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Ms Katy Gallagher MLAACT [email protected]

ATODA Submission to the ACT Budget Consultation 2011 - 2012

Dear Minister Gallagher,

The Alcohol Tobacco and Other Drug Association ACT (ATODA) is the peak body representing the alcohol, tobacco and other drug (ATOD) sector in the Australian Capital Territory (ACT) and seeks to prevent and reduce ATOD related harms. ATODA works collaboratively to provide expertise and leadership in the areas of social policy, sector and workforce development, research, coordination, partnerships, communication, information and resources. ATODA is an evidence based organisation that is committed to the principles of public health, social justice and human rights.

ATODA congratulates the ACT Government for its ongoing commitment to engaging with the community to identify resourcing priorities through the ACT Budget consultation process. Please find attached ATODA’s submission that focuses on six ATOD funding priorities, including:

1. Reducing and preventing opioid overdose-related harms through increasing access to naloxone;

2. Preventing and reducing the transmission and infection of blood-born viruses (e.g. HIV/AIDS, hepatitis C and B) through conducting a needle and syringe program trial in the Alexander Maconochie Centre;

3. Supporting a viable ATOD sector and workforce by implementing the Working with Vulnerable People (Background Checking) Bill 2010;

4. Supporting quality improvement in healthcare through consumer participation; 5. Reducing tobacco-related harms through promoting healthy workplaces; and 6. Improving our support for people experiencing comorbid ATOD and mental health

issues through implementing key actions within the ACT Comorbidity Strategy.

As the peak body for the ATOD sector, ATODA stands ready to work with the ACT Government to identify, and support the implementation of, resourcing priorities to prevent and reduce ATOD related harms in the Canberra community.

Sincerely,

Carrie FowlieInterim Executive OfficerAlcohol Tobacco and Other Drug Association ACT

17 December 2010

ATODA Submission to the ACT Budget Consultation 2011 – 2012

Table of Contents

1. Introduction...........................................................................................................3

2. Summary of Funding Priorities to Prevent and Reduce Alcohol, Tobacco and

Other Drug Related Harm in the ACT...................................................................4

3. Funding Priority Areas...........................................................................................6

Priority 1: Increasing Access to Naloxone Trial.......................................................6

Priority 2: Needle and Syringe Program Trial at the AMC........................................7

Priority 3: Implementing the Working with Vulnerable People (Background Checking) Bill 2010....................................................................................................8

Priority 4: Enhancing Consumer Participation in the ATOD Sector.......................9

Priority 5: Community Sector NRT Grants Program and Prison Workplace Tobacco Management Project................................................................................10

Priority 6: Implementing the ACT Comorbidity Strategy.......................................12

4. Attachments........................................................................................................14

For further information about this submission, the ACT alcohol, tobacco and other drug sector or ATODA please contact:

email: [email protected]

post: PO BOX 7187 Watson ACT 2602

visit: 350 Antill St., Watson ACT

phone: (02) 6255 4070

web: www.atoda.org.au

ATODA Submission to the ACT Budget Consultation 2011 – 2012 2December 2010

http://www.atoda.org.au/

mailto:[email protected]

1. IntroductionATODA would like to thank the ACT Government for the opportunity to provide a submission to the ACT Budget Consultation 2011 – 2012. This submission is divided into 4 sections:

1. Introduction: Provides information about the Alcohol Tobacco and Other Drug Association ACT, and the process for developing this submission

2. Summary of Funding Priorities to Prevent and Reduce Alcohol, Tobacco and Other Drug Related Harm in the ACT

3. Funding Priorities 1 – 6: Provides information on the six resourcing priorities areas related to alcohol, tobacco and other drug issues

4. Attachments of proposals to implement some key initiatives.

1.2 About the Alcohol Tobacco and Other Drug Association ACT (ATODA)

The Alcohol Tobacco and Other Drug Association ACT (ATODA) is the peak body representing the alcohol, tobacco and other drug sector in the Australian Capital Territory (ACT).

ATODA works collaboratively to provide expertise and leadership in the areas of social policy, sector and workforce development, research, coordination, partnerships, communication, information and resources. ATODA is an evidence informed organisation that is committed to the principles of public health, social justice and human rights. ATODA participates in ACT and national government and non-government advisory structures and is funded by the ACT and Australian Governments. For further information please visit: www.atoda.org.au.

1.3 Process for developing this submission

The process for developing this submission has included:

Regular agenda items discussed since August with the ATODA Board, ACT ATOD Chief Executive Officers / Executive Directors Group; ACT ATOD Workers Group; ACT Comorbidity Strategic Working Group; and the General Practice Working Group;

Consultation forum in September 2010, focusing on progressing some key areas within the ACT Alcohol, Tobacco and Other Drug Strategy 2010 – 2014;

Consultation in October 2010; Consultation in conjunction with ACTCOSS at the ACT ATOD Chief Executive

Officers / Executive Directors Group meeting in November 2010; Draft proposals distributed to stakeholders for feedback; and, Regular meetings and discussions with members and stakeholders.


http://www.atoda.org.au/

2. Summary of Funding Priorities to Reduce and Prevent Alcohol, Tobacco and Other Drug Related Harm in the ACT

Area Initiative Description Funding

1 Overdose Prevention and Intervention

Increasing Access to Naloxone Trial

To reduce the incidence of death, disability, and injury from opioid overdoses in the ACT by conducting an overdose prevention program targeted at people who may be present at an opioid overdose, which includes an evaluated trial of the implementation of naloxone distribution.

$100,000 annually for 2 years

2 Preventing and Reducing Blood-Borne Virus Transmission and Infection

Needle and Syringe Program Trial at the Alexander Maconochie Centre

To prevent and reduce the transmission of blood-borne viruses (e.g. HIV/AIDS, hepatitis C and B), improve the safety of staff, and improve the health of prisoners by conducting a trial, which includes a feasibility study, of a needle and syringe program (NSP) in the Alexander Maconochie Centre (AMC).

$200,000 one-off for the trial

3 Alcohol, Tobacco and Other Drug Sector and Workforce Viability

Implementing the Working with Vulnerable People (Background Checking) Bill 2010

To work with the ACT Government to protect vulnerable people, to support vulnerable people to access employment, and to support the community sector to be viable and diverse by conducting an initiative to support the implementation of the Working with Vulnerable People (Background Checking) Bill 2010 within the alcohol, tobacco and other drug and mental health sectors.

$120,000

4 Healthcare Quality Improvement

Enhancing Consumer Participation in the Alcohol, Tobacco and Other Drug Sector

To improve consumer participation as a quality component of healthcare; by implementing a facilitated quality improvement project with alcohol, tobacco and other drug services funded by ACT Health to develop sustainable consumer participation strategies.

$150,000 annually

5 Workplace Health / Capacity Building

Community Sector NRT Grants Program

To establish a Nicotine Replacement Therapy (NRT) grants program that aims to provide quit smoking support to community sector employees and increase the capacity of community organisations to address tobacco issues (The grants are to purchase NRT to support smoking cessation

$50,000 annually


programs undertaken in community sector organisations that work with disadvantaged groups).

Prison Workplace Tobacco Management Project

A 12 month pilot project aimed at supporting tobacco management policies and at decreasing smoking rates among staff at the Alexander Maconochie Centre, as a step towards enhancing tobacco management with prisoners.

$200,000 for pilot

6 Improve service system capacity to respond to people experiencing comorbid alcohol, tobacco and other drug and mental health issues

Implementing the ACT Comorbidity Strategy

To increase understanding of comorbid care in the ACT by developing a tool to support appropriate referrals within the alcohol, tobacco and other drug and mental health sectors.

$40,000

To implement a universal screening tool with alcohol, tobacco and other drug and mental health services to improve the identification and treatment of people experiencing comorbidity.

$40,000

To increase the capacity of frontline workers to support people experiencing co-occurring alcohol, tobacco and other drug and mental health issues (comorbidity) in the ACT through an innovative workforce development initiative (ACT Comorbidity Bus Tours) delivered in partnership by three peak bodies utilising a cost-sharing model.

$20,000 annually

To support alcohol, tobacco and other drug and mental health workers to gain the knowledge and skills to identify and respond to people experiencing comorbidity through implementing accredited training.

$20,000 annually

To increase the levels of workplace tobacco management and smoking cessation support in the alcohol, tobacco and other drug, mental health, youth and allied sectors through the expansion of the Workplace Tobacco Management Pilot Project.

$200,000 annually


3. Funding Priority AreasPRIORITY 1: Increasing Access to Naloxone Trial

Overdose Prevention and Intervention:Increasing Access to Naloxone Trial

Opioid overdose is a continued and substantial contributor to death, disability, and injury among individuals who misuse opioids in the ACT. Since 2000, reduced heroin availability has drastically reduced the number of fatal and non-fatal heroin overdoses in Australia. However, this period has also seen a substantial increase in the number of prescriptions for pharmaceutical opiates, such as MS Contin and OxyContin. The diversion of these pharmaceutical opiates, and their use in conjunction with other depressant drugs, such alcohol, benzodiazepines, and heroin are leading to an increase in the number of opiate-related overdoses in Australia. In the first six months of 2010, the ACT Ambulance Service responded to more than 40 suspected heroin overdoses. However an ambulance is only called to a minority of overdoses.

If warnings of an influx of heroin into Australia over the coming years prove to be warranted, fatal and non-fatal opioid overdoses are likely to increase. Consequently, it is in the interests of the ACT Government and community to implement strategies to reduce opioid overdoses now, so they can be evaluated and refined before the number of overdoses increases further.

Naloxone (Narcan ©) is an opiate antagonist used specifically to reverse the effects of opioid overdose. It is widely used in Australia and internationally by paramedics and emergency room staff in cases of suspected opioid overdose. It is usually administered intramuscularly in pre-hospital settings. It has no psychoactive effect, is not a drug of dependence, and therefore, is not a substance which is likely to be diverted or misused. The argument for a trial of wider distribution of naloxone stems from findings that show that:

People who inject drugs commonly experience overdose; Overdoses are often witnessed by people who can respond; Peers, family members and others can successfully respond to assist in the

management of overdoses among people who inject drugs; and, Peers and family members are keen to respond to overdoses if they occur.

Initiative: Increasing Access to Naloxone Trial

Area: Overdose Prevention and Intervention

Description: To reduce the incidence of death, disability, and injury from opioid overdoses in the ACT by conducting an overdose prevention program targeted at people who may be present at an opioid overdose, which includes an evaluated trial of the implementation of naloxone distribution.

Funding: $100,000 annually for a 24 month trial of the implementation of the program.

Details: See Attachment A, pg 14 for a full proposal including evidence, policy context and support for the initiative.


PRIORITY 2: Needle and Syringe Program Trial at the Alexander Maconochie Centre

Preventing and Reducing Blood-Borne Virus Transmission and Infection:Needle and Syringe Program Trial at the Alexander Maconochie Centre

Over 80% of all newly acquired hepatitis C infections in Australia and the vast majority in most Western countries are associated with injecting (illicit) drug use. Sharing injecting equipment is the primary manner in which blood-borne viruses (e.g. HIV/AIDS, hepatitis C and B) are spread in this population. Needle and Syringe Programs (NSPs) are one of the major components of Australia’s approach to reducing the spread to blood-borne viral infections among injecting drug users.

Each case of hepatitis C infection costs the Australian community and health services between $798 and $18,835 per year. NSPs in the ACT have been cost-effective at preventing the spread of blood-borne viruses, including hepatitis C. However, the substantial savings from NSPs in the community are being eroded by transmission of hepatitis C among a confined and identifiable population (i.e. prisoners).

The prisoner population should be targeted for interventions which reduce the risk of blood-borne virus infection. Prisoners who may contract hepatitis C in prison are generally released into the community within a relatively short period of time; such prisoners become a substantial contributor to the spread of hepatitis C in the ACT community.

Overwhelming evidence indicates that incorporating NSPs into prisons is safe and effective in reducing the risk of blood-borne virus transmission among prisoners, staff and the community.

Initiative: Needle and Syringe Program Trial at the Alexander Maconochie Centre

Area: Preventing and Reducing Blood-Borne Virus Transmission and Infection

Description: To prevent and reduce the transmission of blood-borne viruses (e.g. HIV/AIDS, hepatitis C and B), improve the safety of staff, and improve the health of prisoners by conducting a trial, which includes a feasibility study, of a needle and syringe program (NSP) in the Alexander Maconochie Centre (AMC).

