Philip Clare

Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study

BACKGROUND Despite opioid analgesics being essential for pain relief, use has been inadequate in many countries. We aim to provide up-to-date worldwide, regional, and national data for changes in opioid analgesic use, and to analyse the relation of impediments to use of these medicines. METHODS We calculated defined daily doses for statistical purposes (S-DDD) per million inhabitants per day of opioid analgesics worldwide and for regions and countries from 2001 to 2013, and we used generalised estimating equation analysis to assess longitudinal change in use. We compared use data against the prevalence of some health disorders needing opioid use. We surveyed 214 countries or territories about impediments to availability of these medicines, and used regression analyses to establish the strength of associations between impediments and use. FINDINGS The S-DDD of opioid analgesic use more than doubled worldwide between 2001-03 and 2011-13, from 1417 S-DDD (95% CI -732 to 3565; totalling about 3.01 billion defined daily doses per annum) to 3027 S-DDD (-1162 to 7215; totalling about 7.35 billion defined daily doses per annum). Substantial increases occurred in North America (16,046 S-DDD [95% CI 4032-28,061] to 31,453 S-DDD [8121-54,785]), western and central Europe (3079 S-DDD [1274-4883] to 9320 S-DDD [3969-14,672]), and Oceania (2275 S-DDD [763-3787] to 9136 S-DDD [2508-15,765]). Countries in other regions have shown no substantial increase in use. Impediments to use included an absence of training and awareness in medical professionals, fear of dependence, restricted financial resources, issues in sourcing, cultural attitudes, fear of diversion, international trade controls, and onerous regulation. Higher number of impediments reported was significantly associated with lower use (unadjusted incidence rate ratio 0.39 [95% CI 0.29-0.52]; p<0.0001), but not when adjusted for gross domestic product and human development index (0.91 [0.73-1.14]; p=0.4271). INTERPRETATION Use of opioid analgesics has increased, but remains low in Africa, Asia, Central America, the Caribbean, South America, and eastern and southeastern Europe. Identified impediments to use urgently need to be addressed by governments and international agencies. FUNDING International Narcotics Control Board, UN.

The relationship between socioeconomic status and ‘hardcore’ smoking over time – greater accumulation of hardened smokers in low-SES than high-SES smokers

Objectives This paper used national survey data to investigate ‘hardcore’ smoking as predicted by the ‘hardening hypothesis’, and to examine the relationship between ‘hardcore’ smoking and socioeconomic status (SES). Methods Analyses were performed using data from four waves of the Australian National Drug Strategy Household Survey between 2001 and 2010, a large national survey with a sample size of approximately 24 000 participants per wave. The primary outcome variable was ‘hardcore’ smoking, comprised of the variables: ‘no quit attempt in past 12 months’; ‘no plan to quit’; and smoking more than 15 cigarettes per day. The main predictor variables used were SES assessed by the Socio-Economic Indexes for Areas (SEIFA), and survey wave. Other sociodemographic variables were also examined. Results Overall, ‘hardcore’ smoking remained stable from 2001 to 2010. However, ‘hardcore’ smoking declined among high-SES smokers (from 1.8% to 1.0%), but not among low-SES smokers (around 3.4%). ‘Hardcore’ smoking was strongly associated with SEIFA quintile (p<0.001). There was a significant interaction effect between top and bottom SEIFA quintiles and wave (p=0.025), with a decline in ‘hardcore’ smoking measures over the four waves among those in the top two SEIFA quintiles, with odds in 2010 of 0.39 (95% CI 0.17 to 0.87; p=0.012), down from 0.64 (95% CI 0.50 to 0.82; p<0.001) in 2001, while ‘hardcore’ smoking remained stable among those in the bottom two SEIFA quintiles. Conclusions The results from high SES smokers suggest ‘hardcore’ smokers are able to quit, but outcomes among low-SES smokers are less encouraging.

