BACKGROUND AND AIMS:There is significant concern about potential rising harms from gamma-hydroxybutyrate (GHB) but an absence of studies internationally synthesising data across indicators to identify changes in harms and broader patterns of use. This paper contributes to addressing this gap by measuring national trends in GHB use, harms and treatment in Australia. DESIGN, SETTING, AND CASES:Triangulation of indicators (2013-2024) from Australian triennial population surveys; annual interviews with cross-sectional non-representative samples of people who use illicit stimulants or who inject drugs; and administrative data on GHB-related hospitalisations, GHB-related deaths, and treatment episodes where GHB was the principal drug of concern. MEASUREMENTS:Annual trend data were analysed using Joinpoint regression. Survey data were modelled as the annual percent change in the proportion reporting lifetime, past 12-month, and past 6-month use, depending on the survey. Administrative data were modelled as the annual percent change in crude rates per 100 000 population. FINDINGS:Lifetime and past 12-month GHB use in the general population remained below 1.2% and 0.2% respectively, but the latter increased from 0.07% in 2013 to 0.19% in 2022-2023 (annual percent change [APC] 9.3; 95% confidence interval [CI]: 5.2, 13.2). The percentage of people who use illicit stimulants reporting past 6-month use increased from 5.7% in 2013 to 7.3% in 2017 (APC 11.6; 95%CI: 0.2, 52.9) and from 5.4% in 2019 to 11.5% in 2024 (APC 17.8; 95%CI: 5.9, 41.1). The proportion of people who inject drugs reporting use varied between 7.2% and 17.5% over the short period studied (2020-2024). There were statistically significant increases in GHB-related hospitalisations from 5.3 in 2012-13 to 19.1 per 100 000 people in 2022-23 (APC 19.0; 95%CI: 11.9, 31.1) and GHB-related deaths from 0.02 in 2013 to 0.24 per 100 000 people in 2022 (APC 36.5; 95%CI: 27.2, 58.1). Treatment episodes also increased across the period, from 0.07 in 2012-13 to 6.0 episodes per 100 000 people in 2020-21 (APC 97.3; 95%CI: 83.5, 830.9), with no subsequent statistically significant change (8.4 per 100 000 people in 2022-23). CONCLUSIONS:Gamma-hydroxybutyrate use, harms and treatment engagement increased in Australia from 2013 to 2024. These findings highlight a need to implement acceptable, tailored prevention and harm reduction strategies for key populations, and implement stronger monitoring efforts nationally and internationally.

Background Integration — the ongoing process of revisiting, making sense of, and incorporating the content of a psychedelic experience into daily life — is a core component of psychedelic-assisted therapy (PAT), but is variably operationalised and poorly reported in clinical research. Objective To map how integration is described, delivered, and reported in clinical studies of classic psychedelics and to identify common practices and research gaps. Methods A PRISMA-ScR scoping review was conducted searching PubMed, Scopus, and CENTRAL for English-language studies between 1990 and January 2025. Data was extracted on integration session structure (number, timing, duration), therapeutic frame, and facilitator training and conduct. Results Forty-four articles met inclusion, comprising 30 clinical trials, eight prospective trial protocols, and six therapeutic manuals. Psilocybin was the most studied classic psychedelic (k = 37 publications). In clinical trials that reported integration (k = 24), 1–4 integration sessions were provided per dose (median = 2); reported session duration was between 1 and 3hrs (median = 1.5hrs). Typically, clinical trials provided an initial integration session 24–48hrs post-dose and a second session approximately 1 week later. Reporting of integration content, therapeutic conduct, and facilitator training was minimal, particularly outside psilocybin-assisted therapy trials. Conclusion Psychedelic integration is central to PAT, yet its delivery remains vaguely operationalised in clinical research. Future trials should routinely publish comprehensive protocols specifying integration session goals and timing, facilitator roles, therapist qualifications, and fidelity monitoring. Standardised, transparent reporting will improve participant safety and continuity of care, enable cross-trial comparisons, and support safe progression to phase III trials.

