Ground Zero An Advocacy Project On behalf of Pharmacotherapy clients A right; to participation, empowerment and involvement.
AcknowledgementsThis project is a collaborative one and we would like to express our appreciation andthanks to all contributors who gave freely of their time and assistance towards it. Wewould also like to thank the Tasmanian Polytechnic, Diploma of Community Servicesstaff for their advice, mentoring and guidance over the last 2 years. The hope is that wehave assisted in progressing policy, procedures and positive discourse surroundingconsumer led advocacy in the ATOD sector. Bucaan Community House. The Link Youth Health Services Anglicare Tasmania Aboriginal Health Service Mission Australia (Chigwell) ATI (Aron Perkins) North Hobart Pharmacy (Amcal) TasCAHRD Bridgewater Community House and NSP Pharmacist (anon) 3 sector workers (anon) The Honourable Scott Bacon, ALP member for Denison Andrew Wilkie, MHR, Denison Office of the State Health Minister .
Preface This work is copyright and apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without permission ofTasmania Polytechnic or the authors of this document. The opinions expressed in this document are those purely of the authors and not those of TasCAHRD or Tasmania Polytechnic
Table of ContentsSECTION PAGEPreface iiAbbreviations ivDefinitions viEXECUTIVE SUMMARY viiRecommendations ix1.0 Introduction 1 1.1 Background 1 Table 1 PAR vs. CR 1 Graph 1 Number of Active Opioid Substitution Therapy 4 Patients per Annum, Tasmania, 2000-2012 4 Table 2 Number of clients, by sex, pharmacotherapy type, state and territory 4 Figure 1 Accidental Addict 5 1.2 Methodology 6 Table 3 Organisations referred to by respondents 62.0 Literature Review 9 Graph 2 Number of Opioid & Opioid Plus BZD-related Deaths in Tasmania per Annum 11 Graph 3 Oxycodone Deaths in Aus 12 Figure 2 Dope is top drug worry 133.0 Community Profile 14 Graph 4 Rapid Uptake of OxyContin Prescribing 14 Graph 5 Methadone Prescribing in Tasmania vs. AUS 15 Figure 3 Deadly epidemic fears over common painkiller 16 Graph 6 Opioid Prescribing is Escalating 17 Figure 4 Drug hauls skyrocket 17 Graph 7 S8 Authorities per Annum in Tasmania 1989-2012 18 Table 4 Perceived need for Specialist Alcohol, Tobacco, and Other Drugs in Tasmania 18 Figure 5 Our state of Dependence 194.0 Outcomes 20 Figure 6 How to reduce opioid overdose deaths in Australia 20 Figure 7 Oprah Quote 215.0 Summary 226.0 Appendix 23 6.1 Appendix I – Letter from DHHS 23 6.1 Appendix II – Survey Flyer 24 6.2 Appendix III – Survey 257.0 References 28
AbbreviationsADS Alcohol and Drug ServicesAIDS Acquired Immune Deficiency SyndromeAIVL Australian Injecting and Illicit Drug Users LeagueATDC The Alcohol, Tobacco and other Drugs Council of TasmaniaATOD Alcohol Tobacco and other DrugsATI Advocacy Tasmania Inc.BMJ British Medical JournalCALD ` Culturally and Linguistically DiverseCHF Consumers Health Forum of AustraliaCSO Community Service OrganisationDHHS Department of Health and Human Services (Tasmania)DSM Diagnostic and Statistical Manual of Mental DisordersEMCDDA The European Monitoring Centre for Drugs and Drug AddictionEU European UnionGP General PractitionerHMA Healthcare Management AdvisorsICD International Classification of DiseaseIDU Injecting Drug UsersKE Key ExpertNGO Non Government Organisation
NMDS National Minimum Data SetNOPSADC National Opioid Pharmacotherapy Annual Data CollectionNPPPDO National Pharmacotherapy Policy for People Dependent on OpioidsPAR Participatory Action ResearchPSAC Polytechnic Student Advocacy ClassPSB Pharmaceutical Services BranchCGP Royal College of General PractitionersRCPSYCH Royal College of PsychiatristsTasCAHRD Tasmanian Council on Aids, Hepatitis and Related DiseasesTOPP Tasmanian Opioid Pharmacotherapy PolicyTUHSL Tasmanian users Health and support LeagueWHO World Health Organization
DefinitionsClosed Treatments: (HMA 2008, pg 26) states, “a period of contact, with defined startand end dates, between a client and a treatment agency”.Dependence: The DSM criteria refer to ‘abuse’ rather than misuse. Both the DSM andthe ICD refer to ‘dependence’ rather than using the term ‘addiction’, which is generallyregarded as unclearly defined and often used more to label than describe behaviours,(Parrish 2011, pg. 192)Drug: McDonald, D (2012 pg 5), quotes the (NDS) definition of ‘drug’ as stated: The term ‘drug’ includes alcohol, tobacco, illegal (also known as ‘illicit’) drugs, pharmaceuticals and other substances that alter brain function, resulting in changes in perception, mood, consciousness, cognition and behaviour.Health: as adopted by WHO ‘Health is a state of complete physical, mental and socialwell being, not merely the absence of disease or infirmity’.Opioids:Opioids include both natural and synthetic opiates. They are either a natural compoundderived from the opium poppy or a synthetic compound that act on opiate receptors. Dueto the fact that they have an analgesic effect they are used in the medical profession.Since they are addictive their use can lead to drug dependence. This dependence canoccur with pharmaceutical opioids as well as illegal opioids. Some of the common typesof opioids are as follows: Codeine; Heroin; Morphine; Oxycodone; Percodan; Demerol;and Darvon. AIHW 2012Pharmacotherapy client: A person receiving pharmacotherapy treatment for eitheropioid maintenance or withdrawal management (detoxification) from a prescriber (AIHW2012).Policy: McDonald, D (2012 pg 5), outlines this term from Althaus, Bridgman and Davis(2007) “A statement of government intent, and its implementation through the use ofpolicy instruments”.Polydrug Use: ‘Is the use of more than one drug or type of drug by an individual, often at the same time or sequentially and usually with the intention of enhancing or countering, the effects of the drug’ (Hinton 2008 pg 25)Recovery: The RCPSYCH and RCGP (2012 pg10), explains (HM Government, 2010)definition of recovery as ‘well-being, citizenship and freedom from dependence, and asan ‘individual personal journey’.Substance Dependence: Dr Adrian Reynolds (2011-2012 pg. 21), quotes the DSM IV-TR 2000, definition of dependence ‘substance dependence occurs when an individualcontinues using a substance despite it having a significantly negative effect on his or herlife, including functional impairment and emotional distress.