Parental supply of alcohol and alcohol consumption in adolescence: prospective cohort study

BACKGROUND Parents are a major supplier of alcohol to adolescents, yet there is limited research examining the impact of this on adolescent alcohol use. This study investigates associations between parental supply of alcohol, supply from other sources, and adolescent drinking, adjusting for child, parent, family and peer variables. METHOD A cohort of 1927 adolescents was surveyed annually from 2010 to 2014. Measures include: consumption of whole drinks; binge drinking (>4 standard drinks on any occasion); parental supply of alcohol; supply from other sources; child, parent, family and peer covariates. RESULTS After adjustment, adolescents supplied alcohol by parents had higher odds of drinking whole beverages [odds ratio (OR) 1.80, 95% confidence interval (CI) 1.33-2.45] than those not supplied by parents. However, parental supply was not associated with bingeing, and those supplied alcohol by parents typically consumed fewer drinks per occasion (incidence rate ratio 0.86, 95% CI 0.77-0.96) than adolescents supplied only from other sources. Adolescents obtaining alcohol from non-parental sources had increased odds of drinking whole beverages (OR 2.53, 95% CI 1.86-3.45) and bingeing (OR 3.51, 95% CI 2.53-4.87). CONCLUSIONS Parental supply of alcohol to adolescents was associated with increased risk of drinking, but not bingeing. These parentally-supplied children also consumed fewer drinks on a typical drinking occasion. Adolescents supplied alcohol from non-parental sources had greater odds of drinking and bingeing. Further follow-up is necessary to determine whether these patterns continue, and to examine alcohol-related harm trajectories. Parents should be advised that supply of alcohol may increase childrens drinking.

Smoking Cessation among Low-Socioeconomic Status and Disadvantaged Population Groups: A Systematic Review of Research Output

Background: Smoking cessation research output should move beyond descriptive research of the health problem to testing interventions that can provide causal data and effective evidence-based solutions. This review examined the number and type of published smoking cessation studies conducted in low-socioeconomic status (low-SES) and disadvantaged population groups. Methods: A systematic database search was conducted for two time periods: 2000–2004 (TP1) and 2008–2012 (TP2). Publications that examined smoking cessation in a low-SES or disadvantaged population were coded by: population of interest; study type (reviews, non-data based publications, data-based publications (descriptive, measurement and intervention research)); and country. Intervention studies were coded in accordance with the Cochrane Effective Practice and Organisation of Care data collection checklist and use of biochemical verification of self-reported abstinence was assessed. Results: 278 citations were included. Research output (i.e., all study types) had increased from TP1 27% to TP2 73% (χ² = 73.13, p < 0.001), however, the proportion of data-based research had not significantly increased from TP1 and TP2: descriptive (TP1 = 23% vs. TP2 = 33%) or intervention (TP1 = 77% vs. TP2 = 67%). The proportion of intervention studies adopting biochemical verification of self-reported abstinence had significantly decreased from TP1 to TP2 with an increased reliance on self-reported abstinence (TP1 = 12% vs. TP2 = 36%). Conclusions: The current research output is not ideal or optimal to decrease smoking rates. Research institutions, scholars and funding organisations should take heed to review findings when developing future research and policy.

Predictors of retention in a randomised trial of smoking cessation in low-socioeconomic status Australian smokers

BACKGROUND AND AIMS Little is known about the factors associated with retention in smoking cessation trials, especially for low-socioeconomic status (low-SES) smokers. This study examined the factors associated with retention of low-SES smokers in the Australian Financial Interventions for Smoking Cessation Among Low-Income Smokers (FISCALS) trial. DESIGN A two-group parallel block randomised open-label trial with allocation concealment. SETTING Australia. The study was conducted primarily by telephone-based interviews with nicotine replacement therapy delivered via mail. PARTICIPANTS 1047 low-SES smokers interested in quitting smoking were randomised. MEASUREMENTS Participants completed computer assisted telephone interviews (CATIs) at baseline, 2-month and 8-month follow-up. Smoking-related, substance use, mental or physical health, general psychological constructs, sociodemographic and recruitment sources association with retention at 8-month follow-up were examined using binary logistic regression. FINDINGS 946 participants (90%) completed the 2-month follow-up interview and 880 participants (84%) completed the 8-month follow-up interview. Retention at 8-months was associated with higher motivation to quit (OR: 1.15; 95% CI: 1.04, 1.27 p<0.01), more recent quit attempts (OR: 1.20; 95% CI: 1.04, 1.40 p<0.05), increasing age (OR: 1.05; 95% CI: 1.03, 1.07 p<0.01), and higher level of education (OR: 2.24; 95% CI: 1.45, 3.46 p<0.01). Lower retention at 8-months occurred for those participants recruited from posters placed in Department of Human Service Centrelink Offices (OR: 0.56; 95% CI: 0.35, 0.89, p<0.05) compared to participants recruited from Quitline services. No significant differences in retention were found for participants recruited via newspaper advertisements or word of mouth compared to Quitline services. No significant associations were found between health-related or behavioural factors and retention. CONCLUSIONS In the context of high overall retention rates from disadvantaged smokers in a randomised trial, retention was greater in those smokers with higher motivation to quit, more recent quit attempts, increased age, higher level of education and for those recruited through Quitline or newspaper advertisements.

