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Well it has been a long time since Newsletter 2 and some people are wondering if the Feasibility Study is dead. No - we are alive and well. For the last six months or so we have been conducting the research which will provide the information on which the feasibility decision will be made. There is now a long queue of working papers on the floor of my office waiting to be polished and published. We still plan to make a recommendation about whether or not the feasibility considerations should move to Stage 3 (a pilot study) by the end of September.
Two new working papers have appeared in the last month or so. Working paper 2 is the proceedings of a very successful drug markets workshop and is described below. Working paper 3 by Bev Sibthorpe and coworkers investigated heroin use by under-18s who were homeless or at risk of being homeless and there was a report on that research in the last newsletter.
In this newsletter there is also a brief account of what is in the queue. I anticipate that newsletters will be issued more frequently over the next few months to report on the conclusions of these investigations
And what happens after we make our recommendation? If the recommendation is that work towards a trial should not proceed, then, apart from promoting understanding of why that decision was reached, our work is essentially finished. If the recommendation is that work towards a trial should proceed, preparations for a pilot study can begin. This will need support both from the ACT Legislative Assembly and from the Ministerial Council on Drug Strategy, not least because legislative change will be required. In either case, we anticipate that the work we have done will lead to public discussion of the issues and improved understanding of heroin use and its effects on society.
Australian Drug Markets Research Workshop
This one-day workshop examined Australian research on the structure and economics of drug markets, the interaction of drug markets and law enforcement and the impact of drug markets on health. Participants gave an overview of available data bases and current research. In addition, consensus statements were developed from discussions about methodological problems and research gaps.
The main findings from the discussion about methodological problems were that:
Co-operative research between academics and the law enforcement community needs to be strengthened. This involves improved communication, collaboration in the use of data bases and funding support.
There needs to be standardisation in units and techniques of measurement and in terminology.
Academic researchers need legal protection from being summonsed, or having their information subpoenaed, by a court. The Commonwealth and ACT Epidemiological Studies (Confidentiality) Acts provide models for such protection.
There is an inherent dilemma in much drug markets research: should researchers ask participants to provide information which could potentially be used against them or other illicit drug users? There is no obvious resolution, but this issue needs to be taken into account when researchers are establishing informed consent relationships with participants and when they are preparing material for publication.
The main findings from the discussion about research gaps were that:
Research should be able to evaluate the effectiveness of interventions and policies and to predict likely effects of new policies. To do this data collection needs to be strengthened at the local level.
The impact of law enforcement on public health and vice versa need to be investigated and documented. There was general agreement that in the current Australian situation the effects on public health of law enforcement strategies need to be considered and that strategies which were likely to have negative public health impact should be avoided.
That there is a need to build and integrate health and law enforcement data bases, which should be regularly monitored and independently replicated.
Specific gaps included the size and nature of the dealer population, polydrug considerations, price elasticity of demand, pricing differentials from export/import to street levels, changes over time, measurement of demand through consumption, focus on young drug users and hepatitis.
Next In the Queue
Working papers from the following projects will be available shortly:
Becoming an Ex-user: Would the Controlled Availability of Heroin Make a Difference?
This project has involved in depth interviews with 19 ex-heroin users. The aim was to interview a diverse group of people and we had participants who stopped using with no or minimal formal treatment, detoxification programs, methadone programs or therapeutic communities. As well as eliciting views on the controlled availability of heroin, we focussed on the pathways out of heroin dependence, including factors which had influenced the decision to stop, the role of treatment in the transition out of dependence and on factors important in maintaining abstinence. This investigation therefore has relevance not only to the feasibility considerations but also has broader ramifications for understanding pathways out of dependence and how both policy and service provision can impact on these. This seems to be the first study of its kind in Australia.
Sue Weekes and Gabriele Bammer have been primarily involved with this study.
The Aboriginal Community AIDS Project
This was the working title given to a project to examine whether or not a 'heroin trial' would be appropriate and feasible for Aboriginal users. Many other issues were also examined. The project had two components. The first consisted of interviews with 19 local Aboriginal community leaders and aimed to determine what the needs of the community are. We examined this in a broad context and then focussed in on alcohol and other drug issues, HIV/AIDS and hepatitis. As well as looking at problems we also asked about the adequacy of existing services and how they could be improved. The second component comprised interviews with 29 service providers, both Aboriginal and non-Aboriginal, whose services had some relevance to alcohol and other drug users and/or to the prevention of HIV/AIDS, although this might not be their primary focus. The main aim was to examine how adequate these services are for Aboriginal people.
Two reports are in preparation. One is titled It will kill us faster than the white invasion. Views on alcohol and other drug problems and HIV/AIDS risk in the Canberra/Queanbeyan Aboriginal community and on the suitability of a heroin trial for Aboriginal heroin users. The other is Finding out for Ourselves. An analysis of the needs of Canberra/Queanbeyan Aboriginal people, especially with regard to alcohol and other drug problems and HIV/AIDS risk. The project was conducted in collaboration with Winnunga Nimmityjah, the Aboriginal health clinic, and we see it as the foundation for the eventual establishment of a comprehensive data base of local health status, needs and available services.
Those primarily responsible for this project are Glenda Humes, Michele Moloney, Francesca Baas Becking and Gabriele Bammer. An advisory group also provided valuable input.
Trial design
A workshop on trial design issues was held in mid-June. This brought together epidemiologists, statisticians, criminologists, sociologists, clinicians and others with an interest in evaluation. Advantages and disadvantages of conventional randomised controlled trial design, modifications of conventional RCTs and cross-over designs were discussed. The impact of trial design on service provision and vice versa was also examined.