AIMS:To identify: (i) availability of nitazenes for purchase on international cryptomarkets and surface web shops, (ii) country of origin and country of destination of advertised products and (iii) types and forms of nitazenes available. We also identified shifts in market characteristics over time where possible. METHODS:Observational study of cryptomarkets and surface web marketplaces selling drugs and specifically nitazenes. Data comprised: (i) all drug listings on 34 cryptomarkets, collected twice monthly from October 2021 to September 2024, and from which nitazene listings were identified and (ii) all nitazene listings on 10 surface web shops, identified in April 2024 via search query on purchasing nitazenes in Australia on a common search engine. The former were analysed using Joinpoint regression; the latter descriptively. RESULTS:While nitazene listings comprised a small proportion of total drug listings across the cryptomarkets (0.16%), the proportion of nitazene listings had a small and fluctuating increase over the 3 years [average monthly percent change (MPC) = 1.7%; 95% confidence interval (CI) = 0.4%, 2.4%]. Overall, 78.9% of listings were reported as available for delivery to Australia, decreasing from 90.4% in October 2022 to 67.7% in September 2024 (MPC = -2.1%; 95% CI = -2.8%, -1.6%). The proportion reported as originating from Asia decreased from August 2023 (52.8%) to September 2024 (12.1%) (MPC = -11.7%; 95% CI = -16.3%, -8.9%), while listings originating from North America increased from April 2023 (19.3%) to September 2024 (82.8%) (MPC = 9.0%; 95% CI = 7.3%, 11.2%). Isotonitazene, protonitazene and metonitazene were most frequently identified, with proportion of isotonitazene and protonitazene listings increasing over the 3 years (average MPC = 2.1%; 95% CI = 1.5%, 2.8% and average MPC = 4.1%; 95% CI = 2.8%, 5.4%) and metonitazene declining (average MPC = -3.5%; 95% CI = -4.2%, -2.7%). Powder was the predominant form (87.2%), although the proportion of pills statistically significantly increased between October 2021 (0.0%) and September 2024 (20.2%) (MPC = 11.8%; 95% CI = 7.7%, 16.5%). Seven out of 10 surface web shops sold nitazenes for Australian delivery. Ten types of nitazene were identified on surface web shops. Powder was also the main form listed, followed by nasal sprays. CONCLUSIONS:From October 2021 to September 2024, nitazenes were listed across a range of cryptomarkets and surface web shops, with shifts in the types available and their reported country of origin. These market insights show the importance of ongoing digital trace monitoring and reinforce the need for comprehensive harm reduction strategies and strong public health risk communication frameworks.

INTRODUCTION:People who inject drugs may experience several non-viral injecting-related injuries and diseases (IRID), including skin and soft tissue infection (SSTI) and venous disease, often resulting from bacteria introduced via unsafe injecting practices or environments. Women are overrepresented among those reporting multiple and recent IRID. However, limited evidence exists about how gender interacts with known IRID risk factors. METHODS:Surveys were conducted 2009-2023 with approximately 900 Australians who inject drugs per year (N = 7538 total). Participants self-reported past-month drug use behaviours and IRID experience. We conducted multivariable binary logistic regression to determine the relationship between gender and SSTI and venous disease. To examine whether gender uniquely affected specific injecting risk behaviours with respect to SSTI and venous disease, two interaction terms were separately added: (i) gender and injecting frequency; (ii) gender and reuse of one's needles. RESULTS:Surveys were completed by 5038 men and 2500 women. Past-month SSTI was reported by 8% of the sample (95% confidence interval 7%-9%), with a higher proportion among women (10%) than men (7%). Overall, 4% reported past-month venous disease (95% confidence interval 3%-4%), a higher proportion among women (5%) than men (3%). Examining both outcomes, no statistically significant interactions between gender and needle reuse or injecting frequency were found. DISCUSSION AND CONCLUSIONS:Despite no statistically significant interaction between gender and reuse or injecting frequency, our study demonstrates a gender difference in exposure to risk factors associated with SSTIs and venous disease. Interventions to reduce SSTI and venous disease, particularly those deemed safe and appropriate by women, are needed.

