The BULLETIN | August 2022 | Vol. 19, Ed. 2

THE

BULLETIN

Q&A with Mick Palmer Former Australian Federal Police Commissioner

THE WORLD IS GET TING CREATIVE FOR

IOAD 2022

THE WAITING GAME:

AUSTRALIA’S CAPACITY CRUNCH FOR RESIDENTIAL TREATMENT

FROM ‘PASSING THE BUCK’ TO INTEGRATED CARE C0- OCCURRING MENTAL HEALTH AND SUBSTANCE ABUSE CRISES

VOLUME 19

EDITION 2

A M E S S AG E F RO M T H E C E O August is one of the most important months at Penington Institute as we embark on the homestretch to this year’s International Overdose Awareness Day (IOAD).

I’m truly heartened by the hard work of individuals and communities all around the world, united by our common cause: to end the overdose crisis. It is worth reflecting on years gone by and acknowledging how far we’ve come.

However, we have a long way to go.

As illustrated in the recently released UNODC World Drug Report, fatal overdose is on the rise, with estimates of over 107,000 overdose deaths in the United States in 2021, up from approximately 92,000 in 2020. Here in Australia, the loss of life from overdose continually outnumbers the road toll. We must stay strong and hold our course – this issue is too important and requires every one of us to work together to make real change. Read on in this issue to get inspired by others and see what you can do this IOAD. One well-established lifesaver is opioid pharmacotherapy, which helps reduce overdose, mortality, and the transmission of blood-borne viruses. But what about other harms associated with injecting drugs? Recent research using Australian patient data demonstrates that retention in a pharmacotherapy program for over four weeks is positively, though modestly, associated with lower hospitalisation rates for injection-related conditions such as sepsis and endocarditis.

DISCLAIMER. The Bulletin is published by Penington Institute and funded by the Australian Government. The views expressed in this publication are not necessarily those of the Australian Government or Penington Institute.

Penington Institute takes no responsibility for loss or damage that may result from any actions taken based on materials within the Bulletin and does not indemnify readers against any damage incurred.

Penington Institute connects lived experience and research to improve the management of drugs through community engagement and knowledge sharing. A not-for-profit organisation, our focus is supporting cost-effective approaches that maximise community health and safety in relation to drugs including pharmaceuticals and alcohol.

The same data also show that ongoing engagement with a pharmacotherapy program substantially reduces the risk of suicide and self-harm – dangers that are extremely heightened for people who inject drugs. However, the risk of hospitalisation for self-harm increases in the initial weeks of pharmacotherapy, and suicide risk spikes sharply and immediately upon cessation of treatment – a sobering reminder of the need to prioritise support for people transitioning in and out of pharmacotherapy.

Cover image: Louie Douvis

Finally, a reminder to send us your feedback. We believe that Australia’s only publication for frontline NSP workers must be shaped by frontline NSP workers. Get in touch and please share The Bulletin far and wide with your colleagues and friends.

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Copyright © 2022. All rights reserved. All written material in this publication may be reproduced with the following citation: “Reprinted from vol. 19, ed. 2 of The Bulletin, published by Penington Institute, with credit to the author(s).”

John Ryan

www.penington.org.au

CEO Penington Institute

WAITING GAME

THE

A U S T R A L I A’S CA PA C I TY C R U N C H F O R R E S I D E N T I A L T R E AT M E N T

People seeking treatment for problematic drug use at residential facilities are facing significant backlogs in several states and territories across Australia, leading to worries about how delayed treatment affects people’s lives and calls for more funding.

The issue has been well publicised in Victoria, where the Victorian Alcohol and Drug Association (VAADA) has registered rising waitlists for all types of treatment, with the residential treatment backlog spiking from 230 people in September 2020 to 452 in December 2021.

Other states have not produced similarly dramatic headlines – due in part to spotty data – but expressions of concern are common. In the ACT, for example, there is no centralised waitlist, but according to Dr Devon Bowles, CEO of the Alcohol Tobacco and Other Drug Association ACT (ATODA), ‘demand for drug services in the ACT is probably around double the availability of places.’

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Michael White, executive director of the South Australian Network of Drug and Alcohol Services, notes that in his state ‘it’s very hard to compute [the data]; people disengage at the initial contact point when told there will be a week or a month’s wait. This means that there is likely to be a degree of unmet and unmeasured need.’

Although the issue precedes the Covid-19 pandemic, the implementation of social distancing guidelines led to services operating with significantly reduced staff, which worsened capacity shortfalls – just as demand for treatment spiked.

According to analysis by the Australian Institute for Health and Welfare, treatment episodes at residential treatment facilities declined markedly, a shift that, in most states, was attributable to reduced capacity.