Executive SummaryAnecdotal evidence of rising dissatisfaction levels amongst pharmacotherapy clients insouthern Tasmania prompted this project. The ADS, which is contained within the DHHSis a state government managed service that is comprised of various services. Our area ofinterest lies within the delivery, co-ordination and management of the NSP,pharmacotherapy and detoxification services and the interactions that take place inSouthern Tasmania. Discussions with stakeholders, held in October 2012, raised concernsregarding punitive and judgemental service, lack of resources within the program,prolonged waits and other difficulties including the unavailability of an advocacy servicewithin the sector. According to the AIVL, (2012), they discover that a main site ofdiscriminatory treatment and micro-aggressions, occurred at drug treatment sites. People on pharmacotherapies elicited some sympathy for trying to ‘help themselves’ but were also seen as simply seeking a cheap source of drugs rather than as making use of treatment or harm reduction services (AIVL 2011, p. 2).Evaluation of statistics showed that in and around 2008 there was only an average of 50%occupancy of the St John’s Park detoxification unit due to staff shortages. Furtherevaluation identified that there was under-utilisation of the public facility with only 11clients being dosed from St John’s Park, (HMA 2008, pg 34 -36).In the period 2008-09 Tasmania had 2081 treatment episodes and 15 government–fundedalcohol and other drug treatment agencies, which highlights a reduction of agencies byone and 221 fewer treatment episodes, compared with the 2007-08 period (AIHW 2011).Clients report being treated punitively and feel they cannot voice their concerns to ADSdue to the fear of repercussions. They also state their treatment is inconsistent anddecisions about their treatment were being made for them without consultation. From thisinformation the project evolved. The title for this project, Ground Zero is taken from‘Voices on Choices: working towards consumer led alcohol and drug treatment’ as adescription of the lack of consumer led activity within this community sector in Tasmania(Hinton 2010 pg 83). This project has set out to discover what the literature in this areaand stakeholders have to say about the pharmacotherapy services offered in southernTasmania. It has been coincidentally written at the implementation of new treatmentguidelines TOPP See Appendix 6.1.Little has altered since the release of ‘Voices on Choices’ however, the ATI has beenfunded from April 2010 to June 2013 by the DHHS via ADS to be the provider ofadvocacy services in the ATOD sector. ATI have created a ‘Consumer and CarerParticipation Program’. This suggested model was approved by ADS. In ATI’s documententitled ‘Response to Tasmanian Opioid Pharmacotherapy Policy and Clinical Standards
Draft 2011’ (TOPP) ATI state that they were ‘informed at an early stage that someimportant issues (including take-away dosing) were not really “on the table” forconsideration’ (ATI 2011, pg 2).‘Advocacy seeks to represent the interests of powerless clients to powerful individualsand social structures’ (Payne 2005, pg 295). Reading the ATI’s service development plan2011-2012, it could be argued that it is tokenistic and the delivery of this product has thepossibility to constrain the ATOD client group to that of passive consumers of ATI’sproduct. Payne (2005, pg 301) looks at Croft and Beresford’s (1994) viewpoint that ‘a participative approach is valuable because people want and have a right to be involved in decisions and actions taken in relation to them. Their involvement reflects the democratic value base of social work; it increases accountability, makes for more efficient services and helps to achieve social work goals. It also helps to challenge institutionalised discrimination’.In Dec 2008, the Tasmanian Minister for Health released a five year plan encompassing2008-2013 for the ATOD sector. Its aim was to highlight opportunities for investmentand provide a quality, sustainable, supportive system for those in our society who havesubstance abuse issues. The plan stated that 17.1 million would be spent over 4 years.Outcomes of this investment would be improved services within the withdrawalmanagement unit and higher expenditure in the pharmacotherapy program.The DHHS has benchmarked certain standards to be achieved by 2020 in their AnnualReport 2009-2010. The benchmarks include, reducing the levels of Tasmanians who usedillicit drugs from 14.8% in 2007 to 9 % by the year 2020. The report also states that understandard 4.3 they will increase service delivery, meeting client need for those withserious mental illness from 35 % in 2009 to a target of 90 % by 2020 (DHHS 2010).The importance of working effectively with clients cannot be overstated as theoccurrence of mental illness will affect more than one in five Australians. Thoseundergoing mental unwellness are precipitously placed to go on to develop co morbiditiesinvolving alcohol, tobacco and other drugs (NSW Health 2007, pg 3). Many clients in theATOD sector have a dual diagnosis, which includes a mental illness. Whilst reviewingcurrent literature there has been a lack of documentation that provides a roadmap toachieving these targets.Trends further from home illustrate that stakeholders need to have a global awareness toallow for appropriate future planning. The EMCDDA (2011, pg 13) states ‘Polydrug use,including the combination of illicit drugs with alcohol, and sometimes, medicines andnon-controlled substances, has become the dominant pattern of drug use in Europe’.Further to this the RCPSYCH and RCGP College report (2012, pg 6) makes thedistinction that,
Heroin and cocaine use is stable or in decline, whereas new drugs such as ‘legal highs’ areemerging. Increasing numbers of young people are using alcohol and stimulants, and long-termdrug and alcohol use by older people is becoming more significant. This trend of ageing populations of drug users in treatment has also been reported on previously by the EMCDDA.