BACKGROUND:Polysubstance use is associated with negative health and social outcomes among people who inject drugs. We aimed to describe trends in polysubstance use and identify psychosocial correlates and associated drug use risk behaviours. We defined polysubstance use as intentional same day use of more than one of three drug classes: opioids, other non-opioid depressants (hereafter 'depressants'), and stimulants. METHODS:We used 10 years (2012-2022, excluding 2020) of data from annual surveys in Australian capital cities with people who inject drugs (N=5657) to construct five mutually exclusive polysubstance use profiles: opioid-depressant, opioid-stimulant, stimulant-depressant, opioid-stimulant-depressant, and single drug class use. We examined time trends using the Mann Kendall test and identified correlates using multinomial logistic regression. RESULTS:Same day polysubstance use was relatively common among this sample (43.6%). Opioid-depressant use was the most frequent polysubstance use profile, but this decreased over the study period (32.6% to 13.3%, p<0.001). This aligned with observed decreases in use of pharmaceutical opioids (p<0.001), opioid agonist treatment (p=0.007), and benzodiazepines (p=0.001). There was no evidence for any trend in the other polysubstance use profiles, although single drug class use increased (51.9% to 64.7%, p=0.031). The different polysubstance use profiles were variously associated with psychosocial factors, including unstable housing and very high psychological distress, and other drug use risk behaviours, including non-fatal overdose, receptive and/or distributive needle sharing, and reusing one's own needles. CONCLUSION:Same day polysubstance use has remained relatively common among this sample over time, although the typology has changed. Collectively, our findings point to diverse drug use patterns among people who inject drugs and reiterate the need for a range of harm reduction, treatment, and support options.

BACKGROUND AND AIMS:There is evidence to suggest that earlier initiation to alcohol increases the rate and severity of alcohol consumption. However, this often overlooks the fact that earlier initiation also means a longer drinking history. This paper estimated differences in patterns of alcohol use and harm across adolescence and early adulthood, allowing for the fact that the patterns over time may differ depending on the age at which initiation occurred. DESIGN:Prospective cohort study. SETTING:Australia. PARTICIPANTS:The Australian Parental Supply of Alcohol Longitudinal Study (APSALS), a cohort of n = 1906 adolescents recruited in adolescence (mean age 12.9) from 107 Australian schools and followed up until adulthood (11 annual waves total, 2010-2021). MEASUREMENTS:We defined age of initiation as the age at which alcohol consumption was first reported in the study. Our outcomes were amount of alcohol consumed, monthly heavy episodic drinking, alcohol-related harm and self-reported symptoms of alcohol use disorder in the years following initiation. FINDINGS:Those who initiated at age 12 had a lower risk of consumption [risk ratio (RR) 0.01; 95% confidence interval (CI) = 0.01-0.02] in the year following initiation (age 13), compared with those who initiated at age 18. Similarly, those who initiated at age 15 had a lower risk of alcohol use disorder in the year after initiation (RR 0.66; 95% CI = 0.52-0.83), compared with those who initiated at age 18. However, at age 20, those who initiated at age 12 showed higher consumption (RR 1.57; 95% CI = 1.18-2.09), monthly heavy episodic drinking (RR 1.24; 95% CI = 1.02-1.51) and alcohol-related harms [incidence-rate ratio (IRR) 1.73; 95% CI = 1.21-2.46] than those who initiated at age 18. Similar results were seen for symptoms consistent with DSM-IV alcohol dependence (RR 1.20; 95% CI = 1.05-1.38), DSM-IV alcohol abuse (RR 1.54; 95% CI = 1.04-2.29) and DSM-5 alcohol use disorder (RR 1.36; 95% CI = 1.12-1.65). However, there was evidence of ageing out, with risk of heavy episodic drinking and alcohol-related harm peaking around age 20 and then declining, regardless of when initiation occurred. CONCLUSIONS:Later initiation to alcohol appears to be associated with more rapid escalation in drinking and related harm, but lower 'peak' harm than earlier initiation. The findings support the current guidelines recommending adolescents avoid alcohol until adulthood, and reinforce the need for public health intervention targeting both children and parents.

INTRODUCTION:The substance use recovery evaluator (SURE) is a new patient-reported outcome measure of recovery from alcohol and other drugs. The original SURE validation study did not include clients from residential rehabilitation treatment, and the possible challenges in applying the measure in this setting were noted. This study evaluates the factor structure and scoring of the substance use recovery evaluator for people after discharge from residential alcohol and other drug rehabilitation in Australia. METHODS:Two hundred and twenty-five participants interviewed at 14 weeks post-discharge from residential rehabilitation between 2018 and 2020 were included in a cross-sectional analysis of longitudinal data. Item response theory statistics (IRT) were used to determine optimal scoring methods for the SURE. Confirmatory factor analysis (CFA) models were used to confirm the SURE's factor structure. RESULTS:An initial CFA of the 5-factor model using original scoring could not be fitted. Although IRT indicated a combination of binary and three-point scale scoring could be used, a binary scale included most of the information from other response categories, and CFA using a Bayes estimation to confirm the original structure with binary data indicated good model fit, p = 0.164. DISCUSSION AND CONCLUSIONS:The SURE has the same five underlying factors identified by the original study, each of which provides important clinical information about recovery. Binary rescoring provides a valid, parsimonious and clinically relevant way of measuring substance use recovery for residential treatment populations post-discharge.