This crunch occurred just as lockdown pressures led to increases in demand for residential treatment. Clinics in New South Wales reported growing waitlists for alcohol and substance abuse treatment programs, while the Alcohol, 3

Tobacco and other Drugs Council Tasmania (ATDC) reported increasing harm from alcohol use, alongside 11-week waits for residential rehabilitation.

Even after the easing of restrictions, extended waitlists for residential treatment persist, in part because the aftereffects of lockdown are still reverberating throughout the sector. In a May 2022 media release, VAADA noted ‘unprecedented increases in demand since the pandemic, with average wait times blowing out for some treatment types by over 25 per cent. This means extra weeks for those in desperate need of help in a queue, which for many dangerously increases the rate of attrition.’

For clients, such delays can jeopardise potential progress – or worse. If treatment is not accessible, clients run the risk of falling through the cracks. According to VAADA’s David Taylor, ‘the intention of getting treatment isn’t always enduring.

Some may feel ready to enter treatment for a number of days but may then experience a traumatic event or a relapse, causing them to move themselves off the waiting list.’

As another lived experience advocate put it: ‘By the time people reach out to seek admission to a residential rehabilitation centre they are often at crisis point in their substance use. Long delays to enter rehabilitation result not only in continued use, but in some cases have been the difference between life and death.’

What can be done? It is clear that more funding for dedicated detox and residential treatment is necessary in many states and territories. In Victoria, the state government

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has opened several new residential rehabilitation facilities, and in May officials announced funding for a 30-bed facility in Mildura. While improving infrastructure is crucial, the extent of waitlists only partly reflects the number of available beds. According to data compiled by VAADA, Victoria currently has 0.74 residential beds per 10,000 residents, ahead only of South Australia.

On the other hand, Tasmania has 1.86 beds per 10,000 residents, and several dozen residential rehabilitation beds have been added, but the ATDC has noted that a lack of communitybased withdrawal beds is acting as a bottleneck, prompting a December 2021 call for $4.9 million across 3 years to add beds.

Staffing is another potential obstacle. VAADA identified

funding cuts of $39 million in overall support for the AOD sector in Victoria’s 2022/2023 state budget, which it says will lead to job cuts and delay training for the workers necessary to fill positions – thereby potentially creating new barriers for clients seeking treatment. In a similar vein, although the NT has the highest number of residential treatment beds per capita, Katie Flynn of the Association of Alcohol and other Drug Agencies noted that ‘the main issues we have are appropriately funded staffing levels for each service and those staff being adequately trained and qualified.’

Finally, states must also be aware of the intersection between residential rehabilitation backlogs and other challenges, particularly access to housing. Devon at ATODA notes that ‘many AOD clients struggle to obtain stable housing, and, anecdotally, there is some suggestion that some people who are in residential treatment could benefit equally from a less intensive form of treatment if they had access to housing.’

A lived experience advocate based in Tasmania likewise emphasised the housing crisis’s impact on available beds, observing that ‘clients stay in treatment longer than necessary due to lack of housing options and aftercare,’ adding that ‘clients have nowhere to go and so are holding

SA Vic Qld

up space in beds that might otherwise be available.’ In the short term, some organisations have attempted forms of waitlist harm reduction.

The Bridge Program in Hobart has implemented a process to check in on people waiting for treatment more often. ‘They provide one-on-one and regular support once someone’s made contact,’ a Tasmanian lived experience advocate said.

‘Also, they have a triage system to determine who needs the beds most urgently and are able to successfully treat far more people now that they are running more day programs for outpatients and outreach-type services.’

That said, increased contact support is no silver bullet. As David at VAADA points out: ‘While [contact support] goes some way to diminish the harms, it simply doesn’t provide the same level of in-depth support.’

When asked about the long-term effects of extended wait times for residential treatment, VAADA Executive Officer Sam Biondo is clear: ‘It will be incredibly devastating for many,’ he said. ‘Lots of individuals will find themselves in dire circumstances; while some clients will end up in the health system, others will end up in the justice system, and some may not survive at all.’

0.50 0.74

Residential rehabilitation beds per 10,000 head of population (2021)

1.00

NSW WA Tas ACT

1.22 1.39 1.86 2.52

NT

9.55

Beds / 10,000 head of population

Source: Victorian Drug and Alcohol Association

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Picture: Louie Douvis

Q&A MICK PALMER with

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Mick Palmer, AO served as commissioner of the Australian Federal Police from 1994–2001, the capstone to a policing career that spanned more than three decades.

In addition, he has practiced as a barrister and contributed to many public policy and civil society endeavours, all of which have contributed to a significant evolution in his thoughts on drug policy, which he shares here.