Recommendations The authors propose the following recommendations with the belief that their implementation would pioneer a positive shift towards aligning the mental health, ATOD and pharmacotherapy services toward best National Practice Standards and create a new voice on policy agendas. • That funding is made available for the development of an independent of services consumer-led advocacy group with the mission of participation, empowerment and involvement. This will place Tasmania on an equal footing with other states and territories. • A fully costed Tasmanian roadmap is constructed for the integration of services in the mental health and ATOD sector that is underpinned by a holistic philosophy. The roadmap to be in line with evidence that this will meet service user and community expectations. • That the social determinants of health as defined by the WHO are recognised and incorporated into policy changes in the ATOD sector. • Review international and national models of education and implement workforce training that incorporates CALD policy and that said training be available nationally for stakeholders ie; medical professions and allied health care services, law enforcement agencies and students in the ATOD sector. This is to be undertaken collaboratively with CSO’s, KE’s, NGO’s and educational institutions to identify and prioritise skills shortages and develop pathways and frameworks for referral and engagement that are consistent nationally. An example of this type would be that used by health funds when members transfer. • DHHS to fund availability of the TOPP guidelines for ADS clients and provide information sessions about these guidelines. • Undertake cost analysis of new drug technologies for possible implementation in Tasmania as part of a best practice and client centred strategy
1.0 Introduction 1.1 Background ‘we are people living with the outcome of over two centuries of highly repressive and unjust social and legal responses to injecting drug use’ (AIVL 2011, pg vii)From the onset of this project it was the intention to utilise Participatory Action Research(PAR) to assess the needs of pharmacotherapy clients; however there have been barriersto this that will be discussed under methodology. This project sought to take aninterpretive stance and advocate for change by bringing the need for an independentlyfunded ATOD consumer led advocacy group to the attention of those with power tocreate change. PAR involves the stakeholders who will be mostly impacted by theoutcomes of the research. From a strengths perspective PAR can be liberating,empowering and educative and create relations of mutual respect that can bring thecommunity involved into the policy debate therefore validating their knowledge (ElsevierScience Ltd, 1995). In conventional research there is little stakeholder involvement, yet itis these individuals who are mostly impacted by its outcomes. The table below illustratesa comparison between the two processes:Table 1 PAR vs CR Participatory Research Conventional Research What is the research for? Action Understanding with perhaps action later Who is the research for? Local people Institutional, personal and professional interests Whose knowledge counts? Local people Scientists Topic choice influenced by? Local priorities Funding priorities, institutional agendas, professional interests Methodology chosen for? Empowerment, mutual Disciplinary conventions, learning ‘objectivity and ‘truth’ Who takes part in the stages of research process? Problem identification Local people Researcher Data collection Local people Researcher, enumerator
Interpretation Local concepts and Disciplinary concepts and frameworks frameworks Analysis Local people Researcher Presentation of findings Locally accessible and useful By researcher to other academics or funding body Actions on findings Integral to the process Separate and may not happen Who takes action? Local people, with/without External agencies external support Who owns the results? Shared The researcher What is emphasized? Process Outcomes Elsevier Science Ltd, 1995In 1997 the Tasmanian user’ Health and Support League (TUHSL) was established. Theirwork consisted of peer support, community education work for injecting drug users andthe development of a drug user magazine TASTE. Due to the lack of funding, resourcingthe organisation became unsustainable and was eventually integrated with the work ofTasmanian Council on AIDS, Hepatitis B & related diseases (TasCAHRD). AlthoughTasCAHRD continues to promote consumer participation activities they are not aconsumer-based organisation. Unlike other states, Tasmania no longer has a consumergroup who promote the interests of this community.Through their relationship building, TasCAHRD engages consumers involving them inprogram development and planning. This is done by: having consumer representativesattending quarterly program advisory group meetings; participation in focus groups in thedevelopment of information resources; appointing people who are injecting drug users asAustralian Injecting and Illicit Drug Users League (AIVL) delegates to participate innational policy debate (Hinton 2010, p.82).The National Pharmacotherapy Policy for people Dependent on Opioids (NPPPDO)states,"The provision for treatment services for people who are drug dependent reduces drug use andprevents drug-related harm". These harms include health costs, not only to the individual but tothe community, spread of blood borne viruses, risk of overdose, family breakdown, economiccosts associated with morbidity, mortality and absenteeism related to illicit drug use and the costof law enforcement for drug related crime". The NPPPDO further states, "there is an expectationin the community and among drug users and their families that treatment services will be