Funding: $200,000 (estimate) for the implementation of a trial (including feasibility research with detailed consultation with all key stakeholders, trial implementation and trial evaluation). The recurrent costs of an NSP in the AMC would be significantly less. Due to the national interest of the initiative, additional funding may be identified to contribute to the costs of the trial.

Details: See Attachment B, pg 21 for a full proposal including evidence, policy context and support for the initiative.

PRIORITY 3: Working with Vulnerable People (Background Checking) Bill 2010


Alcohol, Tobacco and Other Drug Sector and Workforce Viability:Implementing the

Working with Vulnerable People (Background Checking) Bill 2010

The Working with Vulnerable People (Background Checking) Bill 2010 was tabled in the ACT Legislative Assembly in August 2010. ATODA supports appropriate and rigorous risk management practices to protect children and vulnerable adults, and acknowledges that social policy reform in this area is inevitably a balancing act.

Under the current proposed checking system, the objective of protecting vulnerable service users unnecessarily conflicts with the objectives of encouraging and maintaining diverse and experienced workforces. This is of particular concern given the recovery or peer-led support orientation of both the alcohol, tobacco and other drug (ATOD) and mental health sectors. The challenge for the proposed system is to ensure people are not penalised, in terms of their access to employment; for their past behaviour that bears little or no relevance to the risk they pose to the vulnerable people they may work with now or in the future.

The ACT Government originally estimated that the Screening Unit may be able to process 6,884 applications annually, based on 1% of the total applicants requiring complex case analysis. Over 80% of staff in some ATOD and mental health services could be significantly affected by this legislation. This disproportionate impact on the ATOD and mental health sectors requires proactive redress, particularly since processing each complex case could take up to 28 days – a delay that could cripple these workforces. Recruitment and employment practices will also require significant change processes, therefore; resources will be required to support both sectors to positively implement the legislation once it has been passed.

ATODA and the Mental Health Community Coalition ACT have been proactively engaging with the ACT Government and members of the ACT Legislative Assembly to highlight the significant impacts on the ATOD and mental health sectors and to identify strategies for constructively moving forward. The ACT Council of Social Service has also identified that the community sector will require targeted support and resourcing to implement this legislation.

Initiative: Implementing the Working with Vulnerable People (Background Checking) Bill 2010

Area: Alcohol, Tobacco and Other Drug Sector and Workforce Viability

Description: To work with the ACT Government to protect vulnerable people, to support vulnerable people to access employment, and to support the community sector to be viable and diverse by conducting an initiative to support the implementation of the Working with Vulnerable People (Background Checking) Bill 2010 within the alcohol, tobacco and other drug and mental health sectors.

Funding: $120,000 annually (estimate)

Details: See Attachment C, pg 30 for two implementation proposals.

PRIORITY 4: Enhancing Consumer Participation in the ATOD Sector

Healthcare Quality Improvement:


Enhancing Consumer Participation in the ATOD Sector

Consumer participation is a necessary component of any consumer focused alcohol, tobacco and other drug (ATOD) service delivery model for three primary reasons:

Active consumer participation leads to more accessible and effective health services;

Effective consumer participation in quality improvement and service development activities leads to better targeting and uptake of services; and,

Effective consumer participation facilitates participation by those traditionally marginalised by mainstream health services and therefore improves health outcomes across the community.

The importance of consumer participation in ATOD treatment services has been acknowledged through the implementation of an ACT Health funded client satisfaction survey for ATOD services; which will be implemented every 12 – 18 months. The success of consumer participation in health care settings is well known. However, the process for implementing consumer participation in ATOD treatment settings is not as well documented or funded. Although there has been a focus on consumer participation in primary health care settings in the past; ATOD treatment services have identified a need to improve levels of participation within treatment services.

The need for increased consumer participation in ATOD treatment services is identified as a priority in the ACT Alcohol, Tobacco and Other Drug Strategy 2010 – 2014, which articulates a need to move from a culture of complaint and review, to one that focuses on continuing improvement. Enhanced consumer participation within ATOD services will also strengthen the ATOD sector’s linkages with the mental health sector, as identified in the ACT Comorbidity Strategy.

An investment is required by the ACT Government to address the findings of the regular consumer satisfaction survey; reach its consumer participation policy commitments; and implement its broader policy commitments to the provision of quality health care in the ACT.

Initiative: Enhancing Consumer Participation in the Alcohol, Tobacco and Other Drug Sector

Area: Healthcare Quality Improvement

Description: To improve consumer participation as a quality component of healthcare; by implementing a facilitated quality improvement project with alcohol, tobacco and other drug services funded by ACT Health to develop sustainable consumer participation strategies.


Details: See Attachment D, pg 34 for a project proposal.

PRIORITY 5: Community Sector NRT Grants Program and Prison Workplace Tobacco Management Project

Workplace Health and Capacity Building:Community Sector Nicotine Replacement Therapy Grants Program


&Prison Workplace Tobacco Management Project

It is widely recognised that promoting health and wellbeing in the workplace contributes to happier, healthier and more productive employees and reduces business costs associated with illness, injury and absenteeism. The ACT Government has stated its commitment to workplace health promotion programs and resources that promote healthy lifestyles and reduce risk factors for chronic disease.

The ACT is a signatory of the National Partnership Agreement on Preventative Health (NPAPH), through the Council of Australian Governments (COAG), which aims to support all Australians to reduce their risk of chronic disease by embedding healthy behaviours in settings that include workplaces.

Disadvantaged people, and people who work with disadvantaged people, have higher rates of smoking than the broader community, with prison populations having a smoking prevalence that is over three times that of the general population and rising.

In December 2010, the Australian Government announced that Nicotine Replacement Therapy (NRT) is to be included on the Pharmaceutical Benefits Scheme (PBS), creating incentives for lower socioeconomic groups to access smoking cessation support. Similarly, employees of ACT Health can access NRT to assist them with their quit attempts and to comply with the ACT Health Smoke-free Policy. However, community sector workers (i.e. people working with disadvantaged communities in non-government organisations) do not have access to this support.

The Workplace Tobacco Management Pilot Project has demonstrated that there are higher rates of smoking within the community sector, with 51.5% of employees being current smokers in participating workplaces, than the broader Canberra community, of which 14.7% are current smokers.

The provision of NRT and positive engagement in workplace tobacco management policy development can be effective incentives for these smokers to access support and increase their knowledge and skills regarding tobacco management.

Reducing tobacco smoking in prisons has been identified as a policy priority nationally and within the ACT, including at the recent National Summit on Tobacco Smoking in Prisons and within the Evaluation of Drug Policies and Services at the Alexander Maconochie Centre. Anecdotal evidence suggests that the smoking rate of ACT prison staff is up to 65%.

Community sector workers need to be provided with access to NRT and support to allow them to reduce the harms from smoking and increase their knowledge and skills regarding tobacco management. Changing attitudes to smoking, and enhancing healthy workplace practices amongst community sector and prison staff is an integral first step towards implementing changes with the people they work with.

Initiative: Community Sector Nicotine Replacement Therapy Grants Program & Prison Workplace Tobacco Management Project

Area: Workplace Health and Capacity Building


Action 1: To establish a Nicotine Replacement Therapy (NRT) grants program that aims to provide quit smoking support to community sector employees and increase the capacity of community organisations to address tobacco issues (The grants are to purchase NRT to support smoking cessation programs undertaken in community sector organisations that work with disadvantaged groups).

Funding: $50,000 (estimate)

Details See Attachment E, pg 38 for a full proposal.

Action 2: A 12 month pilot project aimed at supporting tobacco management policies and at decreasing smoking rates among staff at the Alexander Maconochie Centre, as a step towards enhancing tobacco management with prisoners.


Details See Attachment F, pg 42 for a full proposal.


PRIORITY 6. Implementing the ACT Comorbidity Strategy

Improving our support for people experiencing comorbid alcohol, tobacco and other drug and mental health issues:

Implementing the ACT Comorbidity Strategy

The initiatives below are identified as priorities in the ACT Comorbidity Strategy. This Strategy clarifies directions and priorities for those working with people at risk of, or experiencing, both mental health problems and alcohol, tobacco and other drug problems (comorbidity).

The ACT Mental Health Services Plan 2009-2014 and the ACT Alcohol, Tobacco and Other Drug Strategy 2010 - 2014 recognise that working with people with comorbidity is core business of both mental health and alcohol, tobacco and other drug services.

In addition to aligning the above policy context, the priorities identified below would be supported by the ACT Comorbidity Strategic Working Group, which is comprised of a range of key stakeholders including alcohol, tobacco and other drug and mental health treatment services, policy developers and allied stakeholders such as the ACT Division of General Practice, Youth Coalition of the ACT and Mental Health Community Coalition of the ACT. ATODA provides secretariat and support to this group.

Initiative: Implementing the ACT Comorbidity Strategy

Area: To improve service system capacity to respond to people experiencing comorbid alcohol, tobacco and other drug and mental health issues through the implementation of priorities identified in the ACT Comorbidity Strategy.

Action 1: To increase understanding of comorbid care in the ACT by developing a tool to support appropriate referrals within the alcohol, tobacco and other drug and mental health sectors.


Details: See Attachment G, pg 45 for further details regarding this action item.

Action 2: To implement a universal screening tool with alcohol, tobacco and other drug and mental health services to improve the identification and treatment of people experiencing comorbidity.


Details: See Attachment H, pg 47 for further details regarding this action item.


Action 3: To increase the capacity of frontline workers to support people experiencing co-occurring alcohol, tobacco and other drug and mental health issues (comorbidity) in the ACT through an innovative workforce development initiative (ACT Comorbidity Bus Tours) delivered in partnership by three peak bodies utilising a cost-sharing model.


Details: See Attachment I, pg 48 for further details regarding this action item.

Action 4: To support alcohol, tobacco and other drug and mental health workers to gain the knowledge and skills to identify and respond to people experiencing comorbidity through implementing accredited training.


Details: See Attachment J, pg 50 for further details regarding this action item.

Action 5: To increase the levels of workplace tobacco management and smoking cessation support in the alcohol, tobacco and other drug, mental health, youth and allied sectors through the expansion of the Workplace Tobacco Management Pilot Project.


Details: See Attachment K, pg 51 for further details regarding this action item.


4. Attachments

Attachment A:Increased Access to Naloxone Trial Proposal

A1. Proposal

To reduce the incidence of death, disability, and injury from opioid overdoses in the ACT by conducting an overdose prevention program targeted at people who may be present at an opioid overdose, which includes an evaluated trial of the implementation of naloxone distribution.

A2. Background and Rationale

Opioid overdose is a continued and substantial contributor to death, disability, and injury among individuals who misuse opioids in the ACT. Since 2000, reduced heroin availability has drastically reduced the number of fatal and non-fatal heroin overdoses in Australia.1 However, this period has also seen a substantial increase in the number of prescriptions for pharmaceutical opiates, such as MS Contin and OxyContin. The diversion of these pharmaceutical opioids, and their use in conjunction with other depressant drugs, such alcohol, benzodiazepines, and heroin are leading to an increase in the number of opiate-related overdoses in Australia.2 In the first six months of 2010, the ACT Ambulance Service responded to more than 40 suspected heroin overdoses. However an ambulance is only called to a minority of overdoses.3

If warnings of an influx of heroin into Australia over the coming years4 prove to be correct, the incidence of fatal and non-fatal opioid overdoses is likely to increase. Consequently, it is in the interests of the ACT Government and community to implement strategies to reduce opioid overdoses now, so that preventive interventions can be evaluated and refined before the number of overdoses increases further.

A3. Increased availability of naloxone to reduce overdose deaths

Since the 1990s, there have been repeated calls from researchers, public health professionals, advocates, and user groups to initiate trials allowing heroin users, their peers, and family members with access to naloxone for use in instances of heroin overdose.

Naloxone (Narcan ©) is an opiate antagonist used specifically to reverse the effects of opioid overdose. It is widely used in Australia and internationally by paramedics and emergency room staff in cases of suspected opioid overdose. It is usually administered intramuscularly in pre-hospital settings. It has no psychoactive effect, is not a drug of dependence, and therefore, is not a substance which is likely to be diverted or misused.

An Australian review of the literature on peer administered naloxone was undertaken by Lenton and Hargraves in 2000.5 They concluded that making naloxone available

ATODA Submission to the ACT Budget Consultation 2011 – 2012December 2010 14

to peers of heroin users showed promise in reducing the number of fatal overdoses as part of a comprehensive overdose response.