We always start with the question ‘How did you get to where you are?’, so maybe a quick tour of your career would be good.

I’m essentially a whole-of-life police officer, John – I joined the Northern Territory Police when I was 21. I was always going to be a teacher and I was waiting for acceptance to teachers’ college in NSW when I saw the advert, and a mate and I applied.

I’d never thought about being a police officer prior to that, and my father was horrified, but I fell in love with the Northern Territory, and with the job, and finished up initially serving 15 years in the NT Police. I then left and studied law in Queensland before practising at the private bar for about two years.

I then re-joined the NT Police for a further ten years – the last seven as Commissioner of Police. In 1994 I was appointed the Commissioner of the AFP, a position I held until mid-2001, when I retired – luckily for me – just prior to the 9/11 disaster.

Since that time, I have conducted a series of reviews and inquiries for the Federal and for State governments, working on average about 90 days per year. My inquiries included the Inquiry into the Immigration Detention of Cornelia Rau and reviews into prison services in Victoria and in Tasmania.

During that time, I’ve become quite deeply involved in a number of law reform issues: drug law reform, PTSD and suicide, issues and problems associated with depression and mental health, particularly homelessness and disadvantage.

I’ve worked pretty closely with Matt Noffs and the Noffs Foundation over the last several years in regard to homeless and disadvantaged children, particularly Indigenous and Pacific Islander children.”

And what’s the itch you’re scratching in terms of those difficult issues? Like, you could actually just play golf all day every day.

[Laugh] I’m a pretty awful golfer. In regard to drug law reform and mental health, it just started to become pretty obvious [during my career] – initially in the NT where street disorder and low-level crime is in your face and there are so many disadvantaged groups within the communities – that the way we were dealing with problems were pretty simplistic and symptoms-focused rather than cause-focused.

The more that I looked at these issues, the more determined I became that when I got a chance I might try and see if I

could do something about it. I guess it was an evolutionary process; I didn’t start where I finished. It became obvious to me that the Tough on Drugs policy wasn’t achieving the ends we set for ourselves – we were probably creating more problems than we were ever curing. And in regard to mental health, it became pretty obvious (as it has to anybody who’s looked at it) that the infrastructure and facilities in support were nowhere near good enough, broad enough, or available enough to achieve the desired outcomes.

And it became absolutely obvious that there was a direct connection between the two issues – drug use and the social disorder that can flow from it, and mental health and other problems that obviously led to that sort of behaviour. They were being dealt with in narrow silos, they weren’t being dealt with very well even in those silos, and there was a real and desperate need for an understanding of the broader picture.

And when you go back to circa 2000, the brand for the policy initiative was “Tough on Drugs” but the underlying technical name was “Illicit Drug Diversion Initiative” – there was actually a lot of money that the Howard government threw at trying to shift people out of the criminal justice system for personal use and possession, and also some harm reduction initiatives. Where was your thinking circa 2000?

I think 1998 was when John Howard brought in the Tough on Drugs policy; I was Commissioner of the AFP at that time.

And what you say is quite right, and I think the fact that it was launched at the Noffs Foundation headquarters was a reflection of Prime Minister John Howard’s attitude. He had a real focus on drug trafficking and the need to get tough on the organised crime side of the drug equation, but at the same time more money was given to diversion and demand reduction than was given to supply reduction.

The sexy bits of course were supply reduction – we got enough money to create a series of strike teams and guys dressed up in black with guns and so on, seizing ships offshore. It was great media coverage and a lot of quite significant seizures were made in those first few months, so that tended to hog the headlines.

But yes, there was a lot of money given to diversion, to the creation of things like drug courts and rehabilitation processes and support mechanisms, and I was involved in both sides of that. And, you know, it sadly lost its way over time – the diversion side didn’t get any publicity and the intention that was at the heart of what Prime Minister Howard intended sort of lost out, I think, to dealing with the more simplistic side of the drug equation.

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What are your reflections on the institutional inertia that’s often seen in relation to drug policy – I think the perception that Australia hasn’t progressed since the 1980s is inaccurate considering diversion away from the criminal justice system et cetera, but I don’t think we’ve progressed very significantly. What are the government barriers to moving toward a more cost-effective model?

I’ve had conversations with senior government ministers at both state and federal level over the last few years, and some of them have said quite clearly to me, ‘We know what to do, we just don’t know how to get re-elected after we do it’. They agree with the need for a change to drug policy, they know that what we have is not working, but as leaders around the world sometimes very publicly have said, ‘We don’t quite know how to deal with it’.

I think there’s a fear in the minds of politicians as to what ordinary people will think if they’re seen to be going soft on drugs. There’s probably a fair amount of truth in that people do get frightened – the bad side of the drug equation is there for all to see, and I don’t shy away from that for a moment.

