled by communities are more likely to provide relevant and appropriate services, resulting in better outcomes [24, 30, 108, 141, 142].

Culturally appropriate

Services that include cultural practices in evidence-based approaches have been shown to have better results than mainstream services which lack cultural competence [30, 70, 140, 141, 143, 144].  

Ensuring that services are culturally appropriate includes [30]:

Holistic

Many of the problems faced by Aboriginal and Torres Strait Islander clients (such as drug use and social and emotional wellbeing issues) cannot be properly dealt with in isolation. The provision of holistic services helps to address multiple issues [30, 144, 145] and an organisation that can address many needs at one location is likely to benefit clients.

Partnerships

Strong partnerships between Aboriginal and Torres Strait Islander and mainstream services provide a network of care for clients [24, 30, 138, 141]. These partnerships allow organisations to use their own expertise and, when required, refer clients to other organisations that are supported, trusted, and respected by the community.

Flexible and innovative

The need for services that are flexible and offer innovative solutions to clients has been identified as important [24, 30, 143, 146]. This includes being able to personalise services around client needs (such as arranging for staff to meet clients in a variety of locations) and taking account of a client’s cultural duties (such as missing appointments because of family business).

Inclusion of family and community

Some studies suggest that including family and community may improve the likelihood of success of alcohol and other drug services for some Aboriginal and Torres Strait Islander people, especially with treatment services [22, 24, 70]. Families can sometimes play a vital role in the success of an individual’s experience in drug treatment, by supporting healthy lifestyle choices [24].

Confidentiality

An important strategy for effective service [143], especially among people who inject drugs [24, 46], is making sure that the client’s information is not shared without their permission (confidentiality).

Workforce development

Good management within organisations (governance) is essential to support staff in delivering services to meet the needs of clients and communities. [144, 147, 148].

Developing the skills of workers strengthens an organisation’s ability to respond to alcohol and other drug issues [15, 24, 30, 141, 149-151]. This can be achieved by:

Studies show that ongoing training increases the confidence of workers who become more willing and able to provide a wider variety of services [114, 116, 152].

Barriers to services

Some barriers to providing effective alcohol and drug services Aboriginal and Torres Strait Islander people are outlined below.

Lack of adequate resources

Lack of ongoing funding was identified as a major barrier to organisations providing alcohol and other drug services to Aboriginal and Torres Strait Islander people [30, 83, 150]. Organisations without adequate funding are not able to attract and keep qualified staff and are not able to provide continuity in their services [30].

Lack of ongoing care

Aboriginal and Torres Strait Islander people need follow-up care after they have completed rehabilitation treatment [30, 116, 138]. A 2010 review found only two services were funded to provide ongoing care [30].

Geographic and service gaps

The provision of appropriate and integrated alcohol and other drug services across Australia, regardless of location, is required to meet the needs of the Aboriginal and Torres Strait Islander population. However, a 2010 review of Aboriginal and Torres Strait Islander alcohol and other drug services found that some regions were poorly serviced, and  many regions did not have a suitable range of services [30]. The provision of services did not match the size of population or level of remoteness.

Lack of reliable information

Currently, there is a lack of information about which alcohol and other drug services and programs best serve the needs of Aboriginal and Torres Strait Islander people [83, 137]. Up-to-date and reliable data, information, and knowledge is needed to assess the effectiveness of services and determine ‘what works’ in addressing illicit drug use among Aboriginal and Torres Strait Islander people.

Concluding comments

While more than half of Aboriginal and Torres Strait Islander people do not use illicit drugs, the levels of illicit drug use are substantially higher among Aboriginal and Torres Strait Islander people than among non-Indigenous people in Australia [31, 32]. The effects from illicit drug use – deaths due to drug use, social and emotional distress and risk of infection from blood-borne viruses - are greater for Aboriginal and Torres Strait Islander people than for non-Indigenous people. Factors contributing to these higher proportions of illicit drug use are directly associated with social and economic disadvantage and colonisation.

Research has found that services that are likely to be more effective among Aboriginal and Torres Strait Islander people are those that:

The National Aboriginal and Torres Strait Islander people’s drug strategy 2014-2019 identifies a number areas for action, including building culturally appropriate and responsive services, strengthening partnerships and improving data collection.

All levels of government have an obligation to work with Aboriginal and Torres Strait Islander communities and health organisations to address the current levels of illicit drug use among Aboriginal and Torres Strait Islander people. Policies addressing illicit drug use need to provide long-term, culturally appropriate guidance that equally addresses each of the three pillars of harm minimisation. Illicit drug use services need to be adequately resourced and funded in the long-term to be able to provide the holistic quality of care Aboriginal and Torres Strait Islander Australians deserve.

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