The Australian National Council on Drugs, in a series of position papers addressing heroin-related overdose, supported these claims and nominated a number of options to increase the availability of naloxone.6 One of these options was: “Distribute naloxone widely, for use by injecting drug users and their peers, families and friends.” However, due to the rapid decline in the number of heroin-related deaths since 2000, such attempts were not pursued. Anex, a national leader in public health, has recently released a position paper on naloxone distribution in Australia.7

The argument for the wider distribution of naloxone stems from findings that show that:8

People who inject drugs commonly experience overdose;7-8

Overdoses are often witnessed by people who can respond;9-10

Peers, family members and others can successfully respond to assist in the management of overdoses among people who inject drugs;11-12 and,

Peers and family members are keen to respond to overdoses if they occur.10

12-13

A4. Aims and Strategies

The primary aim of the program is to reduce opioid overdose-related morbidity and mortality, through:

Increased effectiveness of interventions in opioid overdose management; Provision of comprehensive overdose management training; Provision of take-home naloxone to identified program participants; and, Reduction in opioid overdose through overdose prevention education.

Additional expected benefits include a reduction in costs to the ACT health system through a reduction in ambulance call outs and a reduction in hospitalisation as a result of opioid overdose.

A5. Evidence of Effectiveness and Safety

Since 2000, international evidence has accumulated demonstrating that making naloxone available to appropriately trained injecting drug users, family members, and outreach workers can lead to successful overdose reversal with few, if any, adverse effects.9,10,11

A 2010 survey identified 155 programs operating in 16 states in the USA with 53,339 naloxone kits having been dispensed and 10,194 overdose reversals reported.12 Where evaluations of these programs exist, none of the major concerns raised by some commentators (e.g. unsafe administration of naloxone, problems with re-intoxication where longer acting opioids had been used, or more risky drug use if heroin was to be seen as less dangerous) eventuated.13 This evidence has led to renewed calls in Australia and the ACT to support wider access to naloxone.14,15

Australian experts in this field16 have identified that ‘peer’ and other wider naloxone distribution programs established overseas have clear evidence that:

Peers and non-medically trained professionals can be trained to administer naloxone for overdose reversal;12 14-18


People who come into contact with people experiencing opiate overdose can recognise the signs of overdose and administer naloxone appropriately;14

Naloxone that has been administered in the context of these programs has successfully reversed the effects of overdose; and, 12 15-17 19 20

Having naloxone as part of overdose response training assists those present to respond to overdose19 and helps engage otherwise hard to reach populations of drug injectors to contact service agencies.15

A6. Priority groups

Individuals who die from heroin overdose tend to be single, unemployed men aged in their late twenties and thirties, with a long history of dependence. Individuals not in treatment, those combining opioids with alcohol or benzodiazepines, and those with a recently depleted tolerance to opioids are also at elevated risk.17 These risk factors help to identify priority populations for opioid overdose prevention strategies in the ACT. These populations include: people exiting prison, people exiting opioid detoxification, people exiting opioid maintenance therapy, and Aboriginal and Torres Strait Islander injecting drug users.

A6.1 People exiting prison

People with a history of heroin dependence are at an elevated risk of overdose in the four weeks immediately following release from prison.18 This is because of a reduced tolerance to opioids following periods of abstinence or opioid maintenance therapies. Consequently, recently released prisoners are priority groups for interventions which reduce the risk of fatal and non-fatal opioid overdose. Making naloxone available to injecting drug users is one manner in which the risks of overdose after release from prison can be addressed.

Incorporating a comprehensive overdose prevention strategy for at-risk prisoners in the period prior to release, combined with increased access to naloxone among non-incarcerated injecting drug users, is likely to have an impact on the number of fatal opioid overdoses in this population.19 Any trial of increased availability of naloxone should consider targeting peers or family members of injecting drug users who are due for release from the Alexander Maconochie Centre and/or the prisoners themselves.

A6.2 Aboriginal and Torres Strait Islander Injecting Drug Users

The number of Aboriginal and Torres Strait Islanders who inject drugs is increasing as a proportion of the total injecting drug using population.20 Additionally, this group is less likely to be in treatment and more likely to be incarcerated than other injecting drug users.21 Aboriginal and Torres Strait Islander people are often at an elevated risk of overdose compared with other populations. Given this, Aboriginal and Torres Strait Islander people should be considered a priority group for any opioid overdose prevention program, including the provision of naloxone. Training individuals who have an understanding of Indigenous cultural practices and conventions and regular contact with Aboriginal and Torres Strait Islander injecting drug users may be able to help reduce overdose deaths, disability, and injury among this population.

A7. Policy Context

The program is:


Consistent with the principles of continuity of care emphasised in the ACT Adult Corrections Health Services Plan 2007 – 2010;

Consistent with initiatives being undertaken through the Alexander Maconochie Centre including the throughcare and evaluation of drug polices and services at the Alexander Maconochie Centre;

Consistent with and progresses Actions 20, 36, 50, 59 from the ACT Alcohol, Tobacco and Other Drug Strategy 2010 – 2014;

Consistent with and progresses Action 26 from the A New Way: The ACT Aboriginal and Torres Strait Islander Health and Family Wellbeing Plan 2006 – 2011;

Strategically aligned with the development of the National Pharmaceutical Misuse Strategy, as agreed to by the Ministerial Council on Drugs; and,

Consistent with the National Heroin Overdose Strategy that states “It is important to engage drug users in the development of strategies as this may enhance uptake and effectiveness, and accordingly drug users, and drug user organisations have an important role to play in this Strategy”.22

A8. Issues for consideration

A8.1 Comprehensive program to address overdose

A naloxone trial will need to be part of a comprehensive overdose prevention program, which will increase its effectiveness and result in fewer adverse events than may otherwise be the case.23,24 Comprehensive training programs for people who are provided naloxone will need to be developed and evaluated. Training programs can be modelled on those used in the USA by services such as the Chicago Recovery Alliance. Such a program will need, at a minimum, to address the following:

Risk factors and prevention techniques for opiate overdose; Signs and symptoms for the early recognition of opiate overdose; Prevention of choking and aspiration in the unconscious patient; Techniques for rescue breathing; Routes of administration and dosing guidelines for Naloxone; Blood-borne virus risks and universal precautions; Protocols for follow up care; Protocols for maintenance, safe storage, and replacement doses; and, Information and instructions on participating in an evaluation component of

program.

A8.2 Scheduling of Naloxone

Naloxone is a schedule 4 drug and therefore needs to be provided through prescription. Program participants could be provided with a prescription of naloxone that is to be administered to them by a third party. “Any schedule 4 drug can be prescribed for use with the primary restriction being that the drug will be used on the patient for whom the drug is prescribed in accordance with the doctor’s instructions.”25

If naloxone was re-scheduled in the future to schedule 3, this would remove the necessity for a prescription and allow over the counter availability. Re-scheduling naloxone from schedule 4 to schedule 3 could be achieved through ACT Health or a professional association making an application through the Therapeutic Goods Administration.26

A8.3 Duty of Care


Individuals who administer naloxone could place themselves at risk of criminal prosecution or civil liability. 27 Regardless of any need to legislate, clarification must be obtained as to any duty of care arising from administering naloxone in emergency situations and to define what standard of care is necessary, if any. Possible legislative options include the following:

Amendment to the ACT Civil Law Act 2002 - Remove the specific mention of ‘impairment by a recreational drug’ to ensure bystanders who administer naloxone are protected from liability under this Act;

New legislation that specifically addresses issues related to naloxone administration; and/or,

Amend current legislation to protect third parties who act in good faith administrating a life saving drug (Good Samaritan legislation). The United Kingdom has implemented such legislation.

A8.4 Community Acceptance

Making naloxone available to injecting drug users is consistent with an Australian culture of resuscitation. Increasing the availability of naloxone in the community is analogous to the introduction of public access defibrillators through Project HeartStart Australia28 or supplying persons with an allergy an epi-pen for use in case of an allergic reaction. Individuals should be promoted to act in ways that save lives, even when such actions incur some risks. The risks, in the case of naloxone, are minimal.

This pilot program would be the first in Australia to distribute naloxone with the intention of making it a permanent part of our community’s response to minimising the harms caused by opioids. Ensuring the support of the ACT community for the program is important. Several key stakeholders have expressed their support, including:

Specific General Practitioners (GP) have expressed interest in participating in the trial;

ACT Division of General Practice’s GP adviser for alcohol and other drug issues has given support;

Illicit drug users, user groups, peers and families; ACT Ambulance Service; Alcohol, tobacco and other drug treatment services; and, Researchers and technical experts.

The ACT Minister for Health has also stated:

“I am very keen to see a trial like this in the ACT. I think it makes an incredible amount of sense. And I think we are a community that would support a proposal like this.”29

A Committee has been established to drive the development and design of the proposed trial.

A9. Program Design and Evaluation


The program will include:

A governance model, including advisory structures; Training and education as part of a comprehensive response to overdose;

and, An evaluation, which can be informed by protocols that have been used in

other countries.

The evaluation would contribute to the evidence base both within the ACT, nationally and internationally.

A10. Funding Estimates

Preliminary estimates are that the initiative could be trialled for 24 months at a cost of $100,000 annually. This estimate includes:

$50,000 for a service to implement the program; and,

$50,000 for external research consultancy and evaluation of the trial.


Attachment B:Needle and Syringe Program Trial in the Alexander Maconochie Centre

B1. Proposal

To prevent and reduce the transmission of blood-borne viruses (e.g. HIV/AIDS, hepatitis C and B), improve the safety of staff, and improve the health of prisoners by conducting a trial, which includes a feasibility study, of a needle and syringe program (NSP) in the Alexander Maconochie Centre (AMC).

B2. Background and Rationale

Over 80% of all newly acquired hepatitis C infections in Australia and the vast majority in most Western countries are associated with injecting (illicit) drug use.30 Sharing injecting equipment is the primary manner in which blood-borne viruses (e.g. HIV/AIDS, hepatitis C and B) are spread in this population. NSPs are one of the major components of Australia’s approach to reducing the spread to blood-borne viral infections among injecting drug users.

Each case of hepatitis C infection, a blood-borne virus, costs the Australian community and health services between $798 and $18,835 per year.31 NSPs in the ACT have been cost-effective at preventing the spread of blood-borne viruses, including hepatitis C.32 However, the substantial savings from NSPs in the community are being eroded by transmission of hepatitis C among a confined and identifiable population (i.e. prisoners).

The 2007 Australian prison entrants blood-borne virus survey found that 35% of 740 consecutive prison entrants were HCV antibody positive, compared with 0.2% in the general Australian population.33

Prisoners have high rates of hepatitis C upon entry into prison.34 For most, this has resulted from unsafe injecting practices. Injecting drug use occurs in Australian prisons35 and continued injecting behaviours and the sharing of injecting equipment causes the transmission of hepatitis C among prisoners who continue to inject in prison36. NSPs reduce the rate of transmission of hepatitis C and other blood-borne viruses in this population.37

Prison staff safety is essential. The risk of punishment for possessing injecting equipment means that prisoners attempt to hide used syringes which places staff at risk of needle-stick injuries and contracting blood-borne viruses.38 The prohibition of injecting equipment also means that prisoners who do inject are at a greatly elevated risk of negative health outcomes. Syringes are often used many times, increasing the likelihood of blood-borne virus transmission among prisoners, and making a substantial contribution to the spread of blood-borne viruses throughout the community. The very fact that substantial numbers of prisoners continue to inject in prison demonstrates that appropriate treatment and support is not reaching many prisoners who need it most.39

This population should be targeted for interventions which reduce the risk of blood-borne virus infection. Prisoners who may contract hepatitis C in prison are generally released into the community within a relatively short period of time; such prisoners become a substantial contributor to the spread of hepatitis C in the ACT community.


The overwhelming evidence indicates that incorporating NSPs into prisons is safe and effective in reducing the risk of blood-borne virus transmission among prisoners, staff and the community.40

B3. Aim and Objectives

The primary aim is to reduce and prevent the transmission of blood-borne viruses and enhance the safety of staff through trialing an NSP that will make sterile injecting equipment available to prisoners. The objectives include:

1. To reduce blood-borne virus transmissions among prisoners, and as a consequence, the wider ACT community;

2. To improve the safety of staff by reducing the risk of needle-stick injuries and the contraction of blood-borne viral infections;

3. To improve prisoners’ engagement with health services to improve the rates of appropriate alcohol, tobacco and other drug (ATOD) treatment among substance misusing prisoners;

4. To reduce the social and economic costs of blood-borne viruses on prisoners, prison health services, community health services, and the general community;

5. To enhance the AMC’s human rights compliance; and,6. To reduce the exposure of the ACT Government to litigation for failing to

exercise its duty of care towards prisoners.