I just think there’s a need for clearer and deeper debate to what we’re trying to achieve here: what are the problems that really are causing the concerns that people have? How do we best deal with those problems to achieve better results?

It seems to me government officials would be in a strong position if they were to say, ‘Look, it’s clear that what we have is broken, it’s not working. The aims we set for ourselves are exactly the sort of aims that any government should have in terms of reducing harm and increasing safety within the community. Despite our 40-year Tough on Drugs policy, we haven’t achieved any of those aims, so there has to be a better way to do business and we are prepared to trial new ways to see whether we can achieve better

“IT SEEMS TO ME GOVERNMENT OFFICIALS WOULD BE IN A STRONG POSITION

IF THEY WERE TO SAY,

LOOK, IT’S CLEAR THAT WHAT WE HAVE IS

BROKEN ,

IT’S NOT WORKING’.”

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results.’ It seems to me that, in reality, would be a pretty easy political message to give.

Some governments, of course, have gone down that track, as you know, particularly in terms of cannabis, and use and possession of small amounts of drugs in some jurisdictions.

We take baby steps; all those steps seem to be going in the right direction, but we seem to lack the collective political will to have a serious crack at what is a very serious problem.

One of the reasons I was keen to talk to you was that in a conversation we had previously you mentioned an experience that I found quite profound, which was that you charged someone for the offence of attempted suicide in your early days in the Northern Territory.

And just thinking about that in terms of how the world has changed – we’ve had a major shift over 50 years, a real opening up of honest conversations about mental health issues, and certainly a removal of attempted suicide from the statute books. Can you just share that story again and add a reflection on what the lesson might be for those who are currently supportive of criminal sanctions for minor use and possession offences?

I gave you that example of the attempted suicide, where a deeply disturbed young man tried to kill himself, which was then a criminal offence, and found himself charged

essentially for having failed. Buggery was also a criminal offence, as was an offence called Ward Drink Liquor, which was for Indigenous people who were what was termed Wards of the State – that is to say, they had not been made citizens of Australia – they committed an offence by simply having a drink.

At the start of my career in 1964 in Darwin, it was not unusual to lock up 80-100 people every night of the week in a town of about 12,000 people, simply for having a drink.

This generally resulted from a complaint by a shopkeeper or a publican saying two or three Indigenous people had walked into the pub and were drinking the dregs out of glasses; they were generally homeless people, often alcoholics, for reasons we didn’t understand then but of course I understand very clearly now.

These were well intentioned but very simplistic laws, essentially based on convenience for those people who had some influence with governments, and were based on dealing with the symptoms – or the actions of the people, rather than even thinking for any moment about what the causes of that behaviour might have been or what we could do about the causes. I think over time we’ve improved – the Ward Drink Liquor luckily didn’t last long in my day, yet we as a community acquiesced to those laws for longer than we should have. Many of these laws have now been assigned to the rubbish bin of history, and we think a bit more carefully about why we create criminal laws and other ways that we

might deal with some of these problems, but we’re way short of where we need to be, and that’s the case with drug law enforcement, particularly in regard to disadvantaged youth.

You’ve seen it now over fear with terrorism – it’s not hard for governments to reach the conclusion they need to bring in some wide sweeping power to deal with a particular problem, only of course to find a little bit down the track that it has been used far more widely than was intended and has created probably more problems than it’s solved. Attempted suicide is a very good example of ‘Why the heck would you punish people for that?’ – it makes no sense, but everybody thought [suicide] was a coward’s way out and that was the way you dealt with it: to try to deter people from doing it.

That’s the thing, isn’t it: it was an attempt at deterrence, basically a transfer of a moral repugnance against suicide, which is endemic to every religion I’m aware of. Changing that into criminal law statutes seems very much to parallel with use and possession. We can have a government that doesn’t want people to use drugs and encourages them not to; the extra step – and perhaps a step too far – is criminalising that behaviour rather than discouraging it.

I think that’s exactly right: it’s an easy option just to create a criminal offence for something that you don’t think people ought to be doing, as if that is somehow going to solve the problem. Luckily I grew up at a time when drugs

Mick Palmer with politicians Bob Carr and Jeff Kennett 9

were not very prevalent, but we still used to scrump apples off the nextdoor neighbour’s apple tree and drink liquor when underage.