INTRODUCTION:We aimed to determine whether the trend in the rate of drug-induced hospitalisations and deaths changed during the first year of the COVID-19 pandemic in Australia. METHODS:Data comprised crude monthly rates (per 1,000,000 persons) of hospitalisations and deaths directly attributable to illicit drugs, prescription medicines, or medicines available without a prescription, nationally from 2011 to 2021. Observed rates during the COVID-19 pandemic (2020-2021) were compared with their counterfactual forecast in an ARIMA model, overall and disaggregated by sex, age and drug involved. RESULTS:Observed rates of drug-induced hospitalisation and death, overall and by sex, were not significantly different from the forecasted rates. The rates of drug-induced death among people aged 35-54 and 55+ years were lower than forecasted by 2.1 [95% prediction interval = -3.8, -0.4] and 0.7 [-1.3, -0.1] deaths per 1,000,000 persons per month, respectively. The rates of drug-induced hospitalisation and death involving heroin were lower than forecasted by 1.5 [-2.4, -0.7] and 1.0 [-1.3, -0.6] per 1,000,000 persons per month, respectively, as were those involving amphetamine-type stimulants by 12.4 [-21.4, -0.8] and 0.5 [-0.7, -0.2] per 1,000,000 persons per month, respectively. The rate of cannabinoid-induced hospitalisations was higher than forecasted by 3.8 [0.8, 6.8] hospitalisations per 1,000,000 persons per month. DISCUSSION AND CONCLUSIONS:We found no evidence of an overall difference in the rate of drug-induced harms during the COVID-19 pandemic relative to the forecasted trend. However, there were differences by drug involved, which may be explained by drug market disruptions and changes in drug use during the pandemic.

This paper examines: (i) the acceptability of, and behavioural outcomes associated with, take-home fentanyl test strips (FTS), and (ii) support for, and preferences regarding, drug checking services among people who use heroin. Data were obtained from 78 people who had used heroin in the past 6 months, recruited from treatment and harm reduction services in Sydney, Australia in 2020–21. Participants were provided with 10 BTNX Rapid Response™ single-use immunoassay FTS and surveyed 4 weeks later. Among those who completed the follow-up survey (n = 72), 81

Background: Needle and syringe programs, opioid agonist treatment (OAT), and take-home naloxone (THN) are key harm reduction interventions that reduce bloodborne virus transmission and/or overdose. In this study, we provide updated individual-level coverage of these measures among people who inject drugs in Australia. Methods: Data from cross-sectional surveys in 2018 and 2023 were used to report the percentage who: (a) had sufficient sterile needle/syringes to cover all past month injections; (b) received the monthly equivalent of the WHO recommended 200 needle/syringes per year; (c) reused their own needle/syringe during the past month; (d) received OAT during the past six months (among participants with possible opioid dependence); and (e) who had ever acquired THN. Coverage between years was compared using Chi-squared tests; coverage across subgroups in 2023 was compared using Poisson regression with a log link function. Results: In 2018 and 2023, most participants had sufficient past month needle/syringe coverage: 87 % (95 % confidence interval: 80-93 %) and 88 % (82-95 %), respectively (p = 0.338). In 2023, approximately one third of participants reported reuse of their own needle/syringes. OAT coverage was higher in 2023 (78 %, 70-87 %) compared to 2018 (71 %, 64-78 %; p = 0.015). THN coverage in 2023 (55 %, 50-60 %) was more than double the coverage in 2018 (24 %, 20-27 %; p < 0.001). People who reported no housing had lower OAT coverage compared to those with stable housing (adjusted prevalence ratio: 0.38, 95 % confidence interval: 0.16-0.90). People who predominantly injected methamphetamine had lower THN coverage (0.46; 0.38-0.57) compared to those who predominantly injected heroin. Conclusions: Individual-level needle/syringe and OAT coverage among people who inject drugs in Australian capital cities is high relative to targets, but there are gaps in the implementation of THN. Despite high syringe coverage, a notable minority reported needle/syringe reuse.

