Christina Marel

Doing and undoing gender in policing

This article assesses the utility of ‘doing gender’ as a framework for examining gender issues in policing. Drawing on a longitudinal study in an Australian police force, the article seeks to explain the persistence of barriers to the integration of female officers after decades of equal employment laws and policies. The interviews make transparent the agency of male and female actors in sustaining or resisting the status quo. While there are real benefits in opening up the ‘doing gender’ framework to draw attention to contestations and challenges to gender hierarchy as suggested by the notion of ‘undoing gender’, the article demonstrates the complexity of gender practices in policing and rejects the posing of equality and difference as mutually exclusive alternatives.

Long‐term mortality, remission, criminality and psychiatric comorbidity of heroin dependence: 11‐year findings from the Australian Treatment Outcome Study

AIMS To determine the long-term mortality, remission, criminality and psychiatric comorbidity during 11 years among heroin-dependent Australians. DESIGN Longitudinal cohort study. SETTING Sydney, Australia. PARTICIPANTS A total of 615 participants were recruited and completed baseline interviews between 2001 and 2002. Participants completed follow-up interviews at 3, 12, 24 and 36 months post-baseline, and again at 11 years post-baseline; 431 (70.1%) of the original 615 participants completed the 11-year follow-up. MEASUREMENTS Participants were administered the Australian Treatment Outcome Study (ATOS) structured interview, addressing demographics, treatment history, drug use, heroin overdose, criminality, health and mental health at all interviews. Overall, 96.1% of the cohort completed at least one follow-up interview. FINDINGS At 11 years, 63 participants (10.2%) were deceased. The proportion of participants who reported using heroin in the preceding month decreased significantly from baseline (98.7%) to 36-month follow-up (34.0%; odds ratio = 0.01; 95% confidence interval = 0.00, 0.01) with further reductions evident between 36 months and 11 years (24.8%). However, one in four continued to use heroin at 11 years, and close to one-half (46.6%) were in current treatment. The reduction in current heroin use was accompanied by reductions in risk-taking, crime and injection-related health problems, and improvements in general physical and mental health. The relationship with treatment exposure was varied. Major depression was associated consistently with poorer outcome. CONCLUSIONS In an 11-year follow-up of patients undergoing treatment for heroin dependence, 10.2% had died and almost half were still in treatment; the proportion still using heroin fell to a quarter, with major depression being a significant predictor of continued use.

Years of potential life lost amongst heroin users in the Australian Treatment Outcome Study cohort, 2001-2015

BACKGROUND Heroin use carries the highest burden of disease of any drug of dependence. The study aimed to determine mortality rates of the Australian Treatment Outcome Study cohort over the period 2001-2015, and the years of potential life lost (YPLL). METHODS The cohort consisted of 615 heroin users. Crude mortality rates per 1000 person years (PY) and Standardised Mortality Ratios (SMR) were calculated. YPLL were calculated using two criteria: years lost prior to age 65, and years lost prior to average life expectancy. RESULTS The cohort was followed for 7,790.9 PY. At 2015, 72 (11.7%) of the cohort were deceased, with a crude mortality rate of 9.2 per 1000 PYs. Neither age nor gender associated with mortality. The SMR was 10.2 (males 7.3, females 17.2), matched for age, gender and year of death. The most common mortality cause was opioid overdose (52.8%). Using the<65 years criterion, there were 1988.3 YPLL, with a mean of 27.6 (males 27.6, females 27.7). Using the average life expectancy criterion, there were 3135.1 YPLL, with a mean of 43.5 (males 41.9, females 46.3). Accidental overdose (<65 yr 63.0%, average life expectancy 63.7%) and suicide (<65 yr 12.8%, average life expectancy 13.3%) accounted for three quarters of YPLL where cause of death was known. CONCLUSIONS YPLL associated with heroin use was a quarter of a century, or close to half a century, depending on the criteria used. Given the prominent role of overdose and suicide, the majority of these fatalities, and the associated YPLL, appear preventable.

Patterns and correlates of attempted suicide amongst heroin users: 11-year follow-up of the Australian treatment outcome study cohort

Lifetime and recent rates of attempted suicide and suicidal ideation amongst the Australian Treatment Outcome Study cohort of heroin users at 11-year follow-up were examined. The mean elapsed time since heroin initiation was 20.4 years. At 11-year follow-up, 42.2% of the cohort reported ever having made a suicide attempt, 11.1% having made a first attempt subsequent to baseline. In the year preceding 11-year follow-up, 1.6% had made an attempt, suicidal ideation was reported by 10.4%, and 4.2% had a current suicide plan. After controlling for other variables, past 12 month attempts, current ideation or plans were independently associated with a current diagnosis of Major Depression (odds ratios (OR) 1.67) and more extensive polydrug use (OR 1.39), while each standard deviation higher on the SF12 physical health scale (reflecting better health) was associated with reduced odds (OR 0.66). Suicide and suicidal ideation remained a significant clinical issue for heroin users, some 20 years after their heroin use commenced.