accessible regardless of age, race, gender, sexual preference and location" (AustralianGovernment Department of Health and Ageing for National Drug Strategy 2007, pg 2).The general public therefore has certain expectations surrounding standards for treatment,for those undertaking pharmacotherapy. The issues that led to this project and appear tobe ongoing within the ADS do not sit within socially accepted behaviour. AIVL confirmsthis with their research that found members of the wider community were very disturbedby the thought that the medical profession would discriminate against drug users: peoplefeel that medical professionals should be above such human flaws. Once vocations suchas the medical profession start treating one group differently, where might it end? (AIVL2011, pg 71). This is reflective of dominant societal values concerning healthprofessionals and the Hippocratic Oath.Research suggests that clients in this sector are reluctant to lodge complaints an/or areunsure of how this process works.Under s26 of the Ombudsman Act 1978, the Ombudsman is precluded from disclosure ofrelevant information. The Ombudsman report of 2010-2011 states that complaints againstDHHS were 27% of their total complaints received and that nearly all DHHS divisions,were involved in complaints (Allston 2011).Unfortunately there is no further breakdown of statistics for divisions within DHHS.Requests made to the state health minister’s office for relevant data were not productive.Furthermore, p34 of the Health Complaints Commissioner’s 2011 annual report (Allston2011) documents a case which highlights the inequality, problematic and fractured natureof issues that surround service delivery, policy, legislation and procedures surroundingthe ATOD sector. Ongoing, client centred service delivery and client based self-advocacyis required. AIVL has further identified from their online survey that injecting drug usersare‘a group of people who are acknowledged as being extremely reluctant to come forward to reportsuch treatment through formal complaint systems.’ (AIVL 2012, p.8)Treatments in Europe consist of the main modalities of opioid substitution, detoxificationand psychosocial interventions (EMCDDA 2011, pg 29). Ranges of treatments exist inTasmania for those dependent on opioids or other drugs.
Graph 1 Reynolds, 2011According to the National Opioid Pharmacotherapy Statistics Annual Data Collection:2011 (NOPSADC) report there are a total of 645 clients accessing pharmacotherapy inTasmania. (refer to table 2) Of those participants 382 are male and 254 are Female with 9recorded as ‘not stated’.Table 2 Number of clients, by sex, pharmacotherapy type, state and territorySex NSW Vic Qld WA SA Tas ACT NT Australi Australi a a (per cent) MethadoneMales 9,578 5,971 1,738 1,409 1,233 247 400 23 20,599 64.3Females 5,081 2,974 1,254 860 726 168 259 8 11,330 35.4Not — 88 1 — — 4 — — 93 0.3statedTotal 14,659 9,033 2,993 2,269 1,959 419 659 31 32,022 100.0 Buprenorphine(a)Males 2,872 433 509 61 220 26 34 9 4,164 66.0Females 1,300 216 369 75 131 29 11 10 2,141 33.9Not — 3 — — — 1 — — 4 0.1statedTotal 4,172 652 878 136 351 56 45 19 6,309 100.0 Buprenorphine–naloxone(a)Males n.a. 2,697 1,224 640 587 109 81 47 5,385 66.4Females n.a. 1,343 605 337 286 57 40 26 2,694 33.2Not n.a. 30 2 — — 4 — — 36 0.4statedTotal n.a. 4,070 1,831 977 873 170 121 73 8,115 100.0 Total (all pharmacotherapy drugs)Males 12,450 9,101 3,471 2,110 2,040 382 515 79 30,148 64.9Females 6,381 4,533 2,228 1,272 1,143 254 310 44 16,165 34.8Not — 121 3 — — 9 — — 133 0.3statedTotal 18,831 13,755 5,702 3,382 3,183 645 825 123 46,446 100.0
AIHW 2012 p.10Statistics, whilst informative give us only a partial insight into the lived experiences ofthose with dependency issues. Qualitative research can provide us with a deeperunderstanding. Hinton quotes; One worker described a client on a reducing dose of methadone with significant pain issues where they had tried to get the Alcohol and Drug Service to coordinate with the pain management clinic but with little success (Hinton 2008, pg 52)Figure 1 Accidental Addict The Age, 2012
1.2 MethodologySevere limitations to this project require mention. The researchers found engagementwith this community particularly difficult. It was time constrained and undertaken from1.10.12 to 20.11.12 therefore not allowing for adequate time to develop communityrelationships and undertake a full community needs assessment of the communitytargeted in this paperWith a wider timeframe, a comprehensive focus group plus a more detailed survey wouldhave been developed. It is hopeful that this will occur in due course. Arranging meetingsthat would be ideal with the service users could not be accommodated. Many workers inthis sector are overworked, time poor and part-time. Also, attempts to meet with keyexperts/stakeholders had challenges beyond workforce constraints. Those interviewedhave given information supporting the service user’s claims but stated that they wish theirname to remain off the record.Some of the agencies and professional KE had a culture of suspicion and defensiveness.Hinton, whose research suggests that, Tasmania arguably has a culture of denialregarding the extent of drug related harm. Historic failure to commit resources in thisarea, plus the actual geographical and population size of the Tasmanian communitycreates barriers to participation due to privacy and confidentiality issues. Consumerparticipation remains near to non-existent. Others in this sector have also experiencedlow response rates, which appear to be the norm in this community.Hinton also found that ‘this reflects the difficulties workers had in encouraging theirclients to participate and the stigma still attached to talking openly about these issues’(Hinton 2008, pg 21). ATI also acknowledged difficulty in gaining access to thisparticular client group in their report Response to Tasmanian Opioid PharmacotherapyPolicy and Clinical Standards Draft 2011 (TOPP). The breakdown of state-wideresponses (18 in all) they received are as follows; 10 from private prescribers, 8 fromADS and a total of 7 from Southern Tasmania. The HMA report 2008 Appendix b showsa total of 8 responses from the NSP to a specialist ATOD survey undertaken by them.Table 3 Organisations Referred to by Respondents
