Submission in response to the Australia’s National Drug Strategy Beyond 2009 Consultation Paper Associate Professor Tricia Nagel Dr Rama Jayaraj Anthony Ah Kit



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Submission in response to the Australia’s National Drug Strategy

Beyond 2009 Consultation Paper
Associate Professor Tricia Nagel

Dr Rama Jayaraj

Anthony Ah Kit

Valerie Thompson

Neil Spencer
Menzies School of Health Research

John Mathews Building

Royal Darin Hospital Campus

Casuarina

NT 0810
This submission represents the view of the above individuals rather than the institution.
Introduction

The Northern Territory (NT) demonstrates many of the hazards of problem drinking in Australia. We have the highest estimated rates of per capita alcohol consumption (Matthews et al. 2002) and these high rates have persisted over many years (Chikritzhs et al. 2000; Stockwell et al. 2000). Indigenous people comprise 32% of the NT population but suffer much higher proportions of the negative outcomes of substance misuse (Perkins et al. 1994) (Kowalyszyn and Kelly 2003).


While the mortality rate due to alcohol has dropped nation wide, the rate of hospitalisations from alcohol-caused injury and disease has rapidly increased. The leading cause of hospitalisations was alcohol dependence while alcohol-caused death was primarily associated with alcoholic liver cirrhosis (National Drug Research Institute 2009). The percentage of hospitalisations among Indigenous males for conditions associated with high levels of alcohol use were between two and seven times higher than for non-Indigenous males in 2002–2003 (Overcoming Indigenous Disadvantage: Key Indicators 2005).
There remains a significant gap in our knowledge and understanding of the link between alcohol misuse and harm, especially in remote communities (Gray et al. 2006; Matthews et al. 2002). Our knowledge of the trends in substance use in remote communities is also limited (Clough et al. 2002) and little is known about the association between problem drinking and assaults (Kelly and Kowalyszyn 2003).
It is not known to what extent alcohol use directly leads to violence. What is known is that while alcohol consumption among all Territorians has been known to be consistently high (Gray et al. 2000) (Matthews et al. 2002) and Darwin has long held the status of the highest alcohol consuming capital in the world (Alcohol-Related Violence Growing in Darwin 2010) alcohol related violence statistics have been rising.
Key Point
There is a need to understand the link between alcohol misuse and harm, especially in remote communities.
Changes over time

Alcohol consumption has only recently become an accepted social habit among Indigenous Australians (Brady 1997). Today its consequences are unacceptable. Nation wide Indigenous Australians are six times more likely than non-Indigenous people to drink at high-risk levels (Chikritzhs and Brady. 2006). Indigenous men are more likely to consume alcohol at risky levels than Indigenous women, while women are more likely to begin risky consumption at younger ages (25-34 years) compared with Indigenous men (34-44 years) leading to major health concerns in their child bearing years (National Aboriginal and Torres Strait Islander Health Survey).


Colonisation has been linked with suffering for Indigenous peoples which continues to the present day. Racism and separation from family and land continues to impact upon the health of Indigenous people (Kowanko I et al. 2004; Paradies Y 2006; Zubrick SR et al. 1995).

Substance misuse is one of the many negative social consequences of the avalanche of change experienced since the first settlers arrived. The pattern of drinking, too, is linked with history and cultural conflict. Binge drinking was encouraged by the lack of legal access for Indigenous Australians to drinking venues (Ministerial Council on Drug Strategy 2006). This prohibition was only lifted in the last few decades, thus there has only been a relatively short span of time in which to develop and test successful treatment and intervention strategies.


There is a need for innovation which looks beyond the ‘disease’ and abstinence approaches of the past, to an understanding of individual and community risk which calls for individual and community wide strategies. While separation from family, land, and culture is linked with emotional distress there is evidence that community development approaches to health improvement which strengthen culture and empower communities have shown success (Burgess P et al. 2008; Rowley K et al. 2000).
Historic and cultural factors have influenced the pattern of drinking and the severity of alcohol related distress (Alati R et al. 2000). This has led to a multitude of approaches to treatment. Attempts to harness Indigenous Australia’s cultural identity and cultural strength in provision of harm reduction strategies have been limited. Often the time that is needed for ‘proper’ community consultation is not invested. Proper consultation is inclusive of the whole community. Many current supply reduction strategies are merely prohibition in modern guise, reminiscent of historic forms of social control and political oppression of Indigenous peoples. The way forward will be to develop new approaches which strengthen cultural identity and social inclusion, promote cultural continuity and challenge institutionalised racism (Kirmayer L 2003; Murray R et al. 2002).
It is emotional distress and intergenerational trauma which usually drives substance misuse, and emotional distress which is most often its hidden consequence. Conversely it is resilience and well being which will provide protection from substance misuse and emotional distress for current and future generations (Chandler M and Proulx T 2006; Chandler and Lalonde 1998). Strategies which promote wellbeing, identity and cultural continuity must be implemented, whether community-wide, family focused or targeting individuals (Murray R et al. 2002).
Key point
There needs to be greater recognition of the emotional distress which drives substance misuse and exploration of community development strategies to build resilience.
Alcohol related injury, assault and hospitalisation