Patterns and correlates of non-fatal heroin overdose at 11-year follow-up: Findings from the Australian Treatment Outcome Study

BACKGROUND Overdose is a major cause of morbidity and mortality amongst opioid users. This paper reported recent non-fatal overdose amongst the Australian Treatment Outcome Study (ATOS) cohort at 11-year follow-up, and characteristics that predict recent overdose. METHODS Longitudinal cohort, with 431 (70.1%) of the original 615 participants interviewed. Participants were administered the ATOS structured interview, addressing demographics, treatment history, drug use, heroin overdose, criminality, health and psychopathology. FINDINGS Mean time since heroin initiation was 20.4 years. By 11-year follow-up, the proportion who had overdosed was 67.5%, and 24.4% had experienced five or more overdoses. In the 12 months preceding 11-year follow-up, 4.9% had overdosed (11.8% of those who had used heroin in that period). Of the 21 participants who had recently overdosed, 20 (95.2%) had overdosed previously, and 19 (90.5%) were not enrolled in a treatment programme at the time. Those who had recently overdosed reported higher levels of use of opiates other than heroin (57.1% vs 24.9%), benzodiazepines (61.9% vs 30.5%,), methamphetamine (38.1% vs 16.8%) and cocaine (19.0% vs 3.7%). They also had exhibited higher levels of heroin use and other drug use at baseline, 12 and 24 month follow-ups. CONCLUSIONS While the prevalence had declined, overdoses still occurred. A history of overdose and polydrug use patterns continued to provide strong markers for those at continued risk.

Static and dynamic predictors of criminal involvement among people with heroin dependence: Findings from a 3-year longitudinal study

BACKGROUND The link between heroin use and crime has been well established; however, there has been little opportunity to examine this relationship longitudinally. This study examines the relationship between static and dynamic predictors of criminal involvement, and the degree to which changes in dynamic risk factors moderate the risk of criminal involvement over time. METHOD Data were collected as part of the Australian treatment outcome study, a 3-year longitudinal study of 615 people with heroin dependence conducted in Sydney, Australia. Past-month criminal involvement (property crime, drug dealing, fraud, violent crime), demographic, drug use and mental health characteristics were assessed at each interview. RESULTS Criminal involvement was consistently and independently predicted by lack of wage/salary as a main source of income, (OR 2.17), meeting diagnostic criteria for anti-social personality disorder (OR 1.91) and major depression (OR 1.41), screening positive for borderline personality disorder (OR 1.47), male sex (OR 1.44), a criminal history (OR 1.33), greater severity of dependence (OR 1.21), more extensive heroin use (OR 1.09), and younger age (OR 0.96) over the 3-year period. CONCLUSIONS These findings provide strong evidence of the robust nature of the association between more extensive heroin use, severity of dependence, the co-occurrence of mental health conditions, and an individuals capacity for employment, and criminal involvement. Interventions aimed at increasing an individuals employability and improving mental health in particular, may reduce the risk of criminal involvement among people with heroin dependence.

A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia

ISSUES The aim of this paper was to conduct a systematic review of the prevalence of comorbid mental health conditions in people accessing treatment for substance use in Australia. APPROACH A systematic review identified studies meeting the following eligibility criteria: reporting original data published in English; sample presenting for substance use treatment in Australia; assessing the prevalence of mental health and substance use conditions and reporting the percentage of participants with co-occurring mental health and substance use conditions. A narrative analysis was conducted because of the heterogeneity of methods used to assess key outcome variables and small number of studies assessing particular mental health outcomes. The abstracts of 1173 records were screened, and 59 full articles were assessed for eligibility. Eighteen studies were included in the review. KEY FINDINGS Prevalence estimates of current mental disorders in substance use treatment clients varied (47 to 100%). Mood and anxiety disorders were particularly prevalent, with the prevalence of current depression ranging from 27 to 85% and current generalised anxiety disorder ranging from 1 to 75%. IMPLICATIONS The high prevalence of mood and anxiety disorders in substance use treatment settings indicates a need for clinicians to screen and assess for these disorders as part of routine clinical care, and be familiar with evidence-based management and treatment strategies. CONCLUSION Although further studies are required to determine the prevalence of the full range of mental health disorders in this population, these findings emphasise the high prevalence of comorbid mental disorders are among individuals accessing substance use treatment in Australia. [Kingston REF, Marel C, Mills KL. A systematic review of the prevalence of comorbid mental health disorders in people presenting for substance use treatment in Australia. Drug Alcohol Rev 2017;36:527-539].