The trial will determine the feasibility of introducing and operating an NSP in the AMC and will evaluate its outcomes.

B4. Priority populations

B4.1 Prisoners who inject drugs

More than half of Australia’s prison entrants have a history of injecting drug use41 and nearly one-third test positive for the hepatitis C antibody.42 Many of these prisoners will continue to inject in prison.43 Data from NSW has found that 43% of females and 24% of males had injected drugs whilst in prison. Of those, 72% of females and 67% of males had reused the needle and syringe after someone else.44

Because the AMC is a relatively new facility, there is limited publicly available data on rates of blood-borne viral infections, injecting drug use, or the sharing of injecting equipment among inmates. However, and despite substantial efforts on the part of AMC staff; drugs and injecting equipment have been found in the AMC. The Chief Minister has said:

“I would accept, on the information that is available and on the knowledge that we have, illicit substances are still finding their way into Alexander Maconochie despite our best efforts and there is access through whatever illegal means to contraband within AMC.”45

Injecting drug use occurs in the AMC. Consequently, prisoners are almost certainly sharing injecting equipment. There has already been one documented case of a prisoner contracting hepatitis C during their imprisonment at the AMC. The Minister for Health has confirmed that a detainee contracted hepatitis C while in the AMC, less than one year after its opening.46


The first ACT Inmate Health Survey has been conducted (report yet to be released); and the Burnet Institute, commissioned by the ACT Government, is currently reporting on an Evaluation of Drug Policies and Services within the AMC. These reports will provide further information as to the current situation.

B4.2 Aboriginal and Torres Strait Islander Injecting Drug Users

The over-representation of Aboriginal and Torres Strait Islander people in Australia’s prisons is partly due to the high rates of alcohol and other drug misuse in these communities. Consequently, injecting drug use in prison may be major contributor to growing rates of hepatitis C infection among this population. 47

Aboriginal and Torres Strait Islander prisoners are more likely to have hepatitis C before entering prison than other prisoners and are also more likely to inject drugs in prison than other prisoners.48 Consequently, preventing the transmission of blood-borne viral infections in prisons may have a substantial impact upon improving the health of Aboriginal and Torres Strait Islander people.

B5. Evidence of Effectiveness and Safety

The arguments for introducing a NSP into the AMC are many and widely accepted by international and domestic bodies, health professionals, and the ACT Government. The overwhelming evidence indicates that incorporating NSPs into prisons is safe and effective in reducing the risk of blood-borne virus transmission among prisoners, staff and the community.49

Prison NSPs are cost-effective, safe, and endorsed by international and domestic bodies. They have been introduced in 12 countries, where they have been the subject of extensive evaluation. The results demonstrate that prison NSPs can:

Reduce rates of needle stick injuries among corrections staff and reduce the likelihood of contracting a blood-borne virus among those who do sustain a needle-stick injury;

Reduce the rate of blood-borne viral transmission among prisoners who inject drugs in prisons; and,

Improve the uptake of appropriate treatment among people who inject drugs in prisons. 50,51,52,53,54

The ACT Minister for Health has stated:

“From a health point of view, it is a no-brainer; you have a Needle and Syringe Program in the jail as soon as you can.”55

Prison staff’s attitudes to NSPs in prisons have been generally positive once they have been implemented. In a 2004 review of NSPs in European countries, the World Health Organization found that not a single case of syringes being used as weapons by inmates had been reported.56 In Australia, there has been only one reported case, in 1990, in which a prison officer was assaulted with a syringe. However this occurred when there were no NSP facilities available in the prison. Evaluations of Needle and Syringe Programs in overseas prisons have shown that they do not increase drug consumption or injecting and they effectively reduce needle sharing.57 Additionally, there have been no documented cases of adverse events from NSPs in prisons anywhere in the world, making NSPs in prisons a safe health intervention.


B6. Safety guarding the community from blood-borne virus infection

The National Drug and Alcohol Research Centre’s technical report 112 reviewing international research and program development for prison-based syringe exchange programs concludes the following:58

“The rationale for establishing syringe exchange programs in prisons is even stronger than in communities. This rationale is accepted by an impressive number of prestigious bodies… Because of the rapid turnover of inmate populations, spread of blood borne viral infections among prisoners cannot be considered to remain for long within the confines of correctional facilities. There is increasing evidence that experience of incarceration is a strong predictor of HIV and hepatitis C infection.”

The authors elaborate:

“The failure to reduce the risk of hepatitis C and other blood borne viral infection transmission in prisons severely undermines the work being conducted in the community with injecting drug users.”

B7. Improve the uptake of ATOD health services by prisoners

Prison drug treatments are effective in reducing substance misuse and their associate risk behaviours.59 However, for these treatments to be effective, prisoners in need must first access these services. Alcohol, tobacco and other drug (ATOD) assessments of prisoners cannot guarantee that prisoners with ATOD issues are identified and appropriately treated.60 Additionally, the risk of punishment for engaging in drug use in prison, or possessing injecting equipment, ensures that some prisoners will intentionally avoid contact with needed AOD treatment services. Consequently, there is a need to promote engagement with health services among prisoners with problematic AOD issues. NSPs in the community are a primary point of contact between injecting drug users and AOD treatment services. This can also be the case in custodial settings,61 so long as this effort does not act as a barrier to prisoners accessing the NSP.

B8. Enhancing the Human Rights Compliance of the AMC

Developing a human rights culture in the ACT is a progressive process which builds upon the Territory’s previous success. The AMC is a unique opportunity to develop a truly human rights compliant prison. Currently, prisoners are not afforded the same standard of healthcare made available to them in the general community. Dr Helen Watchirs, ACT Human Rights Commissioner, suggests: “To deny protection against disease transmission in such a high-prevalence and closed population in prison may be viewed as inhumane.” 62

The ACT Human Rights Commission conducted two audits of the operation of the ACT’s corrections facilities in 2006 and 2007. One of the Commission’s recommendations was for a trial of an NSP, which was based on a prisoner's right to life, which includes protection from infectious diseases, as well as the right to the highest attainable standard of health.6364

B9. Support for a NSP in the AMC

A range of international bodies with responsibility for developing an international response to drugs and blood-borne virus transmission have indicated strong support for prison NSPs as one of many methods to reduce the spread of hepatitis and HIV/AIDS in prisons. These include the United National Office on Drugs and Crime,65


the World Health Organization, and the Joint United Nations Programme on HIV/AIDS.66

The Australian National Council on Drugs (ANCD), the primary advisory council to the Australian Government, appointed by the Prime Minister, has recommended:

“That each jurisdictional department responsible for the management of prisons and juvenile detention centres, in consultation with staff, health authorities and relevant community-based organisations, develop occupationally safe and culturally appropriate policies, protocols and procedures regarding the introduction of trial needle and syringe programs within at least one of its prisons and juvenile detention centres.”67

The National Hepatitis C Strategy 2010-2013 states:

“In view of the well documented return on investment and effectiveness of Australian community-based needle and syringe program, combined with the international evidence demonstrating the effectiveness of prison needle and syringe programs it is appropriate throughout the life of this strategy for State and Territory governments to identify opportunities for trialing the intervention in Australian custodial settings.”68

The ACT Human Rights Commission has recommended that:

"[a] pilot program for a needle and syringe exchange with provision for safe disposal of needles should be developed for the Alexander Maconochie Centre…"69

The ACT Chief Minister’s and the ACT Minister for Health’s comments, quoted above, further strengthen this support. Adding to that, the Attorney General has stated, "What we want to do is stop the spread of disease that comes from sharing needles.”70

The ACT Greens have called for the establishment of an NSP, developed a discussion paper and a consultation summary.71 Anex, an national leader in public health, has also recently released a paper supporting NSPs in prisons.72

B10. Policy Context

Trialing a NSP in the AMC is:

Consistent with the principles of the ACT Adult Corrections Health Services Plan 2007 – 2010;

Consistent with initiatives being undertaken through the Alexander Maconochie Centre including the evaluation of drug polices and services;

A recommendation from the ACT Human Rights Commission’s Human Rights Audit on the Operation of Correctional Facilities under Corrections Legislation; and the ACT Legislative Assembly’s Standing Committee on Health report 2003;

Consistent with and progresses Actions 19, 20, 29, 30, 57 from the ACT Alcohol, Tobacco and Other Drug Strategy 2010 – 2014;

Consistent with and progresses Action 26 from the A New Way: The ACT Aboriginal and Torres Strait Islander Health and Family Wellbeing Plan 2006 – 2011; and the recommendations from the Winnunga Nimmityjah Aboriginal Health Service report You do the Crime, You do the Time; 73

Part of a broader NSP program which is supported by the National Drugs Strategy, the National HIV/AIDS Strategy and the National Hepatitis C Strategy as part of a harm minimisation framework that is based on the three pillars of supply reduction, demand reduction and harm reduction.


B11. Issues for Consideration

B11.1 Addressing the concerns of some staff

Corrections Officers, their representatives, and ACT Corrective Services have concerns over the introduction of a trial NSP into the AMC. Their concerns to date have focused on issues of occupational health and safety (OH&S) for staff - the risk of needle-stick injuries and injecting equipment being used as weapons. The evidence states that:

“International experience has shown that regulated prison NSPs do contribute to institutional safety, and that they do not result in syringes being used as weapons. The introduction of prison-regulated and controlled NSPs would be consistent with efforts to comply with OHS principles, as well as the approved standards for corrections in Australia.”74

The ACT Minister for Health has said:

“From a corrections staff point of view—I have said this in these forums a number of times—it is more complex than that. Corrections staff have mixed and strongly held views around the commencement of a Needle and Syringe Program. It would be a brave new step. We would be the first jail in the country to head this way—not the first jail in the world but the first jail in the country.”75

Appropriate education and training to staff complemented by appropriate amendment to OH&S policies and practices will need to form part of a trial NSP. However, to maximise the potential benefits of a trial NSP, it will be necessary to have the support of staff.

ATODA believes that engagement by staff with the issues, evidence, and experiences of colleagues from prisons in which NSPs have been introduced will help to facilitate a change in mindset from one of opposition to one of engagement. Opportunities for key staff and representatives to investigate, first hand, the experiences of overseas prisons in which NSPs have been introduced should be considered. Additionally, all staff at the AMC would benefit from hearing the experiences of colleagues from overseas about the introduction of a NSP in their prison.

Extensive consultation with staff will need to be undertaken before, during, and after the introduction of a NSP. Incorporating staff into the implementation and evaluation process may help to develop a sense among staff of ownership over the trial.

B11.2 Legislative Issues 76

New legislation would need to be enacted by the ACT Legislative Assembly to allow a trial of the NSP to be implemented. There is nothing unusual about this. For example the ACT Public Health Act 1997 includes Part 3A: ‘Supply of Syringes’, authorising the Chief Health Officer to approve designated people to supply syringes for purposes of ‘preventing the spread of disease’ (s. 66C) (McDonald 1989) and this approval could be extended to people working in correctional centres.

Most, if not all Australian States and Territories, have removed the offence of possession of syringes for the purpose of self-administration of an illegal drug as a public health measure (Norberry 1997). In 2004, the Legislative Assembly passed the Drugs of Dependence (Syringe Vending Machines) Amendment Act to authorise a


trial of syringe vending machines in Canberra. These are all examples of legislative changes made to facilitate access to sterile injecting equipment as a public health measure.

Acts and/or regulations covering the operation of the Alexander Maconochie Centre (such as the Corrections Management Act) could also be amended to remove any barriers to the NSP, such as current offences relating to the possession and use of syringes. Other existing offences related to drugs would remain in force, including possession, cultivation, manufacture and supply. This mirrors the position in the Canberra community, where all these behaviours are criminal offences that coincide with an extensive community-based NSP without substantial conflict.