INTRODUCTION:Despite high-dose 3,4-methylenedioxymethamphetamine (MDMA) drug alerts being distributed, no research has been conducted as to changes in use in response. This study aimed to determine if: (i) high-dose MDMA drug alerts, and (ii) varied descriptions of dose, effects and actions to reduce harm were associated with intentions to reduce the initial MDMA dose in a hypothetical scenario. METHODS:Australians who used MDMA pills/capsules in the past year completed an online survey. Respondents were randomised into alert (n = 441) or control (n = 184) conditions, with the former receiving a high-dose MDMA alert with systematically varied descriptions of dose, effects and actions to reduce harm. Multinomial logistic regressions determined the association between receipt of drug alert (and varying alert content) and hypothetical MDMA dosing. RESULTS:Almost half (45.4%) of those in any alert condition reported intention to not use (20.7% of control participants) and 46.7% stated they would use and reduce their initial dose (69.0% of control group). Compared to the control group, those who received an alert were significantly more likely to report intention to not use the drug, as compared to taking a smaller initial dose (adjusted relative risk ratio [aRRR] = 3.28, 95% confidence interval [CI] 2.13, 5.07) or taking the same/higher initial dose (aRRR = 2.62, 95% CI 1.31, 5.22). There was no significant association between different alert phrasing and intended behaviour. DISCUSSION AND CONCLUSIONS:While there was no significant effect of variation in phrasing, receipt of an alert promoted intended harm reduction behaviours. Future research assessing actual behaviour and different substances (e.g., heroin, methamphetamine) is important to further understand the utility of this public health communication.

AIMS:This study sought to validate a community-acceptable Substance Use & Sex Index (SUSI) for use in substance use intervention research. SUSI aims to measure behaviours associated with the transmission of blood-borne viruses (BBV) and sexually transmitted infections (STI) among people who use substances and incorporate contemporary sexual and drug practices. DESIGN:Validation of a self-administered online behavioural questionnaire. SETTING AND PARTICIPANTS:An Australian anonymous online questionnaire advertised through health services and social media resulted in 289 respondents with a mean age 35 years (standard deviation [SD] 10.9 years). MEASUREMENTS:A 26-item scale assessing BBV- and STI-associated behaviours based on previous piloting and expert review was assessed for scale structure using exploratory and confirmatory factor analytic approaches. Item Response Theory (IRT) analyses were applied in decisions to retain and categorise items. Item weightings were defined following expert consensus informed by local BBV, STI and HIV epidemiological profiles. Test-retest reliability was examined on a subsample (n = 98) over three to five days. Criterion validity of the new SUSI-2 scale was examined in comparison to the HIV Risk-taking Behaviour subscale of the Opiate Treatment Index (OTI-HRBS). FINDINGS:Factor analysis identified a two-factor model ("sex"; "drugs with sex"), with moderate magnitude correlation (r = 0.38; 95% confidence interval [CI] 0.19-0.54) between factors and acceptable model fit (p = 0.061). IRT discrimination was statistically significant for all items (p < 0.05). Kappa values for test-retest reliability (n = 98 subsample) ranged from 0.66 to 1.00 with high agreement (all above 87%). Free text responses indicated the questionnaire items were acceptable to respondents, with minimal suggestion for improvements. There was a statistically significant positive correlation between the SUSI-2 and OTI-HRBS sex subscales (weighted r = 0.63, p < 0.001) and between the SUSI-2 sex with drugs and OTI-HRBS drug subscale (weighted r = 0.21, p < 0.01). Four additional items were retained to reflect local other BBV and STI transmission risk. CONCLUSIONS:The Substance Use & Sex Index 2 (SUSI-2) appears to be a valid and acceptable two-factor brief scale for the measurement of behaviours associated with blood-borne viruses and sexually transmitted infections for use in substance use interventional research.