“THE GOOD PRACTITIONERS NOW REALISE NO MATTER HOW GOOD WE ARE, HOW HARD WE TRY,

Kids break boundaries and commit ‘offences’, if you like, as part of the reality of growing up; you’re always stretching the boundaries. Drug use and possession, particularly for young people looking to enjoy themselves in an evening, or to make themselves feel a bit better in a difficult time, it’s always going to be an attraction, and so we have to find ways to deal with that, to provide support, to show people other options, to create an environment where they’re likely to tell the truth if they are caught taking drugs and people are trying to help them [rather than] deny what’s occurred simply because they’re fearful of what the penalty might be.

HOW MANY PEOPLE WE ARREST,

WE’RE SIMPLY NOT MAKING ANY DIFFERENCE.

They’re the areas it seems to me that we too easily sort of sweep under the carpet on the basis that ‘Well you play the game, you take the knocks. Drugs are bad so we lock you up’.

I mean, there’s a lot of things that are bad that we don’t lock people up for.

What does it mean when police say ‘We can’t arrest our way out of the drug problem’ – they weren’t saying that 20 years ago, in my observation, but they have been saying it for at least 5-10 years. What does that actually mean in a practical sense?

I think it reflects the fact that many police who are deeply involved in the drug trafficking industry from the enforcement side have come to recognise two things: they’re relatively successful, they make a lot of significant arrests and a lot of large seizures – but at the same time, they’re seeing the demand levels stay as they were, or sometimes even increase, and the numbers of people who are using drugs not diminish at all.

So they’re starting to recognise the fact that it’s finger in the bucket stuff – you take out one syndicate, another one takes its place; the amount of money that can be made on the black market is such that the drug supply will continue.

Demand remains undiminished despite how many arrests we’ve made of young Australians. And you know the United States again is a classic example of that where, as you know, you can get very long terms of imprisonment for just three convictions for cannabis use and possession, and it has made no difference.

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They’re the figures and facts we have to look and deal with if we’re going to make any imprint. And that’s what drives police, I think: the good practitioners now realise no matter how good we are, how hard we try, how many people we arrest, we’re simply not making any difference. If this was a private business, you’d have gone broke a long time ago; on that basis alone we should be saying we need to find another way to do business.

I mean it’s an interesting turn of phrase, but it’s actually the opposite, isn’t it? The more the gangsters arm up, the police arm up to match them; the more the gangsters adopt technological innovations, so do the Customs and Border Force – they keep fighting each other in this vicious circle.

I think police are going broke in the sense that despite how much money is thrown at it, how many more skills we give them, how many more people they are given, how many more arrests they make, at the end of the day, we go broke because we don’t achieve any of the outcomes; we’re not making any profit, if you turn this into a business sense.

We might be selling a lot of equipment – in our case, arresting a lot of people – but at the end of the day we’re not making a profit, we’re not returning a benefit: the reduction of harm, the level of rehabilitation, less drug use in the community, a lowering of the violence and other criminality that goes with it.

We’re essentially not achieving any of those results at all. So if that was the mark of our success, if they were our profit criteria, we would well and truly have gone broke by now.

And politics is often a response to one crisis after another, and issues that are not in crisis are allowed to bubble away because there are more pressing issues for our leaders.

So there are two problems: one is politicians have only got a certain concentration span that is mostly focused on crisis, and secondly, we’ve become tolerant of a level of dysfunction in our community – it’s become normalised to allow this 150,000 arrests per year. How do you cut through to make that a priority for our political leaders, particularly if they don’t have personal experience?

To me, the media coverage of drugs and the political attitude to drugs, is a little like Ukraine – despite the terrible things that are continuing to happen, the media’s got used to it, there’s nothing new; it’s the same old bombing going on every day, so we’re not seeing nearly as much coverage as we were initially.

It is very much the same, I think, with drug policy in most 11

people’s minds: people have got used to it, leave it alone.

You know, if you start tampering with it, you might make it worse and that’ll be politically dangerous to us, so let’s just get on with business and accept that that’s the way life is.

Personalising it is one of the ways you can really change that. I remember Mike Baird, when he was premier of New South Wales, going to Tamworth and joining the first cannabis meeting there, and having his mind fundamentally changed [on medicinal cannabis] on the back of the experience. And I remember Premier Andrews in Victoria talking about his attitude to euthanasia as a result of personal experience. If we can find more ways to do this – even publicising those personal examples as scenarios, as little icons in our publication process, in the discussion process to personalise the sadness, the trauma and the impact, it will make a positive difference.

It’s very much the same with disadvantaged and sometimes socially disruptive youth. When you sit down and they tell you the journey that led them to where they are, certainly in my experience I think, if I’d have had any experience like this young guy, I’d be doing exactly what he’s doing and “T HE M O M E NT YO U H E A R IT probably a lot worse.