Patterns and correlates of alcohol use amongst heroin users: 11-year follow-up of the Australian Treatment Outcome Study cohort

INTRODUCTION The study aimed to determine long-term alcohol use patterns and correlates amongst heroin users. METHODS Longitudinal cohort. 11-year post-baseline follow-up of the Australian Treatment Outcome Study cohort. RESULTS At 11-year follow-up, 431 (70%) participants were interviewed. Alcohol was used in the preceding month by 56%, with 27% reporting daily use and 11% heavy daily drinking. Alcohol use patterns showed remarkable consistency across waves, with the proportion who drank in the preceding month ranging between 49 and 56%, with no significant trend across time. Daily drinking ranged between 20 and 27%, and heavy daily drinking between 7 and 12%. Both declined slightly from baseline to 3-year follow-up, but by 11 years were at levels similar to baseline. Compared to female referents, males were more likely to drink (OR 1.6, CI 1.3-2.1, p < .05), to drink daily (OR 1.8, CI 1.4-2.4, p < .05) and to drink heavily (OR 1.7, 1.1-2.5, p < .05). Compared to those not in enrolled in a drug treatment programme, those enrolled were significantly less likely to drink (OR 0.7, CI 0.5-0.8, p < .05) and to drink daily (OR 0.6, 0.5-0.8, p < .05). Compared to those who did not drink heavily, heavy drinking was associated with a higher likelihood of recent overdose (OR 1.6, CI 1.0-2.4, p < .05), of criminality (OR 1.9, 1.3-2.7, p < .001), and with lower SF12 physical (mean difference -3.0, CI -4.7 to -1.4, p < .001) and mental (-2.4, CI -4.3 to -0.5, p < .001) health scores. CONCLUSIONS There were consistently high levels of both abstinence and regular drinking, with drinking patterns staying relatively stable across the decade. From the clinical perspective, the high rates of heavy drinking are of particular relevance, given the observed associations with a poorer clinical profile.

Can we predict retention in longitudinal studies of substance use? Findings from the Australian Treatment Outcome Study.

BACKGROUND Longitudinal studies are often threatened by difficulties with sample attrition, high rates of which threaten the validity of study findings. The present study examined methodological and participant characteristics associated with sample retention in the Australian Treatment Outcome Study (ATOS) across 3years. METHOD Follow-up interviews were conducted at 3-, 12-, 24-, and 36-months post baseline, with follow-up rates of 89%, 81%, 76% and 70%, respectively. Structured interviews measuring past-month drug use, mental health, criminal involvement and demographic characteristics were administered to participants at baseline and each follow-up. Data were analysed using multinomial logistic regression and generalised estimating equations to produce odds ratios with 95% confidence intervals. RESULTS Completing all follow-up interviews was associated with being in treatment (OR 3.62), using other opiates at baseline (OR 3.45), more years of schooling (OR 1.20), and having completed the previous interview (OR 35.04). A history of incarceration was independently associated with not completing follow-up interviews (OR 0.47). CONCLUSION Retention can largely be predicted at study entry, and is unaffected by changes that occur in the interim. These findings highlight the importance of obtaining and maintaining comprehensive locator information, maintaining strong relationships with treatment agencies, as well as the necessity of patience, perseverance and flexibility.

Health Service Utilization Among Heroin Users: 11-Year Follow-up of the Australian Treatment Outcome Study Cohort

Objectives:The health service use of older heroin users is unknown. The study aimed to determine health service utilization, and dispensed prescriptions, among a cohort of heroin users at 11 years. Methods:A 11-year postbaseline follow-up of the Australian Treatment Outcome Study cohort. Health service utilization and dispensed prescriptions were examined over the month preceding interview. Results:At 11-year follow-up, 431 (70.1%) participants were interviewed, with a mean age of 40.0 years and 20.4 years since heroin initiation. In the month preceding interview, 76.1% used a medical service for issues not related to drug treatment, 66.6% having visited a General Practitioner. Use of a health service was independently associated with poorer physical and mental health. A total of 452 prescriptions were dispensed to 54.3% of participants. A psychotropic medication was dispensed to 40.8% of the cohort, comprising 61.7% of dispensed prescriptions. The most commonly dispensed psychotropics were anxiolytics/hypnosedatives and narcotic analgesics. A nonpsychotropic medication had been prescribed to 26.0% (30.3% of dispensed prescriptions). The most commonly received nonpsychotropic medications were antibiotics and anticonvulsants. Having had a psychotropic medication dispensed was independently associated with poorer physical and mental health, and a nonpsychotropic medication with poorer physical health and not being enrolled in a drug treatment program. Conclusions:Both health service use and dispensed prescriptions were high. The predictors of service use suggest that such use is likely to be primarily related to the declining health of an ageing cohort.