Our original methodology plan for consulting with this community included hosting afocus group, unstructured interviews with stakeholders, online survey, and a mailed outsurvey via the Man2Man magazine. An approach to the Bridgewater NSP to access theirclient base for a focus group was declined. Due to an extremely short window ofopportunity the magazine mail out was missed. Flyers were distributed advertising thebrief anonymous and confidential survey to various locations accessed by the client base.To date there has been two responses. Feedback will be taken on board and a newstrategy regarding surveying this group will be reflected upon. It has proved a valuablelearning experience that can be refined. Results will be posted as indicated on the surveyflyer (refer to Appendix II) by December 7. The original date was extended due to lowresponse rate. Follow up action with the stakeholders will hopefully boost the number ofresponses.Ethics, professionalism and personal values ensured that we did not seek out service usersat source even though this was suggested by a Polytechnic staff member that ‘at thislevel, Diploma, I would expect that you would’. Societal norms would disapprove ofsurvey seekers outside of a breast screen clinic, Warfarin or Diabetes clinic. Theresearchers feel human rights are for everybody, no exclusion clauses. The responsibility for maintaining trust and ethical standards cannot depend solely on rules or guidelines. Trustworthiness of both research and researchers is a product of engagement between people. It involves transparent and honest dealing with values and principles, the elimination of ‘difference blindness’ and a subtlety of judgement required to eliminate prejudice and maintain respect and human dignity. (AVIL 2002, pg 6)Very recent changes to the delivery of Hepatitis programs in southern Tasmania havehindered the consultative process also. Earlier this year the Hepatitis Program was put outto tender. TasCAHRD, the organization that was running the Hepatitis Program put in anapplication to continue, but the tender was awarded elsewhere. The net result of the lossto TasCAHRD has been almost 40% of their funding. This has had a great impact to theorganization. As a result the organization’s capacity to provide support is limited.Stakeholders offered various insights to working with substance dependent clients whichhelps inform our research. A pharmacist with past experience with Methadone patientsand no longer in this sector felt that;All addicts will try to manipulate any situation to their advantage as it is the nature of theirillness, so you could never trust them if they told you there had been a dose change. You alwayshad to double check with the doctor. Some were very impatient and could be quite rude if theyweren’t dosed immediately. If the prescriptions had been delayed because of dose changes orbecause we were busy with other patients they were often not very pleasant. Addicts will crushand try to inject anything Anonymous pharmacist
This pharmacist indicated that they always tried to be nice to all of their patients but attimes this could be quite a challenge. Our lack of real action to end the war on drugs has not only given the ‘green light’ to poor attitudes towards people who inject drugs: it has actively fuelled the epidemic of discrimination and human rights violations we live with today (AIVL 2011, pg 36).During an interview with a former NSP worker they indicated that because of theanonymity surrounding clients it was possible for clients to shop around the NSP’s so thatitems could then be sold on to the ‘big wigs’. There was a feeling that this program couldbe exploited. There was a common thread amongst the clients of wanting to get ontoprograms yet some had no financial means to do so (co-payment) and could not meet thecriteria. There was a lot of negativity about ‘jumping through hoops’. This workerindicated instances throughout the interview where they had been witness to preferential,punitive and judgemental work practices by DHHS employees.Another interview with an ATOD worker, who wish to remain anonymous due to fear ofpersonal ramifications stated:“They feel like they have no voice. I have heard clients say if they try to talk to someoneabout any issues that they have they would be susceptible to punitive actions.”The wait time and lack of consultation in treatment were other issues clients complainedabout. The worker stated, when people come to access services they need our support tomake a change. With the long waiting time to get into the program and the lack of otherservices “we are losing people” who are ready to make the change that will give them ahealthier lifestyle and improve their quality of life.Discrimination and labelling were impediments that researchers came across throughoutthis project. The stigma that is prevalent in this sector is another barrier that limits accessto quality healthcare. In a discussion with another ATOD worker, the researchers askedabout talking with some of their clients. The statement below illustrates clearly thatstigma and discrimination is endemic.“Why would you want talk to them? They are liars and thieves. They will lie to you.”This statement shocked the researchers.Feedback from an AIVL focus group about discrimination experienced by them, withinthe broader community showed that medical professionals and pharmacists were the toptwo offenders (AIVL 2011, pg 62)The authors commenced this project as part of their studies towards their Diploma ofCommunity Services; however they have choosen to use this report as a springboard for afinal draft for advocacy by engaging with a Federal Politician. During a meeting withAndrew Wilkie, (Federal Independent Member for Denison), on 5/11/12, the issue oftreatment towards ADS clients and lack of an independent of services community leadadvocacy group was discussed. The outcome of the meeting was a promise to reconvene
in June 2013 with a final strategic report and business plan for a consumer lead advocacygroup.