A ND YO U’RE TA L K ING TO TH E PE RS O N The moment you hear it and you’re talking to the person who has experienced it, unless you don’t have a heart at all, instantly your attitude changes – you have a much wider understanding and you realise, ‘Gee, this is so important, we’ve got to do more than we’re doing now to deal with this’.

UNLESS YOU DON’T HAVE A HEART AT ALL, INS TA NTLY YO U R AT TITU D E CH A NGE S.”

But it is easy if you’re not that close to it to say, ‘Oh well, you know, you play the game, you take the knocks.’ I think that’s in human nature across the board; I’m not being critical of people there, that’s just the way we are.

And I think it is important for us to find ways to personalise these problems every opportunity we have – to try to understand, so that people really see below the surface in terms of the causes of this behaviour that we are so otherwise critical of. And every time I’ve dealt with people who have taken the time to look, their attitudes have changed, without exception.

Fantastic, thank you, thanks a lot for that.

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W H O H A S E XPE RIE NCE D IT,

THE WORLD IS GET TING C R E AT I V E F O R I O A D 2022 From one single event more than two decades ago to 700+ events globally in 2021, International Overdose Awareness Day (IOAD) is ramping up again.

Creative and meaningful projects are being planned around the world, as we come together to shift the dial on overdose and end this crisis.

“IOAD is really important to do two things: improve community understanding and response so we see fewer overdoses in the future, and also to provide an opportunity for people impacted by overdose to grieve without shame or stigma,” explains Penington Institute CEO, John Ryan.

“People are dying from overdose every day and it doesn’t get the attention it deserves. In Australia, overdose deaths have far exceeded the road toll for many years, yet we don’t talk about it nearly enough.

Our challenge, as a community, is to prevent the future loss of life. IOAD provides an opportunity to actually talk about the issue, and I’m really encouraged by the diversity of events we’re seeing being planned for 2022.”

Tasmania’s Alcohol, Tobacco and other Drugs Council (ATDC) is asking people across the state to fold paper origami cranes for IOAD, in a beautiful

display of Senbazaru – the Japanese art of folding 1,000 paper cranes to make wishes come true. Asking the community to participate in a state-wide Senbazaru, the ATDC aims to raise awareness and pay tribute to Tasmanians lost to overdose, which is sadly more than one person each week.

Back on mainland Australia, Rotary Mount Gambier West and The Limestone Coast Drug Action Team in South Australia are hosting their second IOAD Blue Lake Vigil with public speakers and a minute of silence to remember those lost to overdose, support families and friends impacted by overdose, and actively reduce stigma regarding overdose.

In IOAD’s birthplace of Melbourne, cohealth is hosting the Beyond the Stigma Laneway Light Exhibition. From 25–31 August a city laneway will be lit up with images and artworks created by people who have lived experience of drug dependence, either current or past, personal or indirect.

The project aims to highlight the stigma associated with drug use, promote greater compassion and care for people

How to participate in IOAD 2022 1. Wear purple 2. Host an event 3. Share information 4. Learn more at overdoseday.com

who are drug dependent and create conversations about health-based responses to drug use in the community.

Outside of Australia, momentum is also gathering. The West Africa Drug Policy Network (WADPN) is partnering with Focus GH to lead #LetsWalk2EndOverdose in Accra, Ghana.

Across the Atlantic, people will be walking together at events across North America, from Abbotsford in British Columbia to Casa Grande in Arizona and Conroe in Texas. Butterflies will be released in Rockaway, New Jersey and balloons will be launched in Dolton, Illinois.

Everyone who is part of the growing IOAD movement has the same goal: to end the overdose crisis. How this is done depends on each context and the unique challenges facing each community. Whichever way you intend to mark IOAD this year, remember that your participation does make a difference.

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FROM ‘ PA S S I N G T H E B U C K ’ T O I N T E G R AT E D C A R E C O - O C C U R R I N G M E N TA L H E A LT H A N D S U B S T A N C E U S E C R I S E S

In February 2019, after years of pressure from people living with mental illness or psychological distress, families, carers, and health care professionals, the Victorian government established a Royal Commission into the mental health sector.

The commission found that Victoria’s mental health system had “catastrophically failed to live up to expectations.” Over 3,000 submissions were made, the majority by overwhelmed family members who felt they had been left alone to care for afflicted loved ones.

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One of those submissions came from my mother, Mary K Pershall: “In 2015, my daughter killed her elderly housemate,” Mary told the gathered families and journalists at the public hearings.

Author: Katie Horneshaw “In the years preceding that day, my family and I tried everything we could think of to get Anna help for her escalating mental health and substance use issues. But despite a clear pattern of severe mental illness, psychosis, uncontrolled substance use, self-harm, and violence, we couldn’t find a single service to provide Anna with the comprehensive residential care she desperately needed.

