Substance Use

Disorders in
Australia
A/Prof Michael Baigent
Flinders University & Flinders Medical Centre,
Drug and Alcohol Services South Australia,
Board of Directors
beyondblue
the National Depression Initiative

Context the health system in Australia

Prevalence
Substance use management a quick tour

Australian Public Health Care

System

Where can patients with addictions

go for treatment?

Doctors working in addictions

Addiction specialists

Addiction medicine
Addiction psychiatry
Both

Doctor with a special interest

Doctor who works in a D&A setting
Academic (overlap with all of the above)

Table 5.2: Summary of lifetime drug use, people aged 14 years or older, 1993 to 2013 (per cent)

Evertried(a)

Drug/Behaviour

1993

1995

1998

Everused(b)

2001

2004

2007

2010

2013

Illicitdrugs(excludingpharmaceuticals)
Marijuana/cannabis

34.7

31.1

39.1

33.1

33.6

33.5

35.4

34.8

Ecstasy(c)

3.1

2.4

4.8

6.1

7.5

8.9

10.3

10.9

Meth/amphetamines(d)

5.4

5.7

8.8

8.9

9.1

6.3

7.0

7.0

Cocaine

2.5

3.4

4.3

4.4

4.7

5.9

7.3

8.1

Hallucinogens

7.3

7.0

9.9

7.6

7.5

6.7

8.8

9.4

Inhalants

3.7

2.4

3.9

2.6

2.5

3.1

3.8

3.8

Heroin

1.7

1.4

2.2

1.6

1.4

1.6

1.4

1.2

Ketamine

n.a.

n.a.

n.a.

n.a.

1.0

1.1

1.4

1.7#

GHB

n.a.

n.a.

n.a.

n.a.

0.5

0.5

0.8

0.9

Synthetic Cannabinoids

n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

n.a

1.3

New and Emerging Psychoactive

Substances

n.a.

n.a.

n.a.

n.a.

n.a.

n.a.

n.a

0.4

Injected drugs

1.9

1.3

2.1

1.8

1.9

1.9

1.8

1.5#

37.1

33.1

40.4

34.3

34.8

35.1

37.3

36.8

n.a.

12.3

11.5

6.0

5.5

4.4

4.8

7.7#

Tranquillisers/sleeping pills

n.a.

3.2

6.2

3.2

2.8

3.3

3.2

4.5#

Steroids(d)

0.3

0.6

0.8

0.3

0.3

0.3

0.4

0.5

Methadone/Buprenorphine(f)

n.a.

n.a.

0.5

0.3

0.3

0.3

0.4

0.4

Other opiates/opioids

n.a.

n.a.

n.a.

1.2

1.4

0.9

1.0

1.4#

Misuse of any pharmaceutical(g)

n.a.

14.5

14.9

8.8

7.7

7.5

7.4

11.4#

Illicituseofanydrug(h)

38.9

39.3

46.0

37.7

38.1

38.1

39.8

41.8#

Any illicit(e) excluding pharmaceuticals

Misuseofpharmaceuticals
Pain-killers/analgesics(d)
(d)

(d)

# Statistically significant change between 2010 and 2013.

(a) Question asked as 'Have you ever tried...' from 1993 to 1998. Tried at least once in lifetime.
(b) Question asked as 'Have you ever used...' from 2001 to 2010. Used at least once in lifetime.
(c) Included 'designer drugs' before 2004.
(d) For non-medical purposes.

(e) Illicit use of at least 1 of 12 drugs (excluding pharmaceuticals) in the previous 12 months in 2013; the number and type of drug used varied between 1993 and 2013.
(f) For non-medical purposes and did not include buprenorphine before 2007.
(g) Included barbiturates up until 2007; did not include methadone in 1993 and 1995; did not include other opiates from 1993 to 1998.
(h) Illicit use of at least 1 of 17 drugs in the previous 12 months in 2013; the number and type of drug used varied between 1993 and 2013.