AIMS:This study tested the efficacy and safety of a 12-week course of lisdexamfetamine in reducing methamphetamine use, an outcome which is associated with improvements in health and wellbeing, in people dependent on methamphetamine. DESIGN, SETTING AND PARTICIPANTS:This study was a randomised double-blind placebo-controlled trial conducted in six specialist outpatient clinics in Adelaide, Melbourne, Newcastle and Sydney, Australia (2018-2021). Participants were164 adults with methamphetamine dependence, reporting at least 14 use days out of the previous 28 days (62% male, 38% female, < 1% other; mean age 39 years). INTERVENTIONS:Participants were randomly allocated 1:1 to a 15-week regimen of lisdexamfetamine (1-week induction to 250 mg, 12-week maintenance regimen, 2-week reduction; n = 80) or matched placebo (n = 84), followed-up to Week 19. MEASUREMENTS:The primary efficacy measure was past 28-day methamphetamine use at Week 13. Safety was assessed by adverse event rates. Secondary measures included methamphetamine use during the 12-week treatment period and treatment satisfaction. FINDINGS:Nine randomized participants did not start treatment (five were allocated to lisdexamfetamine and four allocated to placebo) and were excluded from the analyses. Fifty-seven per cent of participants were retained on study medication to primary end-point. There was only weak evidence of a lisdexamfetamine benefit at 13 weeks [adjusted difference in days of methamphetamine use = 2.2, 95% confidence interval (CI) = -0.5 to 5.0; P = 0.49]. However, throughout the whole 12-week treatment maintenance phase, the lisdexamfetamine group had fewer days of methamphetamine use in total (difference = 8.8, 95% CI = 2.7-15.0; P = 0.005). The lisdexamfetamine group reported greater self-reported treatment effectiveness [odds ratio (OR) = 2.89, 95% CI = 1.67-5.02; P < 0.001] and treatment satisfaction (OR = 3.80, 95% CI = 1.93-7.47; P < 0.001). Adverse events with lisdexamfetamine included nausea. Serious adverse events occurred in four (5%) of participants who received lisdexamfetamine. CONCLUSIONS:Lisdexamfetamine appears to reduce methamphetamine use over a 12-week treatment period, although there is only weak evidence that reduced use is maintained during the last 4 weeks.

Background: Previous studies have reported high COVID-19 vaccine hesitancy among people who inject drugs. We aimed to examine COVID-19 vaccine coverage, motivations and barriers to vaccination, and factors associated with uptake among this population in Australia, 1.5 years after vaccine rollout commenced. Methods: In June-July 2022, 868 people (66.0 % male, mean age 45.6 years) who regularly inject drugs and reside in an Australian capital city reported the number of COVID-19 vaccine doses they had received and their primary motivation (if vaccinated) or barrier (if unvaccinated) to receive the vaccine. We compared vaccine uptake to Australian population estimates and used logistic regression to identify factors associated with >= 2 dose and >= 3 dose uptake. Results: Overall, 84.1 % (n = 730) had received at least one COVID-19 vaccine dose, 79.6 % (n = 691) had received >= 2 doses, and 46.1 % (n = 400) had received >= 3 doses. Participants were less likely to be vaccinated than the Australian general population (prevalence ratio: 0.82, 95 % confidence interval [CI]: 0.76-0.88). Key motivations to receive the vaccine were to protect oneself or others from COVID-19, while barriers pertained to vaccine or government distrust. Opioid agonist treatment (adjusted odds ratio [aOR]: 2.49, 95 % CI: 1.44-4.42), current seasonal influenza vaccine uptake (aOR: 6.76, 95 % CI: 3.18-16.75), and stable housing (aOR: 1.58, 95 % CI: 1.02-2.80) were associated with receipt of at least two vaccine doses. Participants aged >= 40 years (versus < 40 years; aOR: 1.66, 95 % CI: 1.10-2.53) or who reported a chronic health condition (aOR: 1.71, 95 % CI: 1.18-2.47) had higher odds of receiving at least three vaccine doses. Conclusion: We observed higher COVID-19 vaccine uptake than expected given previous studies of vaccine acceptability among people who inject drugs. However, it was lower than the general population. People who inject drugs and reside in unstable housing are a subpopulation that require support to increase vaccine uptake.