B12. Design and Evaluation

While it is premature to draw attention to any preferred model, the particular approach used in implementing a prison NSP should be sensitive to context, taking into account the local needs and opportunities of the AMC – including allowing sufficient time for program development and for trust building amongst stakeholders. The approach taken will depend, in part, on the objectives of the program and how health staff interact with the drug-using inmates. Overall, however, across the more than 50 prison NSPs currently operating, some for over a decade, five broad models have been described (Stöver & Nelles 2003). They are:

1. Syringe dispensing machines; 2. Hand-to-hand provision of injecting equipment by corrections health staff; 3. Hand-to-hand provision by the staff of external drug sector agencies; 4. Distribution by peer leaders/educators; and, 5. Various combinations of these.77

The trial would include a feasibility study, which would determine the strengths and limitations to the models available and determine the best way forward given the complex context of the AMC. The program will include a comprehensive evaluation, which will contribute to the evidence base both within the ACT, nationally and internationally.

B13. Funding Estimates

Preliminary estimates are that the implementation of the trial would cost $200,000. This would include:

1. Feasibility research including detailed consultation with all the key stakeholders;

2. Trial implementation; and, 3. Trial evaluation.

The recurrent costs of an NSP in the AMC would be significantly less. Due to the national interest of the initiative, additional funding may be able to be identified to contribute to the costs of the trial.


Attachment C:Implementing the

Working with Vulnerable People (Background Checking) Bill 2010

C1. Proposal

To work with the ACT Government to protect vulnerable people, to support vulnerable people to access employment, and to support the community sector to be viable and diverse by conducting an initiative to facilitate the implementation of the Working with Vulnerable People (Background Checking) Bill 2010 within the mental health and alcohol, tobacco and other drug (ATOD) sectors.

C2. Background and rationale

The Working with Vulnerable People (Background Checking) Bill 2010 (the Bill) was tabled in the ACT Legislative Assembly in August 2010.78 The purpose of the Bill is to reduce the risk of harm to vulnerable people by establishing a mandatory background checking and risk assessment system for people working with vulnerable people in the ACT.79

The challenge for the proposed system is to ensure people are not penalised, in terms of their access to employment, for their past behaviour that bears little or no relevance to the risk they pose to the vulnerable people they may work with now or in the future.

On the basis of current available information on the proposed system, ATODA and the Mental Health Community Coalition of the ACT (MHCC ACT) believe there could be potentially significant unintended consequences of the system on the ATOD and mental health workforces.

The ACT Government originally estimated that the Screening Unit may be able to process 6,884 applications annually, based on 1% of the total applicants requiring complex case analysis.80 Over 80% of staff in some ATOD and mental health services could be significantly affected by this legislation.81 This disproportionate impact on the ATOD and mental health sectors requires proactive redress, particularly since processing each case could take up to 28 days82 – a delay that could cripple these workforces.

Recruitment and employment practices will also require significant change processes, therefore; resources will be required to support both sectors to positively implement the legislation once it has been passed.

As the proposed checking system is the first in Australia to extend to people working with adult clients it is important the ACT Government use all the engagement mechanisms available to it to ensure it is the most effective way to move forward and has the support of the stakeholders to which it applies. It is particularly important to ensure engagement of those it may unintentionally negatively affect.

ATODA and the MHCC ACT have been proactively engaging with the ACT Government and members of the ACT Legislative Assembly to highlight the

ATODA Submission to the ACT Budget 2011 – 2012 ConsultationDecember 2010 27

significant impacts on our sectors and to identify strategies for constructively moving forward.83

C3. Recovery or Peer-Based Orientation of ATOD and Mental Health Services

Within a professional context, ATOD and mental health workers can often support service users to work though their own challenges through peer mentoring. Within these sectors peer support is widely recognised as a key part of effective service delivery. Individuals are often in a long-term (and perhaps life-long) recovery phase, and peer workers’ experiences of mental health or ATOD issues may be in the distant past, recent past, or an ongoing influence in their lives.

It is this recovery or peer-based orientation that can make individuals such empathetic and effective workers. In the context of the proposed checking system, it could render some workers and volunteers (or potential workers and volunteers) susceptible to a potentially unfair or arbitrary screening process, discrimination and disincentives to work in the field. This could undermine their employment prospects, impact on their personal recovery, and threaten the workforce capacity of key parts of the community sector.

C3.1 Treatment should not become a barrier to employment

For many people, their involvement with the criminal justice and / or care and protection systems comes at a time in their lives when they are experiencing significant mental health and / or problematic ATOD issues.

A Recovery Model now guides mental health policy direction in Australia and the ACT.84 In the ATOD sector the effectiveness of a range of drug treatments is widely acknowledged both within the broader community and the criminal justice system with a wide range of pre-sentencing and sentencing drug diversion programs operating across the country. The motivation behind both of these trends is the acknowledgement that with the right support individuals can and do recover from mental health and alcohol and other drug issues, and reclaim meaningful and valued roles as productive members of the community.

It is well documented that a high proportion of people in the criminal justice system have experienced problems with both mental health and ATOD use. Given the evidence supporting the effectiveness of both mental health rehabilitation and drug treatment options these issues in themselves should not become barriers to employment. Employment is also widely recognised as being fundamental to sustaining longer-term recovery for many of those who have experienced mental health and / or problematic alcohol and other drug issues in the past.

C4. About the Two Proposals

Below are two proposed ways forward that have been discussed by the ATOD and mental health sectors. The first proposal could be a way forward if the Bill is introduced without amendments previously called for by the ATODA and MHCC ACT. The second proposal could be a way forward if the Bill is introduced with some amendments called for by the ATODA and MHCC ACT.

C4.1 Proposal One (If the Bill is introduced without amendments)


If the Bill as it was introduced into the ACT Legislative Assembly on 26 August 2010 is passed without amendments, the key challenges for the ATOD and mental health workforces will include:

Continuing to recruit quality staff that assist them to effectively engage and provide quality services to people in the ACT community;

Supporting their existing workers, particularly people with lived experience to move through the checking process at the appropriate time; and,

Continuing to build a workforce that values lived experience.

MHCC ACT and ATODA expect to play a key role in supporting the ATOD and mental health sectors in implementing the proposed scheme.

The sector support program could include:

1. Seeking funding for ATODA and the MHCC ACT to work with treatment, support and education services to assist them to recruit and retain a sustainable, quality workforce. This role could include:

2. Establishment of a centralised information point for those interested in working in the sectors (across non-government and government services), which facilitates access to:

Service delivery information; Opportunities to meet with a range of service providers; Opportunities to undertake training; Pathways for people coming into the sector with differing levels of

experience and qualifications; and, Tips for working with the Centralised Intake Unit (e.g. how to access

clinical and other assessments to provide evidence of recovery to accompany applications to the Intake Unit).

3. Seeking funding to develop resources and information packs for employers about ways to support existing and future staff through the system.

4. Working with the Intake Unit to establish an independent clinical panel that all applicants could access free of charge to gain clinical assessments to provide evidence of recovery to accompany applications.

5. Undertaking an evaluation monitoring the impact of the new unit on our sectors, including on recruitment and resources required by employees. The evaluation could include:

Opportunities to profile prospective applicants (both future employees and current employees) with their consent and monitor the process and outcome of the assessment process; and,

Opportunities to work with the Intake Unit to assist them to undertake their own evaluation of the system.

C4.1.1 Funding Estimates

Preliminary estimates indicate that the initiative would cost $120,000 annually.

C4.2 Proposal Two (If the Bill is passed with amendments)


Should the bill that has been introduced into the ACT Legislative Assembly in December 2010 be amended in line with ATODA and the MHCC ACT’s recommendations85 to exclude ATOD, mental health, and services delivered in a corrections environment:

Part of the legislation: Proposed amendments:Schedule 1Part 1.2Section 1.7Activities or services for vulnerable people(p. 59)

Remove sections1.7 Mental Health1.11 Justice Facilities1.14 Services for the addictions

ATODA and MHCC ACT will work with the ACT Department of Disability, Housing and Community Services (DHCS) with a view to establishing a model to improve the management of risks for employers of those who work with vulnerable adults (e.g. a variation on the NSW model for working with children checks).

If other amendments are made in line with our recommendations, we are committed to engaging with DHCS to building a system that balances the need to protect vulnerable children and adults with the need to build a strong and sustainable mental health and ATOD workforce that values lived experience.


Attachment D:Enhancing consumer participation in the ATOD sector

D1. Proposal

To improve consumer participation as a quality component of healthcare; by implementing a facilitated quality improvement project with alcohol, tobacco and other drug (ATOD) services funded by ACT Health to develop sustainable consumer participation strategies.

D2. What is consumer participation?

Consumer participation is broadly defined as “the process of involving health consumers in decision making about health service planning, policy development, setting priorities and quality issues in the delivery of health services.”86 Consequently, consumer participation can take many forms and occur to varying degrees at different stages of the service delivery process:

Participation in treatment and care; Employment of consumers by services as consultants and advocates; Participation in service delivery and evaluation; Participation in policy and planning; Participation in education and training; and, Participation in staff recruitment.87

D3. Rationale and Context

This proposal seeks to support the ACT Government to address the findings of the regular consumer satisfaction survey; as well as reach commitments related to consumer participation as it relates to the provision of quality health care in our community.

Consumer participation is a necessary component of any consumer focused ATOD service delivery model for three primary reasons:88

Active consumer participation leads to more accessible and effective health services;

Effective consumer participation in quality improvement and service development activities leads to better targeting and uptake of services; and,

Effective consumer participation facilitates participation by those traditionally marginalised by mainstream health services and therefore improves health outcomes across the community.89

The importance of consumer engagement in ATOD treatment services has been acknowledged through the implementation of an ACT Health funded client satisfaction survey for ATOD services; which will be implemented every 12 – 18 months.

The success of consumer participation in a range of health care settings has been well demonstrated. However, the process for implementing consumer participation in ATOD treatment settings is not as well documented or resourced. Although there has


been a focus on consumer participation in primary health care settings in the past; ATOD treatment services have identified a need to improve levels of participation within treatment services.

The need for increased consumer participation in ATOD treatment services is also identified as a priority in the ACT Alcohol, Tobacco and Other Drug Strategy 2010 – 2014, which articulates a need to move from a culture of complaint and review, to one that focuses on continuing improvement.

D4. Aim and Strategies

The overall aim of this proposal is to improve ATOD consumer health outcomes through the following objectives:

1. To work collaboratively with key stakeholders to increase consumer participation in alcohol, tobacco and other drug treatment services;

2. Increase the capacity of both consumers and service providers in undertaking consumer participation to inform policy development, service implementation and review processes;

3. Develop an ACT ATOD consumer participation policy (Action 33 in the ACT Alcohol, Tobacco and Other Drug Strategy 2010 – 2014);

4. Support the implementation of the findings from the ACT ATOD Client Satisfaction Survey (2009) and the development of the next survey; and,

5. Support services to meet their contractual requirements with ACT Health.

These objectives will be achieved through the following strategies:

1. Stakeholder mapping;2. Engagement with key stakeholders as potential collaborators;3. Establishing project governance, including advisory structures, which include

scope for consumer engagement; 4. Undertake literature review;5. Identification of pilot sites;6. Ongoing identification and dissemination of best practice tools and supports

for consumer participation in services;7. Conduct organisational and staff and consumer surveys;8. Undertake needs assessment;9. Develop individualised site workplans, with accompanying support from the

Project to implement consumer participation policies and practice;10. Develop and implement an evaluation framework;11. Determine the feasibility of including a research component (including ethics

approval); and,12. Engage research and technical expertise.

D5. Implementing Policy and Rights Commitments

This proposal seeks to strengthen the ACT Government’s commitment to consumer involvement in healthcare. This commitment is further articulated in the ACT Alcohol, Tobacco and Other Drug Strategy 2010 – 2014, which identifies the need to develop a specific policy framework for consumer participation in drug treatment services.

The project would also seek to support the Australian Charter of Healthcare Rights, established by the Australian Commission on Safety and Quality in Health Care in partnership with State and Territory Government. This national strategy framework


guides efforts in improving the health care system. The Charter defines participation as a key right to support people to be included in decision-making processes regarding health care.

Documentation accompanying the Charter further articulates the role of health care providers as responsible for maintaining policies that encourage and support consumers and their families to participate in decision making; planning and evaluation. The project would seek to support this work, and ensure services are at the fore of engaging consumers in treatment, policy development and review.

D6. Issues for Consideration

D6.1 ATOD service consumer equity, comorbidity, and misalignment of the service system

There have been significant investments in recovery orientated mental health services and consumer participation in ATOD allied sectors, such as mental health. The recovery model is part of Australian mental health policy.90 Recovery models include consumer participation and use of consumer-influenced evaluation criteria.