She was ‘too addicted’ for the mental health services and ‘too mentally ill’ for the alcohol and drug services. Now, a man is tragically dead, and my daughter is in the only publicly funded long-term residential mental health facility in Victoria: prison.”

My family’s submission was one of hundreds to call out the health system for failing people with co-occurring mental health and substance use issues. Families spoke of stigmatising attitudes, disorganisation and lack of communication between the mental health and alcohol and other drug (AOD) sectors, and of being turned away from each sector due to the presence of symptoms managed by the other. They told stories of loved ones who had slipped through the cracks, many of whom were yet to recover, or had already been lost. Victoria isn’t the only state to be plagued by these issues: lack of integrated, respectful crisis care for people with co-occurring needs is an Australia-wide problem.

tell you to be honest and disclose your drug use, but when you do, they judge you and turn you away.”

“My observation is that people learn not to disclose their drug use to health services,” explains Will Tregoning, founder of Sydney’s UnHarm, a non-profit seeking to challenge stigmatising assumptions about drug use by mentoring people who use drugs to ‘come out’ and share their stories publicly. “They have perfectly reasonable fears of being discriminated against and misunderstood.”

Frankie, who was media trained through UnHarm’s mentoring program, continues: “The nurses and doctors at hospitals have this attitude that people who use drugs are dishonest because of their addictions, but we have no other choice if we want a chance at accessing care. We don’t want to lie – we are forced to.” As Will adds, “People who use drugs need to feel they can disclose their history without potential adverse impacts on their care.”

Patrick Lawrence is the CEO of St Kilda’s First Step, one of the few services in Victoria designed to serve people with co-occurring needs. “The system was built on the assumption that there is little overlap between people with substance use issues and those with mental health issues. In reality, these problems go hand in hand the vast majority of the time.” The result is a system notorious for buck-passing.

“We hear all the time about people who have fronted up to hospital in acute crisis and been told that they need to ‘deal with the drug issue first’. They are handed a pamphlet for a rehab and sent away.”

But, as Frankie learned, accessing rehab can be just as tough: “I was told by people in mental health that I needed to get ‘clean’ before they’d treat me. I managed to get into a detox facility and while I was there I spent all day, everyday, calling rehabs – most told me they weren’t qualified to take on someone with mental health needs, or they were way too expensive, or they had years-long waiting lists. I was lucky to finally find somewhere that was willing to take the fee straight from my Centrelink payment.”

According to Robert Stirling, CEO of the Network of Alcohol and other Drugs Agencies (NADA) in New South Wales, the problems start with a workforce culture of stigma towards people who use drugs. “In hospitals in particular, there can be an attitude that people who use drugs are less deserving of crisis care, due to perceptions that they ‘did this to themselves’, My sister had no such luck. “After finally reaching the top of the waiting list for Victoria’s PARKS mental health program, or that their problems are ‘all just caused by the drugs’.”

Anna was expelled on the first day,” Mary explained at the Royal Commission hearings. “She had stashed backups of her Frankie (not her real name), a Sydneysider who spent years prescribed medication in her clothes because she was afraid trying to get help for a combination of depression, anxiety, that she wouldn’t be given enough meds to subdue her and problematic use of methamphetamine, was on the withdrawals. The staff told her she’d broken a rule, and she receiving end of the culture of stigma. “When you’re already was kicked out…. No one would take Anna on.” thinking about killing yourself and you’re there because you’re desperate for support, being shamed and blamed is enough to tip some people over the edge.” she says. “They

Currently, hospital psychiatric wards are the only large15

The sad truth is that in the absence of long-term residential care for people like Anna with complex or co-occurring needs, prisons will continue to function as de facto mental health wards.

scale services equipped to take on people with co-occurring needs who are at crisis point. After years of being turned away from services, my sister’s untreated schizo-affective disorder, uncontrolled drug use, and resulting psychosis finally landed her on an involuntary hold at a psych ward.

My family was elated. It never occurred to us that Anna would be discharged – we assumed that once the severity of her issues had been recognised by health staff, it would be incumbent upon them to ensure she was looked after. But we were wrong. “The hospital discharged my daughter into the care of man twice her age who had worked as her driver in his capacity as a volunteer for a local respite organisation.” said Mary. “We couldn’t believe the psychiatric staff hadn’t taken into account Anna’s lack of capacity to give informed consent, the age of the man, or the ethics of him showing a romantic interest in a mentally ill person he’d worked with.”

The next time Anna was discharged from an involuntary hold, she begged the psych nurses to let her stay. “She didn’t trust herself,” Mary continued. “She didn’t feel in control of this demon inside her that wanted to hurt her and the people around her.” The nurse on duty told Anna “This isn’t a hotel”, and she was sent to a boarding house where people were fighting and using meth.