BACKGROUND:Examining take-home naloxone (THN) uptake using a 'cascade of care' framework could help identify targets for increasing THN training and carriage among people who may witness or experience opioid overdose. We describe the THN cascade and factors associated with engagement among people who inject drugs. METHODS:People aged ≥18 years in Australia who inject drugs were interviewed from 2020 to 2022, reporting lifetime THN awareness and acquisition and past-month carriage. We examined factors associated with engagement using multivariable logistic regression. RESULTS:Of 2,149 participants (64 % men, mean age 44.5), 85 % had heard of naloxone, of whom 76 % were aware of THN programs. Of these, 72 % had ever participated in THN training/brief education, 92 % of whom had acquired THN. Of those who had ever acquired THN and reported past-month opioid use, 63 % always/often carried THN when using opioids. Past six-month opioid agonist treatment (OAT) (adjusted odds ratio [AOR] 2.55; 95 %CI 1.91-3.42) and ≥daily injecting (1.32; 1.01-1.73) were associated with awareness. OAT (1.79; 1.38-2.33), past-year opioid overdose (1.68; 1.18-2.42) and older age (1.02; 1.00-1.03) were associated with acquisition. Primarily injecting methamphetamine (versus heroin) in the past month was associated with lower awareness (0.43; 0.31-0.58) and acquisition (0.59; 0.44-0.78). Reporting no accommodation (squatting/sleeping rough) was associated with reduced odds of carriage (0.46; 0.24-0.88). CONCLUSION:Participants reported high THN awareness and acquisition, with lower carriage. Future efforts should focus on improving THN access and reducing barriers to carriage, particularly for people experiencing homelessness or who primarily inject non-opioids.

BACKGROUND:The management of chronic non-cancer pain (CNCP) is complex. Concerns about adverse effects associated with opioid pain medications and a lack of funding for holistic programs present challenges for decision-making among clinicians and patients. Discrete choice experiments (DCE) are one way of assessing and valuing patient treatment preferences. METHOD:DCE attributes and levels were generated through qualitative research and included number of medicines, side effects from medicines, pain interference, care management, risk of addiction, activity goals, preferred source of information on pain management and willingness to pay. The survey was administered to participants with CNCP recruited through an existing cohort study (n = 442) and a sample of people living with CNCP recruited through Australia's leading pain advocacy body (Painaustralia) (n = 256). RESULTS:The median age of participants was 58 years (SD 12.0), the majority were female. The analysis revealed two latent demographic classes: a younger group with higher levels of private health insurance and an older group with lower levels of private health insurance coverage. There were notable differences in preference. The younger cohort exhibited a greater willingness-to-pay to reduce pain interference, whereas the older group prioritized GP management, preferred more medicines and expressed fewer addiction concerns. CONCLUSION:Patients' treatment preferences diverged based on age and insurance status, underscoring the importance of understanding patient perspectives in treatment communication and care coordination. These findings provide insight into patient decision-making, which is important for promoting access to quality healthcare and engagement with evidence-based treatment of CNCP. SIGNIFICANCE STATEMENT:A discrete choice experiment identified two groups: younger, with more private insurance, and older, with less private health insurance, each with unique pain management preferences. Clinicians should be aware that age and private health insurance may have an impact on a patient's preferences for CNCP management.

OBJECTIVES:Although factors associated with alcohol use have been researched at a population level, descriptions of the alcohol and other drug (AOD) treatment-seeking population in New South Wales (NSW), Australia, are limited. This study addresses this gap by analyzing sociodemographic and health characteristics in the NSW AOD treatment-seeking population. METHODS:Self-reported Australian Treatment Outcomes Profile data on substance use, health ratings, and sociodemographic factors were acquired from public AOD services (offering services from counseling to ambulatory/inpatient withdrawal management) in 6 administrative health districts from 2016 to 2019 (n = 14,287). Gaussian and multiple logistic regressions were conducted to examine associations between these factors and alcohol consumption quantity. RESULTS:Data were analyzed for patients seeking treatment for alcohol consumption specifically (n = 5929; median age, 44 years; 65% male). Valid alcohol consumption data were available for 5460 patients, among whom the mean volume of alcohol consumed was 311 standard drinks (3110 grams of ethanol) over the past 28 days and 15 standard drinks (150 grams of ethanol) per occasion. Higher volumes were consumed by males and those with recent experiences of violence and/or injecting drug use. Caring for children younger than 5 years and having above-median health ratings were associated with lower alcohol consumption. CONCLUSIONS:This study contributes to the characterization of the NSW public AOD treatment population and identifies associations between alcohol consumption, sociodemographic factors, and health ratings among people seeking treatment for alcohol consumption. Findings point towards multilevel assessment and comprehensive interventions for people engaging in treatment for alcohol use. Future research should address barriers to treatment.