These investments have been reflected in both policy and targeted resources to support consumer participation and service improvement as part of quality healthcare. This investment has not been mirrored in the ATOD sector within the ACT or nationally – despite the ACT and national movements towards strengthening linkages between the ATOD and mental health services.

It is well documented that comorbidity (the co-occurrence of ATOD and mental health issues) is common (with rates of comorbidity ranging from 51 – 84%)91 in people presenting to ATOD services. However when an individual presents to ATOD services they are not provided with the same consumer participation opportunities or structures if they were to present to a mental health service. This represents a significant inequity for ATOD treatment services and consumers. It also represents significant systems barriers to implementing ACT Government priorities, such as the ACT Comorbidity Strategy.

This skew in the ACT health system requires redress and an urgent ‘catch-up’ investment for the ATOD sector.

D6.2 Sustainability

A key learning from Australian Injecting and Illicit Drug Users League (AIVL)’s national Treatment Service Users Project is that sustainability strategies need to be embedded at the beginning of the process when services engage in consumer participation development. Therefore, sustainability will be a core component in the design and delivery of the project.

D6.3 Aboriginal and Torres Strait Islander People

Consumer participation is likely to result in better targeting and uptake of ATOD services and to facilitate uptake by traditionally marginalised members of the community. This increased consumer participation in the ATOD sector is likely to have a substantial benefit for Aboriginal and Torres Strait Islander people and other ‘hard to reach’ population groups.


D6.4 Consumer Training and Support

A major barrier to increased consumer participation has been the belief that consumers do not have the capacity to contribute to the sector. A survey of consumers working in NSW Health or non-government organisations in NSW found:

“Many mental health consumers have been placed in the untenable position of being engaged in representation and/or advocacy roles with unclear job descriptions and no training... The rhetoric of consumer participation is not matched by effective and timely strategies that ensure that consumer involvement is underpinned by relevant training and supportive infrastructure. The goal of meaningful consumer participation in mental health services, as outlined in policy, is yet to be achieved.”92

Consequently, this project recognises that any attempt to increase consumer participation in the ATOD sector must be accompanied by the provision of adequate training and support to these consumers.

D7. Funding estimates

Preliminary estimates indicate that the project would require $150,000 annually.


Attachment E:Community Sector Nicotine Replacement Therapy Grants Proposal

E1. Proposal

To establish a Nicotine Replacement Therapy (NRT) grants program that aims to provide quit smoking support to their staff and increase the capacity of community organisations to address tobacco issues (the grants are to purchase NRT to support smoking cessation programs undertaken in community sector organisations that work with disadvantaged groups).

E2. Background and Context

On 1 May 2009 the ACT Health Smoke-free Work Place Policy was implemented. The Policy aims to reduce the health risks associated with smoking and exposure to environmental tobacco smoke in order to provide a healthy and safe workplace for all employees, patients, visitors and contractors. The new policy has three key elementsonly permitting smoking in designated smoking areas; access to smoking cessation programs; and NRT for staff and clients.

The Australian Government announced that NRT is to be included on the Pharmaceutical Benefits Scheme (PBS) creating incentives for lower socioeconomic groups to access smoking cessation support. Similarly, employees of ACT Health can access NRT to assist them with their quit attempts and to comply with the ACT Health Smoke-free Policy. However, community sector workers – working with disadvantaged communities – do not have access to this support.

E3. Rationale

Tobacco smoking is identified as a behavioural risk factor for chronic disease in the ACT Chronic Disease Strategy 2008-2011 and a key area of attention, in line with the burden of harms, in the ACT Alcohol, Tobacco and Other Drug Strategy 2010-2014. Further reductions in the prevalence of daily tobacco smoking will be difficult without specific attention and interventions directed at high prevalence sub-groups in the Australian community.93

Socially disadvantaged population groups bear a disproportionate share of the harms related to smoking. Community service organisations are able to engage with these hard to reach populations that have otherwise been resistant to smoking cessation initiatives, as they have trusted ongoing relationships with their clients and the skills needed to encourage positive change in their clients’ lives.

However, the people who work with disadvantaged people also have higher rates of smoking than the broader community. Community sector workers need to be provided with access to NRT and support to allow them to reduce the harms from smoking and increase their knowledge and skills regarding tobacco management.


E4. Aims and Strategies

The overall aim would be to establish a NRT grants program that aims to provide quit smoking support to their staff and increase the capacity of community organisations to address tobacco issues. The program would seek to:

Promote opportunities for uptake and access to smoking cessation programs for workers in the community sector;

Provide free access for workers to a maximum of four courses of nicotine replacement therapy (NRT) for the purposes of smoking cessation; and,

Promote the increase in knowledge and skills in the community sector regarding tobacco related issues.

The strategies could include:

Encouraging community sector organisations to include smoking cessation in their workplace;

Building the skills and confidence of community sector workers in supporting smoking cessation;

Supporting quit attempts and tobacco management amongst people who work with disadvantaged communities;

Providing communities sector workers with access to NRT;

Supporting the continuity and viability of ACT Health Smoke-free Workplace Policy in community sector non-government organisations;

Decreasing smoking amongst target populations-

o by decreasing the smoking rate (% of target population who smoke),

o by decreasing the amount smoked by those who continue to smoke,

o by preventing uptake of smoking; and,

Contributing to the evidence base in relation to measures effective in reducing exposure to environmental tobacco smoke and rates of smoking in target populations.

E5. Priority populations for decreasing smoking rates

Common features that span the sub-groups disproportionately affected by smoking are less education, unemployment, social isolation, interpersonal conflicts and being poorer.94 These conditions are key elements of the social determinants of health attributed as responsible for avoidable and unfair health inequities. Smoking contributes to and reinforces these social risk factors, compounding the likelihood of adverse health outcomes.

Certain population groups have a higher prevalence of smoking than the general population. The following groups have been identified as some of the priority population groups for decreasing the harms associated with smoking:

People living with a mental illness: Smoking rates amongst those with a mental illness are extraordinarily high when compared with the general


population. A recent study of psychiatric support service clients found that 62% were current smokers;95

Aboriginal and Torres Strait Islander communities: Tobacco use is the leading cause of premature morbidity and mortality among Aboriginal and Torres Strait Islander people. 50% of Indigenous adults reported being a regular smoker;

Illicit drug users: Estimate that 95% of people in alcohol and other drug treatment are current smokers.96 According to a 2007 survey of illicit drug users some 98% of ACT respondents identified as being current smokers;97 and,

Prisoners: Prison populations having a smoking prevalence that is over three times that of the general population and rising.98

These disadvantaged groups are less likely to attend community-based smoking cessation and health promotion programs99 and can experience marginalisation in mainstream settings.100

Akin to the broader population, different workplace environments and sectors have varying rates of smoking. Available evidence suggests that rates of smoking amongst workers in the community sector – the services and organisations that work with disadvantaged populations – are high when compared with the general population. This reflects and is linked to the issues regarding their clients, and highlights the significance of targeting workers.

E6. Promoting tobacco management amongst community sector workers

Improving the health and wellbeing of workers in the community sector who are seen to have higher rates of smoking than the broader community is a worthy goal in itself. However, the people that work with the disadvantaged groups outlined above are able to engage with these hard to reach populations that have otherwise been resistant to smoking cessation initiatives. Changing attitudes to smoking amongst community sector workers is an integral first step towards implementing changes amongst the people that they work with.

The workplace has been identified as a setting through which groups of smokers can potentially be reached by health promotions and to encourage smoking cessation101. Research has identified workplace smoking culture as a challenge to individuals trying to quit, undermining attempts to quit.102 Thus, including workplaces in smoke cessation initiatives would contribute to reducing the harms associated with tobacco smoke.

The Workplace Tobacco Management Pilot Project has demonstrated that there are higher rates of smoking within the community sector with 51.5% current smokers in participating workplaces, as opposed to 14.7% in the broader Canberra community. The provision of NRT has been an incentive for these smokers to access support and increase their knowledge and skills regarding tobacco management.

E7. Funding estimates

Preliminary funding estimates indicate that the program would cost $50,000 annually.


Attachment F:Prison Workplace Tobacco Management Project

F1. Proposal

A 12 month pilot project aimed at supporting the implementation of a Smoke-Free Workplace Policy and at decreasing smoking rates amongst staff at the Alexander Maconochie Centre (AMC), as a step towards enhancing tobacco management with prisoners.

F2. Rationale

Tobacco smoking is identified as a behavioural risk factor for chronic disease in the ACT Chronic Disease Strategy 2008-2011, a priority action within the ACT Alcohol, Tobacco and Other Drug Strategy 2010 - 2014 and the ACT Corrective Services Drug, Alcohol and Tobacco Strategy 2006 – 2008. This pilot would aim to:

Assist the Alexander Maconochie Centre to enhance and implement a Workplace Tobacco Management Policy building on the ACT Corrective Services Anti-Smoking Policy;

Decrease smoking amongst target populations-

o by decreasing the smoking rate (% of target population who smoke),

o by decreasing the amount smoked by those who continue to smoke,

o by preventing uptake of smoking; and,

Contribute to the evidence base in relation to measures effective in reducing exposure to environmental tobacco smoke and rates of smoking in target populations.

F3. Background

On 1 May 2009 the ACT Health Smoke-free Work Place Policy was implemented. The Policy aims to reduce the health risks associated with smoking and exposure to environmental tobacco smoke in order to provide a healthy and safe workplace for all employees, patients, visitors and contractors. The new policy has three key elements:

Only permitting smoking in designated smoking areas; Access to smoking cessation programs; and, Nicotine Replacement Therapy for staff and clients.

Tobacco smoking in prisons has been identified as a policy priority nationally and within the ACT, including at the recent National Summit on Tobacco Smoking in Prisons and within the Evaluation of Drug Policies and Services at the AMC.

ATODA Submission to the ACT Budget 2011 – 2012 Consultation 38December 2010

F4. Priority populations and targeted smoking cessation initiatives

F4.1 Smoking Prevalence in Prisons

Prisons are distinctive environments that include population groups with some of the greatest health needs in the community. Prison populations having a smoking prevalence that is over three times that of the general population and rising.103 Furthermore, the prison population is largely comprised of sub-populations with high rates of smoking, including:

People from lower socioeconomic groups; People living with mental illness; People affected by alcohol and other drug issues; and, Aboriginal and Torres Strait Islanders.

There are many factors specific to the prison environment and associated culture that further contribute to the high rates of smoking within prisons.104 Many people consume more cigarettes in prison than in the community and relapse when entering the prison after prolonged periods of cessation.105 Yet rates of quit attempts and the desire to quit is high amongst prisoners.

F4.2 Workplace Tobacco Management

Akin to the broader population, different workplace environments and sectors have varying rates of smoking. Anecdotal estimations suggest rates of smoking amongst workers within the AMC are around 65% compared to 14.7 % amongst the broader community in the ACT. The workplace has been identified as a setting through which groups of smokers can be potentially reached by health promotions and to encourage smoking cessation.106 Research has identified workplace smoking culture as a challenge to individuals trying to quit, undermining attempts to quit.107 Thus, including workplaces in smoke cessation initiatives would contribute to reducing the harms associated with tobacco smoke.

F4.3 Culture Change in the Workplace

Barriers to implementing tobacco management policies within any workplace are the attitudes, beliefs and misconceptions of staff, acting as an initial impediment to working with their clients, in this case, prisoners. Changing attitudes to smoking amongst workers in the AMC is an integral first step towards implementing changes in the prison culture more broadly. Many myths and misconceptions fuel fears associated with the introduction of smoke-free policies and practices.

The Workplace Tobacco Management Project has demonstrated that the initial reticence and fear of staff to develop and implement tobacco management policies can be tempered through consultation, education and the provision of support. Despite the pre-existing culture of smoking and high rates of current smokers in the project (51.5% of workplace employees) there were high rates of intention to quit but a lack of support. The provision of NRT has been an incentive for these smokers to access support and increase their knowledge and skills regarding tobacco management.

F5. Strategies


The AMC is a setting where tobacco education, counselling and treatment can be routinely offered so as to provide an opportunity to improve the health and wellbeing of those who smoke tobacco. However, the unique context and issues specific to this sector needs to be adequately addressed in order to reduce the rates of smoking. To be successful, tobacco management initiatives need to be implemented with thorough planning, consultation and communication so that staff support it. Equitable access to quitting support, advice and treatment and an understanding of some of the unique issues faced by these disadvantaged groups can help to break down the associations between tobacco and disadvantage.