Gillian Clark, project worker for the mental health royal commission at the Victorian Alcohol and Drug Association, observes that “The psych wards are so short on staff and beds that they can only take people on for a few days, then they are discharged back to the situation they came from – or sometimes worse.”

With so many complex problems, Victoria’s Royal Commission offered a rare glimmer of hope for the possibility of workable solutions for the mental health and AOD sectors and a

potential model for other states. The Victorian government accepted all of the commission’s 65 recommendations, including one that specifically urged integrated care and nonexclusion from treatment for people with co-occurring mental health and substance use issues.

The state Department of Health is currently in the process of translating the recommendation into actionable guidance for the AOD and mental health sectors. But in the meantime, complex problems remain unaddressed. Again and again, people I spoke to identified a need for comprehensive anti-stigma training of hospital and mental health workers.

“We need to be working to foster a culture of respect for all patients,” says Patrick.

The conclusion to my sister’s story remains unknown, but for now, she is safe, medicated, fed, and getting a chance to practice the social and self-care skills she had yet to master on the outside. The sad truth is that, in the absence of longterm residential care for people like Anna with complex or co-occurring needs, prisons will continue to function as de facto mental health wards. There is nothing that we can do now to take back the awful thing my sister did. And despite the lack of support in the preceding years, Anna takes responsibility for her crime and feels that her sentence, of 13-17 years, is a fair one.

What we can do is focus on changing things so other people in situations like Anna’s have access to appropriate health care for co-occurring conditions. As Gillian points out, “Health care is not something that should ever be denied.

Healthcare is a human right.”

You can read more about Anna’s story here and here.

16

THE

CALENDAR OF EVENTS

BULLETIN

3 WED

AUG 10:00 am

Insight Exploring Patients’ Experiences with Depot Buprenorphine and their Motivations to Discontinue with Dr Simon Clay

Online Event info: bit.ly/3P669rX

AUGUST + SEPTEMBER

8

9

AUG 12:00 pm

Online Event info: bit.ly/3chJYR6

9

Turning Point

TUES

TUES

AUG

Online

AUG

Online

1:00 pm

22

IOAD 2022 Crane Folding Session

MON

AUG 12:00 am

Online Event info: bit.ly/3o7h8Fn

23

25 26

Youth Focussed AOD Practices

to

AUG

13

Online Event info: bit.ly/3P669rX https://insight.qld.edu.au

10:00 am

Women’s Alcohol and Drug Service

TUES

AUG

Online

12:30 pm

Event info: bit.ly/3czMAtr https://www.thewomens.org.au

3

Women’s Alcohol and Drug Service

THURS

The impact on infants exposed to methamphetamine in pregnancy with Dr Anna Tottman

SEPT

Online

12 pm

Event info: bit.ly/3axWSKd https://www.hrvic.org.au

WA Govt Mental Health Commission An introduction to trauma informed care and practice

Online Event info: bit.ly/3uOha9c https://www.mhc.wa.gov.au/

17 WED

AUG 10:00 am

Insight Comorbid Mental Health and Drug & Alcohol Addressing the “cracks” in the system with Professor Nick Lintzeris & Dr Sandra Sunjic

Online Event info: bit.ly/3uMcCQp https://insight.qld.edu.au

24 31 to

AUG

7 WED

CoHealth Beyond the Laneway – Laneway Light Exhibition

Melbourne CBD Event info: bit.ly/3Pv2KTj

Insight Living the work. Exploring lived experience in the AOD workforce with Victoria Kostadinov

Online

SEPT

Event info: bit.ly/3P669rX https://insight.qld.edu.au

ATDC Tasmania IOAD 2022 Crane Folding Session

THURS

SEPT

Event info: bit.ly/3ANztil

Mental health and methamphetamine use in pregnancy with Dr Tram Nguyen

https://www.atdc.org.au/

YSAS

10:00 am

https://www.turningpoint.org.au

https://www.thewomens.org.au

ATDC Tasmania

AUG

https://www.atdc.org.au/

A multi-disciplinary approach to managing methamphetamine use in pregnancy

Event info: bit.ly/3yAQWYU

9 TUES

Connect & Learn August 2022 “Every time we relapse, I learn more” with Dr Samuel Brookfield

12:30 pm

Online Event info: bit.ly/3chJYR6 https://www.atdc.org.au/

17

IOAD 2022 Crane Folding Session

MON

https://insight.qld.edu.au

Women’s Alcohol and Drug Service

ATDC Tasmania

Welcome to the first of The Bulletin’s bimonthly event calendars where we feature events from across Australia relevant to the NSP workforce.

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