Background: Low-dose codeine is sold without a prescription in countries like the UK, Ireland, and South Africa. Due to misuse concerns, exploring pharmacy screening tools to identify those at risk and needing additional support is vital. Objectives: The study aims to develop and validate a brief screening tool that assesses the risk of codeine dependence with language appropriate for routine use in community pharmacies. Method: Scale development and validation occurred over two studies. In Study 1, scale item generation was based on structured analyses of psychosocial and pharmacy variables from frequent over-the-counter codeine consumers (N = 795). CFA was used to assess the cohesiveness of the resultant four-item Codeine Dependence Scale (CDS). ROC analyses were used to assess the performance of the CDS against risk cases identified by the Severity of Dependence Scale; identifying an optimal cut-off value of >= 2 as representing individuals at risk of codeine dependence. In Study 2, this CDS threshold was assessed against positive DSM-5 Opioid Use Disorder (OUD) cases related to codeine use assessed using the AUDADIS-IV. Results: With a cut-off score of >= 2, the CDS has sensitivity and specificity of 76% and 48%, respectively, against a DSM-5 codeine-related OUD diagnosis using the AUDADIS-IV. For identification of any codeine-related OUD (as measured by the AUDADIS-IV) 15 months after baseline, the CDS achieved an overall correct classification rate of 52%; 72% for positive cases. Conclusions: The CDS exhibits reasonable cross-sectional and longitudinal sensitivity but low specificity, partly due to its brevity. However, the inclusive nature of the CDS is not a negative for application as a screening tool in a pharmacy setting as individual CDS items represent critical conversation points with a pharmacist, regardless of the screening outcome. The non-confronting nature of CDS items make the scale a viable option for pharmacybased SBI in countries where codeine remains OTC.

Codeine was rescheduled in Australia to prescription only in February 2018. Initial studies reported an increase in population level paracetamol and ibuprofen sales following codeine upscheduling. However, to date no study has been able to investigate changes in non-opioid analgesic use at the individual patient level to determine if sales data reflect actual consumption patterns. To address this gap, we aimed to determine the impact of codeine rescheduling on non-opioid analgesic use in people who regularly used over-the-counter codeine, primarily for pain, prior to the rescheduling change. We conducted a prospective cohort study with 260 participants who reported regular over-the-counter codeine consumption at cohort entry. Surveys were completed at baseline (November 2017, 3 months before rescheduling) and at 1 month (February 2018), 4 months (June 2018), and 12 months (February 2019), following rescheduling. The primary outcomes were mean daily doses of non-opioid analgesics, captured through a 7 day medication diary. The mean daily paracetamol dose decreased from 1754.4 mg (95

BACKGROUND:Prevention and early intervention of alcohol use disorder (AUD) is a public health priority, yet there are gaps in our understanding of how AUD emerges, which symptoms of AUD come first, and whether there are modifiable risk factors that forecast the development of the disorder. This study investigated potential early-warning-sign symptoms for the development of AUD. METHODS:Data were from the RADAR study, a prospective cohort study of contemporary emerging adults across Australia (n = 565, mean age = 18.9, range = 18-21 at baseline, 48% female). Participants were interviewed five times across a 2.5-year period. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) AUD criteria and diagnoses were assessed by clinical psychologists using the Structured Clinical Interview for DSM-IV (SCID-IV), modified to cover DSM-5 criteria. Hazard analyses modeled the time from first alcoholic drink to the emergence of any AUD criteria and determined which first-emergent AUD criteria were associated with a faster transition to disorder. RESULTS:By the final time point, 54.8% of the sample had experienced at least one DSM-5 AUD criterion and 26.1% met criteria for DSM-5 AUD. The median time from first AUD criterion to a diagnosis of AUD was 4 years. Social problems from drinking (hazard ratio [HR] = 3.24, CI95 = 2.14, 4.92, p < 0.001), major role (HR = 2.53, CI95 = 1.58, 4.06, p < 0.001), and drinking larger amounts/for longer than intended (HR = 2.04, CI95 = 1.20, 3.46, p = 0.008) were first-onset criteria associated with a faster transition to AUD. CONCLUSION:In the context of a prospective general population cohort study of the temporal development of AUD, alcohol-related social problems, major role problems, and using more or for longer than intended are key risk factors that may be targeted for early intervention.