Examination of opioid prescribing in Australia from 1992 to 2007

InternalMedicineJournal
Volume39,Issue10, pages 676-681, 11 MAY 2009 DOI: 10.1111/j.1445-5994.2009.01982.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1445-5994.2009.01982.x/full#f1

10

Children and adolescents in

Australia
Children 12 17 years old

90% never tried cannabis or illicit substances

75% tried alcohol

Patterns of Harmful Drug Use

Intoxication
e.g., violence, falls, road trauma, overdose
Regular use
e.g., liver disease, cancer
Dependence
e.g., withdrawal symptoms, social problems
Intoxicatio
n
Dependenc
e

Regular Use

12

Substance use disorders

12 month prevalence

Male (%)

Female (%)

Total (%)

Alcohol harmful

3.8

2.1

2.9

Alcohol dependent

2.2

0.7

1.4

Drug use disorder

2.1

0.8

1.4

Any substance use

disorder

7.0

3.3

5.1

Source: National Survey Of Mental Health and WellBeing 2007 (ABS 2008)

13

Prevalence of Substance use

disorders in previous 12 months
4

3.5

2.5

Males

Females
Total

1.5

0.5

0
Alcohol Harmful Use

Alcohol Dependence

DrugUse Disorder

NSMHWB 2007

14

Substance Use Disorders

12 month prevalence, NSMHWB 2007

15

Mental disorders
12 month co-morbidity

Anxiety
disorders
14.3%

9.7%

2.9%

2.2%

Affective
disorders
6.2%

18% with Aff dis had SUD

0.4%
0.7%
22% with SUD had Aff dis

1.0%
3.0%

12% with Anx dis have SUD

33% with SUD have Anx dis

Substance use
disorders 5.1%
source: NSMHWB 2007 (ABS
2008)

MBaigent
April 21, 2016

16

Multiple Drug Use

Common drug associations

Cigarettes and alcohol go hand in hand,

particularly with heavy use of either
Cannabis smokers are usually tobacco
smokers
Heroin users often take benzodiazepines;
nearly all heroin users are tobacco smokers
Heavy drinkers often use illicit drugs

17

Management of
Substance Use Disorders

Alcohol

Who provides?

GP, Non Gov Organisations, D&A services, Mental

Health services (sometimes)

Non-dependent - Brief interventions

Dependent

Detoxification in centres or hospital or home

Counseling
Specific therapies: CBT, 12SF, MI
Groups AA, SMART recovery groups
19

Treatment for problems with

Opioids

Dependent

GPs
Approved methadone prescribers
D&A services

Detox
Opioid substitution
Naltrexone (rarely)
Counseling (NGOs, D&A)
Therapeutic community
NA

20

Other pharmacotherapy
Combination therapy
Acamprosate and naltrexone - may be more effective than
monotherapy (RCT)
Acamprosate and antabuse (case reports, clinical experience)
Trials
Ondansetron - 5HT3 antagonist - type B alcohol dependence
Tompiramate - theoretically and based on case reports

SSRIs - mixed results - type B may drink more (fluoxetine)

Buspirone - helped those with social anxiety only

21

Heroin topics
1.
2.
3.

Australian Drug Policy

Withdrawal management
Maintenance pharmacotherapy

22

Australian National Drug

Policy

National Drug Policy since 1985 Reduce the harm of illicit drugs to Australian
Community
3components
1.

Supply reduction (customs, police, courts, prisons)

2.

Demand reduction (prevention)

3.

Harm reduction (treatments and risk reduction)

(NZsimilar)

24

Symptomatic relief of opioid withdrawals

Temazepam 10-30mg nocte

Metoclopramide 10mg tds
Loperamide
Ibuprofen or other NSAIDs for arthralgia
Clonidine (reduces autonomic features - abdo pain, nausea,
cramps, sweating, rhinorrhea) but is less effective for cravings
and aches.

Upwardly titrate according to severity of withdrawals from 50mcg test

100mcg tds or qid if <60kg; 150mcg tds or qid if >60kg day 1 -3
Reduce to nil in increments of 25% over the next 3 days.