Gabriele Bammer and David McDonald will be writing up the proceedings.
Drug Markets in the ACT
This project addressed the following questions:
To address these questions we conducted a pilot study to collect data about the price, purity and availability of illicit drugs and monitored changes over time. These can be linked with information about overdoses. We also interviewed seven participants from the drug using community and two members of the drug squad in depth about the structure of the ACT drug market.
Gabriele Bammer and Ayse Sengoz were primarily responsible for this study.
An Economic Analysis of the Impact of a Trial on the Drug Market
The proposal for a trial of the controlled availability of opioids in the ACT raises a number of issues concerning the economic analysis which might be conducted as part of a trial. Two postulated design features of a trial have particularly important implications for such an analysis. First, the price of heroin will fall from the current street price to zero for users who satisfy pre-specified eligibility criteria. Secondly, the enforcement of eligibility criteria and possible constraints on supply imply that the quantity of heroin demanded at a zero price will not be satisfied. These design features proscribe to some extent the economic issues which can be addressed as part of a proposed trial. For example, because of non-price rationing and supply constraints, estimation of a price elasticity of demand for heroin will be precluded. However, it will be possible to study the effects of the trial on the black market for heroin, and investigate issues such the importance of price versus purity as equilibrating mechanisms in the market for heroin.
This study has being conducted by Jim Butler and Amanda Neil.
Still to Come
We also still have to write up
In addition we have to finish analysing comprehensive interviews conducted with heroin users who have never been in treatment, current methadone program clients and users who have dropped out of treatment. These results will give us a lot more insight into workable trial outcome measures and possible ways of organising service provision, which will feed into further work on trial and service design.
Changes to the Research Team
Additions
Iain Anderson, Research Assistant, NCEPH (studies with heroin users) Corinna Lee, Research Assistant, NCEPH (studies with heroin users) Greg Morris, Research Assistant, NCEPH (studies with heroin users) Aaron Stowe, Research Officer, NCEPH (studies with heroin users) Sue Weekes, Research Assistant, NCEPH (ex-users, studies with heroin users)
Projects completed
Francesca Baas Becking, Research Assistant, NCEPH (Aboriginal Community AIDS Project) Jim Butler, Fellow, NCEPH (economic analysis of the drug market) Jennifer Chadwick-Masters, Research Assistant, NCEPH (residency criteria) Glenda Humes, Research Assistant, NCEPH (Aboriginal Community AIDS Project) Timothy McGregor, Research Assistant, NCEPH (sexual abuse workshop) Michele Moloney, Research Assistant, NCEPH (Aboriginal Community AIDS Project) Amanda Neil, Research Assistant, NCEPH (economic analysis of the drug market) Ayse Sengoz, Research Assistant, NCEPH (drug markets, youth study) Margaret Shanahan, Research Assistant, NCEPH (sexual abuse workshop) Bev Sibthorpe, Visiting Fellow, NCEPH (youth study) Deborah Tunnicliff, Research Assistant, NCEPH (residency criteria, studies with heroin users)
New Grants Awarded
Australian Institute of Aboriginal and Torres Strait Islander Studies Grant of $16,548 for "HIV Risk for Aboriginal Heroin Users in the ACT" to G. Bammer, O. Brown, D. McDonald and B. Sibthorpe.
Further Information
For further information about the feasibility research contact: Dr Gabriele
Bammer, National Centre for Epidemiology and Population Health Australian National
University GPO Box 4 Canberra ACT 2601 Phone: (02) 6125 0716 Fax: (02) 6125
0740
New Publications
Working Papers
Bammer, G. (editor) 1993 Australian Drug Markets Research: What are we doing?
Where are we going? What are the gaps? Proceedings of a one-day workshop held
at the Scarth Room, University House, ANU, 22 February 1993. Feasibility Research
into the Controlled Availability of Opioids Stage 2 Working Paper Number 2.
Sibthorpe, B., A. Sengoz and G. Bammer in collaboration with The Youth Affairs
Network of the ACT, 1993 Drug use and HIV risk among homeless and potentially
homeless youth ain the Australian Capital Territory. Feasibility Research into
the Controlled Availability of Opioids Stage 2 Working Paper Number 3.
Reprints
Bammer, G. 1993 'Should the controlled provision of heroin be a treatment option?
Australian feasibility considerations'. Addiction 88 467-475.
Bammer, G. 1992 'A trial of controlled availability of heroin for the ACT?'.
In White, J. (ed) Drug Problems in Our Society: Dimensions and Perspectives
(Selected Papers from The Window of Opportunity, First National Congress. An
Intersectoral Approach to Drug Related Problems in Our Society, December 2-5,
Adelaide).57-62.
Preprints
Bammer, G.; Douglas, B.; Moore, M.; Chappell, D. 'A heroin trail for the Australian
Capital Territory? An overview of feasibility research'. Accepted for publication
in Reducing Drug-related Harm: From Principles to Practice. Selected papers
from the Third International Conference on the Reduction of Drug-related Harm.
Forthcoming 1993.
Other
Bammer, G. 1992 'Is a trial heroin treatment program in the ACT feasible?' Criminology
Australia 4 (2) 16-19.
Louise Butt interview with Gabriele Bammer 1993 Controlled use of oipoids study Connexions 13 (1) 8-10.
Bammer, G. 1993 'Australian considerations for a 'heroin trial' - progress report'.
Abstracts for the Fourth International Conference on the Reduction of Drug Related
Harm, Rotterdam, the Netherlands, March.