The initiative as proposed could implement the following strategies:

Develop, implement and raise awareness of a workplace tobacco management policy;

Engage staff through surveys, focus groups and interviews to ensure their concerns and needs are addressed;

Foster ownership in the development of the tobacco management policy by clients, workers and services through collaboration and consultation;

Develop and implement effective smoking management strategies for corrections;

Promote opportunities for uptake and access to smoking cessation programs for workers and clients;

Coordinate approaches to information and skill sharing amongst corrections staff;

Provide free and equitable access for workers and clients to NRT for the purposes of smoking cessation or reduction;

Ongoing access for workers and clients to NRT for the purposes of smoking cessation or reduction;

Provide support and incentives for corrections staff wishing to quit smoking through education and information sessions; and,

Formative and summative evaluation to measure success and to contribute to the evidence base.

F6. Funding estimates

Preliminary estimates are that the initiative could be trialed for 12 months at a cost of $200,000.


Attachment G:Mapping ACT Alcohol, Tobacco and Other Drug and Mental Health Services on

a Continuum of Care and Developing a Tool to Support Referral

G1. Background and Rationale

An initial draft mapping of alcohol, tobacco and other drug (ATOD) and mental health services / programs in the ACT was progressed in 2010 by the ACT Comorbidity Strategic Working Group (see the policy and additional context section of this document for further information on the ACT Comorbidity Strategic Working Group). The mapping is based on the categories of care identified in the draft ACT Comorbidity Strategy of mild, moderate and severe to facilitate alignment and consistency.108

This mapping was progressed in response to the identified needs of ATOD and mental health sectors, and was identified through consultations with General Practitioners in the ACT.

Additional resources are now required to further progress the mapping, and develop a tool for utilisation by the ATOD, mental health, primary health and allied sectors to support referral. Reflecting this need, this further mapping and subsequent tool development is now identified under Strategic Priority 4 in the draft ACT Comorbidity Strategy109 as a means of ensuring the provision of integrated assessment, treatment and care.

The proposed further mapping would provide a framework for understanding the range of comorbid conditions and the level of coordination that service systems need to address them. The model also provides a structure for moving beyond minimal coordination to fostering consultation and collaboration among systems and providers in order to deliver appropriate care to every client with comorbidity.

G2. Aims and Strategies

The primary aim of the proposal is to increase understanding of comorbid care in the ACT, and provide a tool to support more appropriate referrals. This would be achieved through:

Undertaking a further mapping of comorbid care across ACT Health provided or funded alcohol, tobacco and other drug and mental health services in consultation with service providers;

Develop a tool that demonstrates the continuum of care for comorbid clients, and that can be utilised to support cross sectoral referrals; and,

Utilise the tool to encourage service collaboration; identify services gaps and opportunities for linkages; and, to progress strategic planning and service provision in the ACT.

G3. Program Design, Evaluation and Funding Estimates


The program will include a research and evaluation component that will contribute to the evidence base both within the ACT and nationally. Preliminary estimates are that the mapping and tool development could be undertaken over a 12 month project at a cost of $40,000.


Attachment H:Universal Screening Tool with ATOD and Mental Health Services

H1. Background and Rationale

It is important that all alcohol, tobacco and other drug (ATOD) workers are aware of mental health symptoms, and how these can be managed. Despite high rates of comorbidity among clients of ATOD services, it is not unusual for comorbid mental health conditions to go unnoticed. It is a recommendation of the Guidelines on the Management of Co-Occuring AOD and Mental Health Conditions in AOD Treatment Settings that ATOD treatment services should be screened and assessed for comorbidity as a component of comprehensive care.110

Additionally, the draft ACT Comorbidity Strategy identified the following priorities as a means to systematically identify and respond to comorbidity in a timely and evidence based manner:

Reviewing screen tools and improvements made to ensure services are utilising an accepted screening approach; and,

Implement a universal screening tool with ATOD and mental health services.111

H2. Aims and Strategies

The primary aim of the proposal is to implement a universal screening tool with ATOD and mental health services to improve the identification and treatment of people experiencing comorbidity. This could be achieved through:

Undertaking a review of screening tools utilised in ATOD and mental health government and non-government services;

Undertake a literature review and assessment of existing evidence based screening tools;

Engage services in determining the most appropriate tool for utilisation cross-sectorally, and any modifications that would need to be made to make the tool context relevant; and,

Disseminate the tool and provide associated professional development to support utilisation in the mental health and ATOD sector.

H3. Program Design, Evaluation and Funding Estimates

The program will include the development an evaluation framework to support the review and ongoing implementation of the screening tool. Preliminary estimates are that the initiative could be undertaken over a 12 month at a cost of $40,000.


Attachment I:Enhancing the ACT Comorbidity Bus Tours

I1. Background and Rationale

It has been identified through consultations with frontline workers that workers from the ATOD, mental health, youth and allied sectors have significant service system knowledge gaps. These knowledge gaps can lead to a range of issues including the lack of appropriate support, referrals, treatment and case management for people affected by comorbidity and related issues. In response to this, the ACT Comorbidity Bus Tours have been operating on at least a monthly basis since 2004 (through ACT Health, then the Youth Coalition of the ACT). The tours currently operate under a pilot partnership between ATODA, the Youth Coalition of the ACT and the Mental Health Community Coalition of the ACT. The tours run on a cost recovery basis under this pilot, as there is no existing funding for the tours – which are proving a significant barrier for some services. The partial funding of this sector development initiative would complement the workforce and sector development in the respective ATOD, youth and mental health sectors – including supporting the bus tours to become part of the induction process of the ATOD and mental health sectors as described in the ACT Comorbidity Strategy.112

I2. Aims and Strategies

The primary aim of this proposal is to increase the capacity of frontline workers to support people experiencing co-occurring ATOD and mental health issues in the ACT through an innovative workforce development initiative delivered in partnership by three peak bodies utilising a cost-sharing model. This would be achieved through:

Supporting bus tours to be equitably accessed by workers and services on a shared cost recovery basis;

Conducting up to 3 bus tours a month; Supporting the implementation of bus tours as part of induction for new

workers in the ATOD and mental health sectors; Demonstrating the diversity of services provided to support people

experiencing comorbidity; Supporting workers to engage in a greater understanding of the services that

they would frequently refer their clients to or engage with to support their clients;

Increasing the knowledge of frontline workers in ACT services supporting people experiencing comorbidity;

Providing opportunities for workers to network with workers who work with similar client groups;

Facilitating a partnership between the youth, ATOD and mental health peak bodies; and,

Providing an opportunity for host services to share information about their service model and referral pathways; and the common issues experienced by the clients who access their service.

I3. Program Design, Evaluation and Funding Estimates


Each tour will be evaluated by way of written and verbal feedback from participants and feedback will also be provided to host agencies. An evaluation framework and report would be developed annually. Preliminary estimates are that the initiative could be undertaken for $20,000 annually.


Attachment J:Improving Access to Accredited Training and Supernumerary Placements

J1. Background and Rationale

In recent years, the ACT alcohol, tobacco and other drug (ATOD) sector has been implementing a minimum qualification strategy to ensure workers have accredited credentials specific to their field, requiring the completion of units from the Certificate IV in Alcohol and Other Drug Work. This has been undertaken through an agreement between ACT Health and community organisations funded by ACT Health.

As much of the workforce has now achieved this minimum qualification, services have identified the need to support workers to access accredited mental health and comorbidity training as an emerging priority. This is reflected in the draft ACT Comorbidity Strategy which identifies the need to support workers from ATOD treatment services to complete core elements of the Certificate IV in Mental Health and undertake follow up supernumerary placements with a mental health service.113

Supported access to this accredited training, and follow up placements would help to better ensure that staff in ATOD treatment services have the knowledge and skills necessary to identify and respond appropriately to clients experiencing comorbidity.

J2. Aims and Strategies

The primary aim of this proposal is to ensure ATOD workers have the mental health knowledge and skills to identify and respond to people experiencing comorbidity. This would be achieved through:

Engaging and supporting the ATOD sector in the implementation of accredited mental health training;

Identifying, and making available, assessment and accredited training options;

Communicating information regarding the training and placements to the sector;

Formalising a partnership between the ATOD and mental health sectors to undertake supernumerary placements; and,

Identifying process and support requirements for supernumerary placements; and implementing as required.

J3. Program Design, Evaluation and Funding Estimates

The proposed project would be accompanied by an evaluation framework to assess quality and relevance of training and placements; and would inform the development of comorbidity professional development initiatives in the future. Preliminary estimates are that the initiative could be undertaken for $20,000 annually.


Attachment K:Expansion of Workplace Tobacco Management and Smoking Cessation in

ATOD, mental health, youth and allied sectors

K1. Background and Rationale

ATODA is currently funded by ACT Health to implement an 18 month pilot Workplace Tobacco Management Project (the Project) that aims to increase awareness of, and support the implementation of, workplace tobacco management policies and reduce the impact of smoking behaviours for the staff in nine programs within the mental health, alcohol, tobacco and other drug (ATOD) and youth sectors.

The Project is a collaboration between ATODA, as the lead agency, in partnership with the Mental Health Community Coalition of the ACT, and the Youth Coalition of the ACT; and includes a research component with ethics approval from the ACT Health Human Research Ethics Committee.

The original support and funding for this pilot project by ACT Health responds to the disproportionate effect of high smoking rates among disadvantaged groups, including those experiencing ATOD and mental health issues; and further, the disproportionate rates of smoking among workers of these treatment services.

Now in its 6 month of implementation, the success of the Project has been demonstrated through the implementation of workplace tobacco management policies in participating sites and high uptake of smoking cessation support by workers in participating sites.

The initial success of the Project scope and model is also reflected within the draft ACT Comorbidity Strategy which identified the need to improve access to a range of smoking reduction and cessation programs for clients and workers in ATOD and mental health services provided by both the community sector and ACT Health114.

The proposed expansion of the Project would ensure equitable access to tobacco management support across a range of ATOD treatment services (and additional identified stakeholders); and further support the implementation of ACT Health’s smoke-free policy.

K2. Aims and Strategies

The primary aim of this proposal is to increase the levels of workplace tobacco management and smoking cessation support in the ATOD, mental health, youth and allied sectors through the expansion of the Workplace Tobacco Management Pilot Project.

The Project aims to increase awareness of and support the implementation of Workplace Tobacco Management Policies and reduce the impact of smoking behaviours. This would be achieved through identifying a range of participating services in which to:

Communicate and provide information and resources to stakeholders, including those related to smoking behaviours and the ACT Health Smoke-free Policy;


Assist in the development of individual workplans for participating programs to support the development of tobacco management work place policies;

Support participating programs and individuals to implement their individualised workplans, including the implementation of smoke-free workplace policies; and,

Conduct evaluative activities to measure success and contribute to the evidence base.

K3. Program Design, Evaluation and Funding Estimates

The proposed Project would be accompanied by an evaluation framework; with a commitment to contributing to the evidence base regarding workplace tobacco management. Preliminary estimates are that the initiative could be undertaken for $200,000 annually.