25

Buprenorphine/naloxone in opioid
withdrawal
Short withdrawal regime (6 - 8 hours after last heroin use)
Day (inpatient regime). Split dose, begin once withdrawing.
1.
2.
3.
4.
5.

6mg
8mg
10mg
4mg
2mg

+ 4mg prn (except for day 5)

26

Methadone for heroin withdrawal

Generally not well tolerated

Start with 20 -30 mg
Reduce evenly over predicted period

27

Maintenance or
substitution treatment
for Opioid dependence

Methadone induction and maintenance

Outpatient treatment
Begin low and review frequently
10 20mg; + 10mg on review 4-6 h later; never greater than
30mg on day 1
Dose accumulates - only increase after 3- 4 days; max of 50mg
in first week
If not responding, increase monitoring, assess for other psych
problems
Gradual increase if need be by < 10mg per week. Most effective if
maintenance >80mg (range 60-120mg usu)
Level one evidence for efficacy: 50-75% heroin dependent are
retained in treatment at 12 months, half have ceased heroin

29

Methadone

Dose and duration

hold

Problems
nod
Diversion
Benzodiazepines

Aim

30

Methadone problems

cumulative dosing
diversion
LT nature and stigma
OD deaths
Acceptability
take aways
QT prolongation (ECG if dose > 120mg/day)

31

32

Addiction clinic in the mosque

Doctor and religious counselor

Buprenorhine/naloxone induction

Similar outcomes and principles overall but

Wait until patient is clearly withdrawing before commencing

Beware of precipitated withdrawal especially if transferring from

methadone

Begin with 4mg if mild withdrawal, 8 mg if severe and increase if

necessary

12 mg should generally be aimed for by Day 3

Buprenorphine doses can be increased rapidly with safety.

Dose should not exceed 32 mg/day of buprenorphine.

Maintenance doses 12-24 mg (sometimes 32mg)

35

Buprenorphine problems

diversion value
Iv use

36

Buprenorphine/Naloxone
(Subutex)
naloxone has limited bioavailability orally (3-10%)
Naloxone works for 30-60 minutes if taken intravenously
Doses the same as for buprenorphine
Why prescribe?

1.
2.
3.
4.

For diversion minimalisation

37

Amphetamine type
stimulants

38

Methamphetamine Use
Pattern
(adapted from Whoa to Go Aust Comm Gov)

39

Psychiatric problems associated

with heavy methamphetamine use
1.
2.
3.
4.

Dependence
Induced psychiatric symptoms and co-existing psychiatric disorders
Sensitization
Brain changes

Damage to dopamine producing neurons

Loss of brain tissue

Inflammation

Changes to neuronal functioning, which are clinically measurable

leading to impaired inhibitory control.

40

Methamphetamine users and mental

illness
Amongst chronic methamphetamine users
Approx 50% are diagnosed with a mental disorder
40% are prescribed medications for mental illnesses
most (2/3) are diagnosed with mental illnesses after
their use began (average of 2 years later).
(Baker et al 2004)

41

Neurotransmitter functioning -

Positron Emission Tomography (PET)

(Volkow N et al 2001)

Michael Baigent June 2009

42

CANNABIS

43

Cannabis

Tetrahydrocannabinol (THC)

44

Low dose effects

Mood change
Sedation
Altered perception
Increased appetite, reduced nausea
Impaired memory, executive brain
functioning and co-ordination

45

Cannabis high dose effects

Increased anxiety and dysphoria

Paranoia and a range of psychotic
symptoms
negative symptoms (amotivation, apathy)
Cognitive impairment (esp verbal memory)
Exacerbation of symptoms of schizophrenia

46

Cannabis Intoxication

47

Cannabis dependence

THC elimination half life averages 35 hours (range 18 - 96 hours)

Withdrawal
Irritability
Appetite and sleep loss
Dependence/chronic intoxication
Cognitive
Negative
Positive
Time (weeks)

48