2.0 Literature ReviewThe literature review incorporated mainly web based data, statistics and reports as theseproved to be the most up to date and inclusive of current social discourse. Librarybookshelves had a plethora of books regarding health matters but an extremely poorchoice if you wished to research drug addiction or pharmacotherapy. This againreinforced to the authors the strong social stigma surrounding this group. If your drug ofchoice is food the choice of reading material is never ending. Celebrity is the cloak oftolerance towards drug use. Think Paris Hilton, Michael Jackson, various AFL FootballPlayers, Heath Ledger, Whitney Houston. Without this status you are the personattending a visit with your private prescriber who receives discriminatory service andmicro aggression from other patients in the room, the doctor’s receptionist, and/or thedoctor. These judgemental attitudes of the general public and health professionals, speaksof the stigma of criminal activities surrounding their drug use. One could raise thequestion that has not been covered in this review that the decriminalization of certaindrugs would be cost effective and enable substance dependent people to be disassociatedwith the criminal system making dependency a health issue where evidence isincreasingly showing it should sit.A core issue for the ATOD and mental health sector is the disconnect between servicesand lack of holistic intervention across organisations. This can be explained from theviewpoint of funding structures that are currently in play and there is sometimes a senseof client ‘ownership’ that comes with this, thus underscoring a reluctance to seek outservices from other CSO’s for a client that is case managed by a particular organisation.A further explanation is outlined. Due to the different methodologies used by the alcohol and other drugs and mental health sectors there are often difficulties in engaging with clients with both issues and developing an effective treatment approach. There often tends to be a lack of collaboration between the sectors and thus they traditionally have worked in isolation from each other (NSW Health 2007, pg 21).Further exacerbation of this compartmentalising of clients is underscored by geographiclocation of services, differing workplace methodologies and philosophies and differingadministrative practices. One of the issues identified by HMA relating to the ADS wasthat common client assessments weren’t being used and resulted in duplication region toregion (HMA 2008, pg 43). Pharmacotherapy clients are highly impacted by thechallenge of managing their symptoms and dealing with the medication management byADS. One stop shopping is not a preferred option due to lack of skills in the sector, ratheran inter-agency collaborative approach is required to provide best outcomes to clients.Australia’s drug strategy approach differs somewhat from that of the EU and othercountries as it has the broadest scope of substances, with harm minimisation being theoverarching strategy (EMCDDA 2011, pg 20-21). Everyday across the globe,governments and organisations endeavour to have effective policy and to respond toemerging trends. This has occurred since 1912 when the first International OpiumConference was held (AIVL 2011, pg 18).
The Rogerian method proposes empathy, acceptance, genuiness, congruence andunconditional positive regard whilst placing the person at the centre of the care modeland is derived from the humanist perspective. Dr Carl Rogers (1902- 1987) was anAmerican born, influential psychologist who pioneered Client Centred therapy andPerson Centred care (Parrish 2010, pg 135). ‘Rogers’ inherently optimistic regard forpeople is congruent with the strengths perspective associated with social work practice’(Parrish 2010, pg 134). An acceptance of the client being the expert in their own life is asupporting pillar to client centred care. Pharmacotherapy clients in Southern Tasmaniahave no choice currently but to persevere regardless of service levels. Saleebey makes thepoint that; Empowerment-based practice also assumes social justice, recognising that empowerment and self-determination are dependent not only on people’s making choices but also on their having available choices to make (Saleebey 1997, pg 61).A review of the TOPP clinical and practice standards reveals a document that appears toexclude pharmacotherapy clients from social inclusion, choice and opportunity. Thedocument is over 200 pages long and looks to replace the 12 year old TasmanianMethadone Policy. It was published in May 2012 with a review date set for 2014. Itsstated aim is to provide a framework for delivering a safe, effective pharmacotherapyprogram for those with an opioid dependence. It contains among other things backgroundinformation of opioid use in Tasmania, and the provision of pharmacotherapy withinTasmania. Models of Practice referred to are those of the Gateway Model and the SharedCare Model. It outlines the role of the ADS as that of facilitator and motivator of theimplementation of these models.The document highlights structural barriers for TOPP to overcome such as the limitedavailability of daily dosing pharmacies and also that those in existence have limited hoursof operation. It identifies workforce skills shortages as an area that constrains outcomesfor pharmacotherapy clients however it does not address how they will build workforcecapacity to meet outcomes. Workforce development appears crucial to being able to meetthe practice standards as written in this document.Language usage throughout as exampled by ‘clients are made aware’ shows a lack ofclient centred values and a non consultative functionalist approach. This type of focus,which is conservative, emphasises clinical management, clinical risk and anacknowledgement only of ‘expert’ specialist/medicalised knowledge. It providesconsistent practice standards and policy for safe treatment. It does not provide the right ofautonomy thus disallowing client self determination. One could argue that this isrepressive. Pharmacotherapy clients, have as consumers of this service, a right to make aninformed choice. Informed choice raises two important issues; firstly that of dignity ofrisk as it exists in the disability sector is highly relevant here. It is the right of theconsumer to make an informed choice, to avail themselves of opportunities, to beeducated and become competent and independent, thereby enabling a calculated risk tobe taken. Secondly if consumers of this service are not advised or do not have treatmentexplained then how can they give informed consent? The document points to thereduction of clinical risk and speaks of public safety yet as clinicians surely their first
duty is to the patient and if ADS refer to the premise of ‘primum non nocere’ (do noharm), this document elevates the possibility of restrictive practice occurring.The TOPP policy document has awareness of age, gender and CALD specificmanagement issues. It names ATI as an independent body for advocacy services for AODservice users, however as ATI is funded by DHHS it is therefore not independent fromthe services provided by ADS.A notice dated 22.10.12, was circulated to pharmacotherapy service users advising thatall clinical staff were now following the TOPP treatment guidelines. See Appendix I(notice). Upon contacting the Pharmacotherapy team in mid November 2012, advice wasreceived that due to resource shortages, copies of TOPP were not being distributed toclients; however a copy was available online. Some in the community and service usergroup may not have access to the World Wide Web, nor the ability to fully comprehend alarge medicalised document. An attempt to purchase the TOPP report from Print AppliedTechnology on Collins Street Hobart, met with a blank response, as a staff member hadno knowledge of this document. Yet this document applies to all as the ADS areultimately, the higher authority overseeing the pharmacotherapy program.Graph_2 Reynolds, 2011
Graph 3 Reynolds, 2011Tasmania has unique statistics that obviously the TOPP report is respondingto and there is no doubt a requirement for caution and concern around thepattern of misuse of pharmaceutical drugs in this state, the question howeveris how do we proceed forward as currently pharmacotherapy clients arevoicing that they are passengers only in this journey and there is no allowancefor them to be part of the solution.