Crime, hospital, inmate and community statistics provide insight into the problem of injury and assault among Indigenous peoples. Nationally, homicide and violence accounted for 16% of the Aboriginal and Torres Strait Islander injury burden (Anderson 2008). Violence was the most common cause of hospital admission for injury in the NT (You and Guthridge 2005) accounting for 38% of the total injury admissions for Indigenous people.


It is not clear to what extent these crimes are perpetrated by intoxicated people, or to what extent victims and perpetrators are Indigenous, however Indigenous prisoners are vastly overrepresented in the NT. They currently represent 82% (850) of the daily average prison population. Evidence of the link between violence, assault and alcohol misuse is scant. Reports from offenders clearly link alcohol in violent assaults and crime (Morgan and McAtamney 2009). The Drug Use Monitoring Australia (DUMA) program reported that 50% of all offenders detained by police across Australia in 2007 for disorder and violent offences had consumed alcohol in the 48 hours prior to their arrest (Adams et al. 2007).
It is known that factors which influence transition from remote communities to Darwin are: family violence, lack of housing, over crowding in communities and easy access to alcohol in Darwin (Catherine and Eva 2008) and that the harm associated with high risk alcohol consumption in Indigenous Australians includes family conflict, domestic violence and assaults (Kelly and Kowalyszyn 2003; Kowalyszyn and Kelly 2003). Further, it has been reported that most of the assaults against women in remote NT communities, are perpetrated by a drunken husband or other family member (Barber et al. 1988).
Although the factors which render alcohol-fuelled violence more likely are not fully understood, there is evidence that some places represent greater risk compared with others. Both customers and employees of licensed premises are at more serious risk of becoming involved in a violent incident than other locations (Graham and Homel 2008 ). Premises for the consumption of alcohol and the location of assaults are always interconnected with much greater rates of alcohol-related violence and fighting, particularly among non-indigenous males, than any other setting (Poynton 2005; Teece and Williams 2000; Wells 2005) (McIlwain and Homel 2009). In contrast, the close family members and friends involved in the group drinking activity face greater risk in the Indigenous context, and it is likely that the site for Indigenous assaults reflects where the drinking is taking place (bushes or private homes or parks or narrow pathways). Whatever the drinking location, facial trauma is a frequent end result of alcohol-fuelled violence.
Key point
There is a need to better understand the context of alcohol fuelled violence and the risk factors for facial injury secondary to assault.
Alcohol-related facial trauma

Binge drinking is strongly linked with violence-related facial trauma (Gassner et al. 1999) and high risk alcohol consumption is an important contributor to such trauma in the Indigenous population. The incidence of facial fractures in the Northern Territory (more than 350 per year) is by far the highest in the world. While only 32% of the population is Indigenous, 60% of all facial fractures seen are in Indigenous patients and 89% of these are a result of inter-personal violence (Thomas and Jameson. 2007).


Facial injury is often accompanied by emotional distress. In addition to the restoration of physical appearance and functional status for those who face violent associated facial trauma, there is also an urgent need for psychosocial care (Wong et al. 2007). There is an increasing consciousness of the risk for posttraumatic stress disorder (PTSD) after the incidence of violence-related facial injury (Bisson et al. 1997; Lento et al. 2004; Roccia et al. 2005a; Roccia et al. 2005b) and depression is also reported as a result of facial injury (Hull et al. 2003a; Hull et al. 2003b; Levine et al. 2005). In this setting of emotional distress the additional problem of substance misuse complicates rehabilitation (Passeri et al. 1993). In the NT Indigenous population pathways to recovery will be further complicated by cultural difference.
Key point
There is a need to develop integrated assessment and treatment for combined emotional distress (and cultural and spiritual distress), alcohol misuse and facial injury
Strategies for change

A comprehensive array of supply reduction, harm reduction, and demand reduction strategies are recommended in the complementary action plan of the national drug strategy addressing Indigenous Australians. In the NT, a range of supply reduction strategies have been introduced including: restricting take away sales, restricting cask sizes, and limiting trading hours (d'Abbs and Togni 2000; Hogan et al. 2006).