Use of Smoking Cessation and Quit Support Services by Socioeconomic Status Over 10 Years of the National Drug Strategy Household Survey

OBJECTIVES The aim of this research was to examine the use of quit smoking services and support options in Australia with national survey data to determine whether use of quit smoking services and pharmacotherapy contributes to socioeconomic status (SES) differences in smoking. METHODS Analyses were performed with data from 4 waves of the Australian National Drug Strategy Household Survey between 2001 and 2010. The primary outcomes were the use of quit smoking services or pharmacotherapy. The main predictor variables used were measures of SES including the Socio-Economic Indexes for Areas, income, and education. Other sociodemographic variables were also examined. RESULTS There was no systematic SES difference in the use of services or support options, with some used more by high SES and some used more by low SES. Those with university education (odds ratio [OR] = 0.72; 95% CI = 0.56-0.93) were less likely to use prescription medication. Conversely, those with higher incomes were more likely to use patches, gum, or an inhaler (OR = 1.13; 95% CI = 1.01-1.27). Prescription medication was significantly associated with increased odds for recent cessation, although only among those with lower levels of education (OR = 2.50; 95% CI = 1.94-3.23). Those with higher SES had the greatest odds for recent cessation. CONCLUSIONS The evidence suggests that low-SES smokers use quit services and support options equally compared with high-SES smokers; thus, access does not drive the SES differential in smoking. However, the findings are positive, suggesting that increasing the uptake of prescription medication may help increase cessation rates among low-SES smokers.

Association of parental supply of alcohol with adolescent drinking, alcohol-related harms, and alcohol use disorder symptoms: a prospective cohort study

BACKGROUND Some parents supply alcohol to their children, reportedly to reduce harm, yet longitudinal research on risks associated with such supply is compromised by short periods of observation and potential confounding. We aimed to investigate associations between parental supply and supply from other (non-parental) sources, with subsequent drinking outcomes over a 6-year period of adolescence, adjusting for child, parent, family, and peer variables. METHODS We did this prospective cohort study using data from the Australian Parental Supply of Alcohol Longitudinal Study cohort of adolescents. Children in grade 7 (mean age 12 years), and their parents, were recruited between 2010 and 2011 from secondary schools in Sydney, Perth, and Hobart, Australia, and were surveyed annually between 2010 and 2016. We examined the association of exposure to parental supply and other sources of alcohol in 1 year with five outcomes in the subsequent year: binge drinking (more than four standard drinks on a drinking occasion); alcohol-related harms; and symptoms of alcohol abuse (as defined by Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV]), alcohol dependence, and alcohol use disorder (as defined by DSM-5). This trial is registered with ClinicalTrials.gov, number NCT02280551. FINDINGS Between September, 2010, and June, 2011, we recruited 1927 eligible parents and adolescents (mean age 12·9 years [SD 0·52]). Participants were followed up until 2016, during which time binge drinking and experience of alcohol-related harms increased. Adolescents who were supplied alcohol only by parents had higher odds of subsequent binge consumption (odds ratio [OR] 2·58, 95% CI 1·96-3·41; p<0·0001), alcohol-related harm (2·53, 1·99-3·24; p<0·0001), and symptoms of alcohol use disorder (2·51, 1·46-4·29; p=0·0008) than did those reporting no supply. Parental supply of alcohol was not significantly associated with the odds of reporting symptoms of either alcohol abuse or dependence, compared with no supply from any source. Supply from other sources was associated with significant risks of all adverse outcomes, compared with no supply, with an even greater increased risk of adverse outcomes. INTERPRETATION Providing alcohol to children is associated with alcohol-related harms. There is no evidence to support the view that parental supply protects from adverse drinking outcomes by providing alcohol to their child. Parents should be advised that this practice is associated with risk, both directly and indirectly through increased access to alcohol from other sources. FUNDING Australian Research Council, Australian Rotary Health, Foundation for Alcohol Research and Education, National Drug and Alcohol Research Centre.