Figure 2 Dope is top drug worry The Mercury, 2012
3.0 Community ProfileHMA (2008, pg 18) explains the DHHS (1995) drug policy as ‘The Tasmanian state wideMethadone Maintenance Program commenced as a pilot program in December 1992 inHobart’. Initially there was a rehabilitation unit and detoxification, also an outpatientclinic all of which were government funded. This was subsequently followed by the startof community-based pharmacotherapy so that more access would service client need thatexisted outside of the immediate Hobart area. This was undertaken by DHHS (HMA2008, pg 18).Current information informs us that the risk of overdose deaths decreases for those thatundertake substitution treatment.According to a study published in BMJ Injury Prevention, supply to Victoria has increased from7.5 mg per capita in 2000 to 6735mg per capita in 2009. Deaths reported to the Coroner hadincreased 21-fold, from 0.08/100 000 population in 2000 to 1.78/100 000 in 2009. They concludethat the increase in the number of deaths involving oxycodone is significantly associated with theincrease in supply. They further state that most of the drug toxicity deaths, which involvedoxycodone, were unintentional. This trend identified in Victoria helps support concerns thatglobally a pattern of increasing deaths involving oxycodone is emerging (BMJ, 2012).Graph 4 Reynolds, 2012
Research has also established evidence of higher accident rates for those using opioids.The review found that opioid prescribing in Tasmania is around 45% above the nationalaverage and that many GP’s have limited understanding of the impact of excessive use ofpain management medication (HMA 2008, pg ix).Tasmania has also followed this disturbing trend. From the graph below we can see that,like in the other states methadone prescribing has not only increased but is the highest.
Figure 3 ABC News, 2012While we are on different continents the overall picture of illicit drug use is similar as theEMCDDA report 2011 pg 14, suggests that there is growing concern, in North Americaand internationally surrounding the issue of prescription opioids particularly painkillersbeing misused and their availability and that the use of illicit synthetic opioids via thediversion of substitution drugs from drug treatment is a current trend.
Graph 6 Reynolds, 2011From graph 6 we can see overall opioid prescribing is escalating at alarming rates inTasmania. These figures are cause for great concern.Figure 4 The Mercury, 2012
Graph 7 Reynolds, 2012Table 4 shows the chosen top 3 out of 18 choices, response results of survey respondentswithin the ATOD community when asked where they believed there was significantunmet need for services in this sector in Tasmania. The top five are case management,outpatient detoxification, medicated detoxification, residential rehabilitation that is lessthan 35 days and pharmacotherapies.Table 4 Perceived need for Specialist Alcohol, Tobacco, and Other Drugs in Tasmania HMA 2008, pg 67
This is further confirmed by Hinton, whose research outlines that: What workers wanted to see was a case management system which was able to join all the services up together – mental health, alcohol and drug services, accommodation and family support (Hinton 2008, pg 53).Figure 5 Our State of Dependence The Mercury, 2012
4.0 OutcomesSaleebey highlights the importance of working from a strengths based perspective, whichhas true relevance with ATOD clientele. Strengths are all we have to work with. The recognition and embellishment of strengths is fundamental to the values and mission of the profession. A strengths perspective provides for a levelling of the power relationship between social workers and clients. Clients almost always enter the social work setting in a vulnerable position and with comparatively little power. Their lack of power is revealed by the very fact that they are seeking help and entering the social structure of service (Saleebey 1997, pg 63).Figure 6 How to reduce opioid overdose deaths in Australia The Conversation, 2012An independently funded consumer led advocacy group would assist in ameliorating thedeficits in the current ATI model and whilst this type of service is commencing fromground zero in this state it would aid in the recovery process and in time offer a co-ordinated approach for consumer involvement, participation and empowerment.
Tasmania is the only state of Australia without a consumer led organisation. Stigma anddiscrimination are barriers to consumer participation. ‘Stigma is experienced as social,vocational, and recreational barriers in the community due to widespread ignorance andmisunderstanding that reinforces shame and isolation’ (NSW Dept of Health 2007, pg 5).Figure 7 Oprah Quote Positive Motivation, 2012Different studies on drug trials show promising results in relation to naltrexone implants,buprenorphine implants and suboxone in an electronic device and futuristically thesecould assist with compliance, cravings, relapse and treatment diversion. (EMCDDA2011, pg 79). Tasmania could be well placed to avail itself of these newer drugs toameliorate these issues in the community here. However, new technology usually attractsoptimal pricing and treatments would need to be cost effective. Due to Tasmania havinglarge rural areas, which are under serviced in this sector, as a state we need to have ourown solution not a ‘one size fits all’.The fact that engagement with this community was so difficult re-enforces the need foran independently funded consumer lead advocacy group as they have no voice currentlyand how can we provide positive outcomes without hearing their voice.