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PHE 123, Australian Institute of Health & Welfare, Canberra.42 NPEBBV_RBS 200743 Loxley W, Carruthers S, Bevan J. (1995) In the same vein: First report of the Australian study of HIV and injecting drug use. Perth: Curtin University of Technology. Cited in Mogg D, Levy, M (2007) Moving beyond non-engagement on regulated needle-syringe exchange programs in Australian prisons. Harm Reduction Journal. 2009; 6: p. 7.44 Butler T, Milner L. (2003) The 2001 New South Wales Inmate Health Survey. Sydney. Cited in Mogg D, Levy, M (2007) Moving beyond non-engagement on regulated needle-syringe exchange programs in Australian prisons. Harm Reduction Journal. 2009; 6: p. 7.45 The Canberra Times (16 September 2010) p. 146 Legislative Assembly for the ACT (18 May 2010) Select Committee on Estimates 2010 – 2011, Canberra. Available online at: http://www.hansard.act.gov.au/hansard/2009/comms/estimates16.pdf47 National Indigenous Drug and Alcohol Committee (2009) Bridges and Barriers: Addressing Indigenous Incarceration and Health. Canberra: Australian National Council on Drugs.48 Australian Institute of Health & Welfare (2010) The health of Australia's prisoners 2009, AIHW cat. no. PHE 123, Australian Institute of Health & Welfare, Canberra.49 Lines R et al. (2005) Taking action to reduce injecting drug-related harms in prisons: The evidence of effectiveness of prison needle exchange in six countries. International Journal of Prisoner Health 1(1): pp. 49-64.50 Dolan K, Rutter S, Wodak, A.D. (2003) Prison-based syringe exchange programmes: a review of international research and development, Addiction, vol. 98, no. 2, pp. 153-8.51 Lines R, Jürgens R, Betteridge G, Stöver H, Laticevschi D, Nelles, J (2004) Prison needle exchange: lessons from a comprehensive review of international evidence and experience, Canadian HIV/AIDS Legal Network, Montréal, Québec.52 Niveau, G (2005) Prevention of infectious disease transmission in correctional settings: A review, Public Health.53 Stöver H, Nelles J (2003) Ten years of experience with needle and syringe exchange programmes in European prisons, International Journal of Drug Policy, vol. 14, no. 5-6, pp. 437-44.54 Rutter S, Dolan K, Wodak A, Heilpern H (2001) Prison-based syringe exchange programs: a review of international research and program development, NDARC technical report no. 112, National Drug & Alcohol Research Centre, Sydney, NSW.55 Legislative Assembly for the ACT (18 May 2010) Select Committee on Estimates 2010 – 2011, Canberra. Available online at: http://www.hansard.act.gov.au/hansard/2009/comms/estimates16.pdf56 Lines R, Jürgens R, Betteridge G, Stöver H, Laticevschi D, Nelles, J (2004) Prison needle exchange: lessons from a comprehensive review of international evidence and experience, Canadian HIV/AIDS Legal Network, Montréal, Québec.57 I. van Beek (2004) In the Eye of the Needle: Diary of a Medically Supervised Injecting Centre.

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58 Rutter S, Dolan K, Wodak A, Heilpern, H (2001) Prison-based syringe exchange programs: a review of international research and program development, NDARC technical report no. 112, National Drug & Alcohol Research Centre, Sydney, NSW.59 Hall W, Lucke, J (2010) Legally coerced treatment for drug using offenders: ethical and policy issues, Crime and Justice Bulletin no. 144, NSW Bureau of Crime Statistics and Research, Sydney.60 Butler T, Milner L (2003) The 2001 New South Wales Inmate Health Survey, Corrections Health Service, Sydney.61 Lines R, Jürgens R, Betteridge G, Stöver H (2005) Taking action to reduce injecting drug-related harms in prisons: the evidence of effectiveness of prison needle exchange in six countries, International Journal of Prisoner Health, vol. 1, no. 1, pp. 49-64.62 Speech by Dr Helen Watchirs (5 September 2009) Human Rights for Prisoners – the ACT Experience, ACT Human Rights & Discrimination Commissioner. NSW State Library, Sydney. Available online at: http://www.hrc.act.gov.au/content.php/content.view/id/194.63 ACT Human Rights Commission (2007) Human Rights Audit on the Operation of Correctional Facilities under Corrections Legislation. Canberra.64 Mogg D, Levy, M (2007) Moving beyond non-engagement on regulated needle-syringe exchange programs in Australian prisons. Harm Reduction Journal. 2009; 6: p. 7.65 United Nations Office on Drugs and Crime (2008) HIV and AIDS in places of detention: a toolkit for policymakers, programme managers, prison officers and health care providers in prison settings, United Nations Office on Drugs and Crime, Vienna.66 World Health Organization, United Nations Office on Drugs and Crime & Joint United Nations Programme on HIV/AIDS (2007) Interventions to address HIV in prisons: needle and syringe programmes and decontamination strategies, World Health Organization, Geneva.67 Australian National Council on Drugs (2002) Needle and syringe programs. ANCD Position Paper. ANCD, Canberra. Available online at: http://www.ancd.org.au/images/PDF/Positionpapers/pp_needle_syringe.pdf68 Department of Health & Ageing (2010) Third National Hepatitis C Strategy: 2010-2013, Australian Government Department of Health & Ageing, Canberra.69 ACT Human Rights Commission (2007) Human Rights Audit on the Operation of Correctional Facilities under Corrections Legislation. Canberra.70 Mogg D, Levy M (2007) Moving beyond non-engagement on regulated needle-syringe exchange programs in Australian prisons. Harm Reduction Journal. 2009; 6: p. 7.71 For further details see: http://act.greens.org.au/issues-2 72 Anex (2010) With conviction: the case for controlled needle and syringe programs in Australian prisons. Available online at: http://www.anex.org.au/downloads/HMPC%20Paper%20on%20NSP%20in%20Prison%20-%20October%202010.pdf 73 Poroch N (2007) You do the crime, you do the time: Best practice model of holistic health services delivery for Aboriginal and Torres Strait Islander inmates in the ACT prison. Winnunga Nimmityjah Aboriginal Health Service, Narrabundah, ACT.74 Ryan J, Voon D, Kirwan A, Levy M, Sutton. (2010) Prisons, needles and OHS. Journal of Health Safety and Environment. 2010;26(1): pp. 63-72.75 Legislative Assembly for the ACT (18 May 2010) Select Committee on Estimates 2010 – 2011, Canberra. Available online at: http://www.hansard.act.gov.au/hansard/2009/comms/estimates16.pdf 76 This section is an excerpt from McDonald, D. (2005) The Proposed Needle and Syringe Program at the Alexander Maconochie Centre, Canberra’s New Prison – An information paper on the evidence underlying the proposal. Canberra.77 This section is an excerpt from McDonald, D. (2005) The Proposed Needle and Syringe Program at the Alexander Maconochie Centre, Canberra’s New Prison – An information paper on the evidence underlying the proposal. Canberra.78 Legislative Assembly of the ACT (26 August 2010) Available online at: http://www.hansard.act.gov.au/hansard/2010/week09/4036.htm 79 Department of Disability, Housing and Community Services (Accessed 13 December 2010) Working with Vulnerable People Checks. Available online at: http://www.dhcs.act.gov.au/publications/wwvpc 80 Department of Disability Housing and Community Services (August 2009) Working with Vulnerable People Checks Discussion Paper. ACT Government. Canberra. p.5981 Based on sector consultations by ATODA and Mental Health Community Coalition ACT (the peak body for the community mental health sector in the ACT).82 Department of Disability Housing and Community Services (August 2009) Working with Vulnerable People Checks Discussion Paper. ACT Government. Canberra. p.5983 Several meetings have taken place and letters exchanged outlining ongoing concerns and proposed ways forward between ATODA & MHCC and the Minister for Community Services and DHCS since June 2010.84 Australian Government (2009) Fourth National Mental Health Plan: An Agenda for Collaborative Government Action in Mental Health 2009-2014. Canberra. ACT Mental Health Services Plan 2010 – 2014. ACT Government. 85 See ATODA and MHCC letters to Minister for Community Services, September & November 2010.

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86 Commonwealth Department of Health and Aged Care (1998) Consumer Focus Collaboration. Commonwealth of Australia: Canberra.87 These are identified in: Australian Injecting and Illicit Drug Users League (2008) Treatment Service Users Project: Final Report. AIVL: Canberra.88 These are identified in: Australian Injecting and Illicit Drug Users League (2008) Treatment Service Users Project: Final Report. AIVL: Canberra.89 Consumer Collaboration (2001). See Australian Injecting and Illicit Drug Users League (2008) Treatment Service Users Project: Final Report. AIVL: Canberra. p 25.90 Australian Government (2009) Fourth National Mental Health Plan: An Agenda for Collaborative Government Action in Mental Health 2009-2014. Canberra. ACT Mental Health Services Plan 2010 – 2014, ACT Government.91 National Drug and Alcohol Research Centre (2009) Guidelines on the management of co-occuring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings, University of New South Wales, Sydney, Australia.92 Stewart S, Watson S, Montague R, Stevenson C. (2008). Set up to fail? Consumer participation in the mental health service system. Australasian Psychiatry.

93 Baker A, Ivers R.G, Bowman J, et al (2006) Where there’s smoke, there’s fire: high prevalence of smoking among some sub-populations and recommendations for intervention. Drug Alcohol Review, 25: pp. 85–96.94 Baker A, Ivers R.G, Bowman J, et al (2006) Where there’s smoke, there’s fire: high prevalence of smoking among some sub-populations and recommendations for intervention. Drug Alcohol Review, 25: pp. 85–96.95 Moeller-Saxone K (2008) Cigarette smoking and interest in quitting among consumers at a Psychiatric Disability Rehabilitation and Support Service in Victoria, Australian and New Zealand Journal of Public Health, Vol. 32, no. 5, October 2008, pp. 479-481.96 Richter K (2006) Good and bad times for treating cigarette smoking in drug treatment. Journal of Psychoactive Drugs, Vol 38, no.3: 311-316. & Kerle C, Jago A (2005) A Non Smoking Policy in a 15 Bed Detoxification Unit, Australian Resource Centre for Healthcare Innovation. 97 Campbell G, Degendardt L. (2008) ACT Drug Trends 2007: Findings from the Illicit Drug Reporting System, Australian Drug Trends Series No. 3, NDARC: Sydney.98 Butler T, Milner L. (2003) The (2001) New South Wales Inmate Health Survey. Sydney, NSW Corrections Health Service. & Butler T, Papanastasiou C. (2008) National prison entrants’ bloodborne virus and risk behaviour survey report 2004 and 2007. National Drug Research Institute (Curtin University) and National Centre in HIV Epidemiology and Clinical Research (University of New South Wales).99 Australian Institute of Health and Welfare (2002) Australia’s health (2002), Canberra.100 Baker A, Ivers R.G, Bowman J, et al (2006) Where there’s smoke, there’s fire: high prevalence of smoking among some sub-populations and recommendations for intervention. Drug Alcohol Review, 25: pp. 85–96.101 Gruman J, Lynn W. (1993) Worksite and Community Intervention for Tobacco, In: (eds) Orleans C.T., Slade J. Nicotine Addiction: Principles and Management. New York: Oxford University Press, 1993: pp. 396-411 & Cahill K, Moher, Lancaster T. (2008) Workplace interventions for smoking cessation. Cochrane Database of Systematic Reviews, Issue 4.102 Reily P, Murphy L, Alderton D. (2006) Challenging Smoking Culture Within a Mental Health Service Supportively, International Journal of Mental Health Nursing, vol. 15, pp. 272-278.

103 Butler T, Milner L. (2003) The 2001 New South Wales Inmate Health Survey. Sydney, NSW Corrections Health Service & Butler T, Papanastasiou C. (2008) National prison entrants’ bloodborne virus and risk behaviour survey report 2004 and 2007. National Drug Research Institute (Curtin University) and National Centre in HIV Epidemiology and Clinical Research (University of New South Wales).104 Richmond R, Butler T, Wilhelm K, Wodak A, Cunningham M (2009) Tobacco in prisons: a focus group study, Tobacco Control, 2009 Vol 18: pp. 176-182105 Butler T, Milner L. (2003) The 2001 New South Wales Inmate Health Survey. Sydney, NSW Corrections Health Service106 Cahill K, Moher, Lancaster T. (2008) Workplace interventions for smoking cessation. Cochrane Database of Systematic Reviews, Issue 4 & Gruman J, Lynn W (1993) Worksite and Community Intervention for Tobacco, In: (eds) Orleans C.T, Slade J. Nicotine Addiction: Principles and Management. New York: Oxford University Press, 1993: pp. 396-411107 Reily, P, Murphy, L, Alderton, D. (2006) Challenging Smoking Culture Within a Mental Health Service Supportively, International Journal of Mental Health Nursing, vol. 15, pp. 272-278

108 ACT Health (2009) Draft ACT Comorbidity Strategy, unpublished. 109 ACT Health (2009) Draft ACT Comorbidity Strategy, unpublished.

110 National Drug and Alcohol Research Centre (2009) Guidelines on the management of co-occuring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings, University of New South Wales, Sydney, Australia. 111 ACT Health (2009) Draft ACT Comorbidity Strategy, unpublished.112 ACT Health (2009) Draft ACT Comorbidity Strategy, unpublished.113 ACT Health (2009) Draft ACT Comorbidity Strategy, unpublished.114 ACT Health (2009) Draft ACT Comorbidity Strategy, unpublished.

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