Trends in PIEDs use among male clients of needle–syringe programs in Queensland, Australia; 2007–2015

Abstract Background Increased utilisation of needle–syringe programs (NSP) by men who inject performance and image-enhancing drugs (PIEDs) has been reported. While fewer in number, people who inject PIEDs possess distinct service and knowledge needs compared to other NSP clients. Methods Using standardised data from 26 NSP outlets through the Queensland NSP Minimum Data Set (QNSPMDS), trends in occasions of services among males intending to inject PIEDs were assessed using multilevel mixed-effects negative binomial regression, adjusting for month, year, and age, and clustering by site. Results Compared to 2007, PIEDs-related occasions of service increased from 2008 until 2013 (3% and 13% of all occasions of service involving males in 2007 and 2015, respectively). While accounting for the fewest occasions of service, the Northern region experienced the greatest rate of occasion of service increase (2015 IRR 7.46, 95%CI: 6.11, 9.12). Similarly higher rates were seen among males aged Conclusion NSP settings provide an opportunity to engage with this unique population, providing important education on injection-related injuries and diseases, including blood-borne viruses, and greater linkage to primary care.

Associations between behavioural risk factors and smoking, heavy smoking and future smoking among an Australian population-based sample.

INTRODUCTION Tobacco smoking co-occurs with behavioural risk factors including diet, alcohol use and obesity. However, the association between behavioural risk factors and heavy smoking (>20cig/day) compared to light-moderate smoking is unknown. The link between behavioural risk factors and future smoking for both ex and current smokers is also unknown. This study sought to examine these relationships. It is hypothesised that behavioural risk factors will be more strongly associated with heavy smoking. METHOD Data from Wave 7 (2007) of the Household and Labour Dynamics in Australia (HILDA) survey was analysed using logistic regression to determine relationships between diet (fruit and vegetable consumption, and unhealthy diet choices), alcohol consumption, obesity and physical activity with light-moderate smoking and heavy smoking. The association between these risk factors and future smoking (2008) was assessed for current and ex-smokers (2007). RESULTS Obese respondents were less likely to be light/moderate smokers (RRR: 0.53; 95% CI: 0.43, 0.66) but not heavy smokers. Those who consume confectionary weekly were less likely to be light/moderate smokers (RRR: 0.73; 95% CI: 0.61, 0.87), but not heavy smokers. Smokers in 2007 were more likely to continue smoking in 2008 if they consumed 1-4 drinks per occasion (OR: 2.52; 95% CI: 1.13, 5.62). Ex-smokers in 2007 were less likely to relapse in 2008 if they consumed recommended levels of both fruit and vegetables (OR: 0.31; CI: 0.10, 0.91). CONCLUSION The relationships between heavy smoking and behavioural risk factors differ from moderate-light smoking. Future primary care interventions would benefit from targeting multiple risk factors, particularly for heavy smokers.

What is the alcohol, tobacco, and other drug prevalence among culturally and linguistically diverse groups in the Australian population? A national study of prevalence, harms, and attitudes

Abstract In Australia, one in three people are born overseas, and one in five households speak languages other than English. This study explores substance use prevalence, related harms, and attitudes among these large groups in the population. Analysis was conducted using cross-sectional data (N = 22, 696) from the 2013 National Drug Strategy Household Survey. General linear model and binary logistic regression were used to assess substance use and harms, using stabilized inverse propensity score weighting to control for potential confounding variables. Between culturally and linguistically diverse populations and the population born in Australia, United Kingdom, or New Zealand who speak only English at home, there is no statistically significant variation in the likelihood of current smoking; using analgesics, tranquilizers, or sleeping pills; or administering drugs via injection. Culturally diverse populations are less likely to drink alcohol or use cannabis or methamphetamines. No difference between these two major groups in the population is observed in substance-related abuse from strangers; but culturally diverse respondents are less likely to report substance-related abuse from known persons. Lower substance use prevalence is not observed among people from culturally diverse backgrounds who have mental health issues. Australian-, UK-, or New Zealand–born respondents who speak only English at home are more likely to oppose drug and tobacco policies, including a range of harm reduction policies. We discuss the practical and ethical limitations of this major Australian data set for examining the burden of drug-related harms experienced by specific migrant populations. Avenues for potential future research are outlined.