5.0 SummaryFunding is a key component to achieving positive results in the ATOD community onbehalf of and with clients. Each dollar is important and in the interests of good publicpolicy and accountability the most effective methods should be applied to overcomingexisting and on-going problems faced by this community. As a society, we need to askourselves the question of ‘is it enough to just get by?’ or should we, together, strivetoward the attainment of best practice goals that encompass holistic solutions and realoutcomes for clients in the ATOD sector. The strengths perspective requires trust,positivity and a strong emphasis on personal engagement. The health issues related to theATOD and mental health sector may question the validity of using the strengthsperspective in this community however Saleebey again shows us the importance of thisapproach in relation to abilities; A strengths orientation implies increased potential for liberating people from stigmatising, diagnostic classifications that promote “sickness” and “weakness” in individuals, families and communities. A strengths perspective of assessment provides structure and content for an examination of realizable alternatives, for the mobilization of competencies that can make things different, and for the building of self –confidence that stimulates hope (Saleebey 2007, pg 63) Consumer led involvement draws on this perspective. Governments, CSO’s, stakeholdersand policymakers can be informed and guided by evidence that working alongside clientsis proven to have better, cost efficient outcomes. A considerable amount of interlocutorswithin Australia are requesting prioritisation of evidence-based policy that is cost andintervention effective. Having reviewed some of the available reports and literature, thesuggestion is that there is stigma and discrimination, fear of engagement, from this clientbase and a strong medicalised/pathologising of the ‘weak’ or ‘sick’. Our suggestiontherefore is to include those marginalized in this process in solution-focused strategies. Aconsumer led independent of services advocacy group is part of that solution.An academic and sector worker with local and international experience, who also teaches,commented that alcohol, tobacco and other drugs work really, really well for client’s sothat as a worker, one must ensure that the work undertaken and the interventionsemployed are far superior to the effects of the substances used by clients. If one acceptsthat clients are the experts in their own lives especially when well, then the move towardclient involvement and inclusiveness will be a fruitful, justifiable one.The removal of stigma and discriminatory behaviour and policies along with furthereducation in all spheres is the way forward. The ATOD sector needs effective tools,effective workers, and effective systems to bring about change, empowerment, serviceuser involvement and participation. Clients have rights that need to be upheld. TheTasmanian community are deserving of interventions that make a positive cost effectiveimpact. An independent from services funded consumer led advocacy group in Tasmaniawould spearhead this change for better, effective services, for all interested stakeholders.
6.0 APPENDIX 6.1 APPENDIXNotice From the Department of Health and Human Services
6.3 APPENDIXSurvey Service User Survey The purpose of this survey is to measure the quality of service provided by St. Johns Park. Please check 1 Age: ____ Sex: ___Male ___Female ___Intersex Postcode:____________ Are you a current service user of St. John’s Park? (Circle one) Yes No How long have you been a service user of St. John’s Park? _____________ How would you rate their service? (On a scale of 1‐5, 1 being very poor and 5 being excellent) 1‐ very poor 2 – poor 3 – good 4 – very good 5 – excellent How would you rate staff at St. John’s Park? 1‐ very poor 2 – poor 3 – good 4 – very good 5 – excellent
Do you believe this is a non‐judgemental service? (Circle one) Yes No Unsure Do you feel that the Department of Health and Human Services impose their own values on you as a consumer of their services? (Circle one) Yes No Unsure If you had a preference, how would you like to receive your services? (Please circle one) Clinic (i.e. St.Johns Park) Local Pharmacy Private GP Other____________ For additional comments please use the space provided below: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ This survey ends 30/11/12. Thank you for taking our survey. If you would like to see the results of this survey results will be published at www. Dec. 7, 2012, at http://stjpsurvey.wordpress.com/ This survey is also available online at: http://stjpsurvey.wordpress.com/
Survey Disclaimer – Confidentiality and Privacy This research project guarantees respondent confidentiality. We conform to all aspects of the Ethics Code of the Australian Community Workers Associations Code of ethics. Most importantly, we guarantee that we will honor the Confidentiality clause of the Ethics Code, namely "The welfare and community worker shall regard all information concerning clients disclosed in the course of practice as confidential, except where: With the client’s permission referrals are to be made and other professional consultation is sought; Failure to disclose information would breach the terms of the welfare worker’s employment (such exception must be notified to the clients)." All data will be used in a form that will make it impossible to determine the identity of the individual responses. That is, the survey responses will not be integrated, analyzed, or reported in any way in which the confidentiality of the survey responses is not absolutely guaranteed. All survey responses will be transferred to a secure, password-restricted server. Access to raw datawill be tightly restricted to only those individuals directly involved in data analysis. The PolytechnicStudent Advocacy Class members (PSAC) of the Clarence Polytechnic and TasCAHRD will retainthe sole ownership of all raw data.The survey report will be made available to the interested public at http://stjpsurvey.wordpress.com/.Hard copies of the report will be available by contacting the Polytechnic Student Advocacy Classmembers. Once data analysis is completed, a digital file of the raw data will reside with the PSAC. If furtherdata analysis becomes necessary, the PSAC will review the proposed data analysis to ensure itcomplies with the confidentiality policies listed above.If you have any questions about these policies, please email the project staff at email@example.com. Alternatively you can contact TasCAHRD at 62341242.
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