The key take home message from The ‘Living with Alcohol’ program (1992 -2002) in the Northern Territory (NT) was that interventions can make a difference, and that the components of success include a focus on treatment services and broader awareness raising campaigns linked with supply reduction through alcohol taxes (ChikritzhsT et al. 2004).
Turning to harm reduction strategies in the NT, these have generally focused on custodial care and residential treatment. ‘Night patrols’ in Darwin often provide free transport to safe locations such as sobering-up shelters or the police watch house for intoxicated rural and remote Indigenous Australians under custodial care legislation. Sobering-up shelters are neither detoxification centres, nor rehabilitation centres, but provide temporary refuge or asylum for intoxicated individuals at risk of causing harm to themselves or others. They also redirect intoxicated Indigenous population from police custody. Sobering-up centres provide temporary care for high risk individuals and the opportunity for brief interventions by drug and alcohol workers, and referrals for further assistance (Brady et al. 2006). They are only one component of a comprehensive approach to harm reduction, however, and there is as yet no evidence of effectiveness of these albeit limited interventions.
Key point
There is a need to explore the effectiveness of sobering up shelters and other options for custodial care as harm reduction strategies.
Treatment for Indigenous substance misuse

Political and socio-cultural influences underpin the vulnerability of Australian Indigenous peoples to high risk binge drinking. Strategies to address supply reduction must be mixed with culturally adapted treatment approaches. These approaches need to directly address the underlying socio-political causes of emotional distress and substance misuse, which include disempowerment and cultural discontinuity. They need to build an Indigenous workforce able to advocate strongly and treat effectively using community, family and individual approaches which promote cultural identity, kinship and the cultural values of Australian Indigenous peoples.


In specialist treatment settings (rehabilitation services for example) culturally adapted strategies for treatment and models of understanding have only recently begun to flourish (Brady 2007; Brady M et al. 1998). Indigenous rehabilitation services have struggled with issues of isolation secondary to political and historic influences (Alati R et al. 2000). This has led to services which operate separate to mainstream with little evidence of effectiveness and limited systems for self evaluation (Brady M 2002). As a result there is a strong push for engagement of Indigenous services with mainstream services but a clear risk that adopting a ‘one size fits all’ approach will not work given differences of worldview, language and literacy (Ministerial Council on Drug Strategy 2006). This risk will apply to outcome measures as well. Measuring the success of interventions will require the application of culturally valid outcome measures and acknowledgement that differences of world view and cultural framework affect such measures.
There have been important recent attempts to investigate and explore culturally adapted models of service delivery and outcome measurement (Nagel T 2007; Nagel T et al. 2008; Schlesinger CM et al. 2007). These recent studies have resulted from exploration of the high comorbidity of substance misuse with mental illness. This is a strong reason why a focus on supply reduction must work hand in hand with development of treatment services. Limiting the supply of one particular intoxicant will not address the underlying emotional distress within individuals, families and communities that drives its use.
Key point
A focus on supply reduction must work hand in hand with development of treatment services which nurture strong partnerships with Indigenous service providers and use culturally validated outcome measures.
Evidence that culturally adapted treatment may be effective stems from a mixed methods study in two remote communities in the NT. This study showed that participatory action research can result in tools for treatment which can be developed and successfully applied in resource-poor cross cultural settings. A brief psychological intervention was tested, using a randomised controlled design, in the setting of comorbid substance dependence and mental health and found to be effective (Nagel T 2007; Nagel T et al. 2008; Nagel T et al. 2009b; Nagel T and Thompson C 2007). Concurrent development of Indigenous specific screening tools has further added to the cross cultural resources available in the field (Schlesinger CM et al. 2007).
Additional positive change in the field is the development of a community based Indigenous workforce which is developing its own model of engagement with communities using principles of community development combined with best practice in brief interventions (Nagel T et al. 2009a). These two recent NT initiatives represent important new directions toward engaging the strength of culture in development of resilience and resistance to substance misuse.
Key point
There is a need for evaluation and expansion of community preventive and treatment initiatives which are developed in collaboration with Indigenous peoples and integrate community development approaches.
Conclusion

Political and socio-cultural influences underpin the vulnerability of Australian Indigenous peoples to high risk binge drinking. There is an epidemic of alcohol fuelled assault which is frequently the result of family violence and is frequently complicated by facial injury. These high rates of alcohol misuse and injury are likely to be driven by underlying distress and link with high rates of mental and physical illness, social disadvantage and incarceration. Strategies to address supply reduction must be mixed with culturally adapted treatment approaches. These approaches need to directly address the underlying socio-political causes of emotional distress and substance misuse, which include disempowerment and cultural discontinuity. They need to build an Indigenous workforce able to advocate strongly and treat effectively using community, family and individual approaches which promote cultural identity, kinship and the cultural values of Australian Indigenous peoples.



Key point
Many of the above issues are specific to the context of Indigenous peoples and support the relevance of a separate National Drug Strategy Aboriginal and Torres Strait Islander Complementary Action Plan
References




February 2010


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