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2 Disclaimer Inherent Limitations This report has been prepared as outlined in the Introduction section. The report is solely for the purpose and use of the Central and Eastern Sydney Primary Health Network. Central and Eastern Sydney PHN is a business division of EIS Health Limited ABN The report has been prepared through a consultancy process using specific methods outlined in the Methodology section of this report. ConNetica has relied upon the information obtained through the consultancy as being accurate and ConNetica has not undertaken any auditing or other forms of testing to verify accuracy, completeness or reasonableness of the information provided or obtained. Accordingly, ConNetica can accept no responsibility for any errors or omissions in the information provided shown in this report based upon information provided. Suggested Citation Central and Eastern Sydney Primary Health Network. (2016). Alcohol and other Drugs Prevention Needs Assessment, April Central and Eastern Sydney Primary Health Network, Kogarah, NSW. Page 2 of 59

3 Acknowledgements A number of consumers, carers and stakeholders have contributed to this document. Central and Eastern Sydney PHN would like to thank: Our interagency partners for providing data, expertise, and information; The CESPHN Clinical Council and Community Council who have been instrumental to developing our understanding of the current system and opportunities for improvement; A range of peak bodies who provided support and guidance - including the Network of Alcohol and Other Drug Agencies (NADA); and The Mental Health Policy Unit, Brain and Mind Centre, University of Sydney. Most importantly, we wish to thank our local communities, consumers and carers. We have been fortunate to have received input from a number of different consumers through consultations and from hundreds of community members who provided honest and necessary input regarding their experiences of care. Thank you. Your experience, and the experiences of your friends and families has told us that we must do better. Project Team Finally, CESPHN would like to thank the project team: Mariam Faraj Executive Manager, Programs, CESPHN Catherine Goodwin Development Manager Mental Health, Alcohol & Other Drugs, CESPHN Karen Frost Health Planner, CESPHN Nathalie Hansen Manager Strategy and Evaluation, CESPHN David MacGrath David MacGrath Consulting ConNetica John Mendoza, Larisa Karklins, Peter Lockett, Mary Hackett. Page 3 of 59

4 Table of Contents Table of Contents 4 Executive Summary 8 Introduction 10 Purpose 10 CESPHN Region 10 Consultation and data gathering 11 Alcohol and other drug service mapping 12 Overview 12 Sydney Local Health District (SLHD) 13 South Eastern Sydney Local Health District (SESLHD) 14 St Vincent s Health Network 15 Primary Care 15 Non-Government Providers 16 Service Utilisation Measures 17 Region Wide Measures - General Hospital 17 Funded Specialist D&A Services 18 Primary Care 20 Non Government Organisations 21 Population Measures of Need 25 Prevalence Data 25 Population Modelling 28 Residential Rehabilitation 30 Screening and brief Intervention 31 Populations with Special Considerations 31 Aboriginal and Torres Strait Islander Peoples 31 LGTBIQ Community 32 Those in contact with the Criminal Justice System 33 Culturally and Linguistically Diverse Communities 34 Homelessness 35 Young People 35 Gaps and Priorities 37 Standard Service Configurations and Uses 37 Relative Roles and Responsibilities of Funding Bodies 37 Gap Analysis 38 Priorities for Action 39 Appendices 56 Appendix 1 Example of a residential rehabilitation care package. 56 Page 4 of 59

5 List of Tables Table 1: Summary of Drug & Alcohol Services by LGA. 3 Table 2: Non-Government AOA Providers in CESPHN Region 16 Table 3: CESPHN DRG presentations and relative utilisation 17 Table 4: D&A hospital utilisation by place of residence within CESPHN 18 Table 5: Funded Ministry D&A Service Agreement Targets by LHD within CESPHN 19 Table 6: Demographic data on NGO service utilisation for CESPHN 2014/15 21 Table 7: Source of referral to NGO s for CESPHN region 22 Table 8: Treatment types by drug type provided for CESPHN NGO s 23 Table 9: Primary Drug of Concern for CESPHN NGO s 24 Table 10: Epidemiology of drug and alcohol problems 25 Table 11: CESPHN estimated population prevalence of drug disorders at 2016 and Table 12: Age representation in drug disorders in a general population. 27 Table 13: Severity and Modelled Treatment rates 28 Table 14: Estimated D&A resourcing needs CESPHN region. 30 Table 15: Number of screening Interventions required in the primary care setting by drug type for a standard 100,000 population and the CESPHN population. 31 Table 16: Outcomes of the health needs analysis 40 Table 17: Outcomes of the Service Needs Analysis 44 Table 18:. Opportunities, priorities and options 49 List of Figures Figure 1: Map of D&A service provision across PHN 12 Figure 2: Example of epidemiology and treated prevalence using alcohol use in year olds 29 Page 5 of 59

6 Abbreviations and definitions Abbreviation ABF ABS AHP AIHW AOD ATSI AusBoD BMC CALD CES CESPHN CPD DASP DoH DRG ED ESMCL GP IGCD IPS IRSAD LGA LGBTIQ LHD LHN Definition Activity-based funding Australian Bureau of Statistics Allied Health Professional Australian Institute of Health and Welfare Alcohol and Other Drugs Aboriginal and Torres Strait Islander Australian Burden of Disease Study Brain and Mind Centre, University of Sydney Culturally and Linguistically Diverse Central Eastern Sydney Central Eastern Sydney Primary Health Network Continuing Professional Development Drug and Alcohol Service Planning Tool Department of Health Diagnosis-Related Group Emergency Department Eastern Sydney Medicare Local General Practitioner Intergovernmental Committee on Drugs Individual Placement and Support Program Index of Relative Socio-Economic Advantage and Disadvantage Local Government Area Lesbian, Gay, Bisexual, Transgender, Intersex, and Questioning Local Health District Local Health Network Page 6 of 59

7 Abbreviation MBS MDS MERIT MHCC MHDAO NADA NAPOOS NGO NMHC OOP OSP OTP PBS PCEHR PHN RACGP SEIFA SESLHD SESMCL SLHD WHO Definition Medicare Benefits Schedule Minimum Data Set Magistrates Early Referral into Treatment Mental Health Coordinating Council Mental Health and Drug & Alcohol Office Network of Alcohol and Other Drug Agencies Non Admitted Patient Occasions Of Service Non-government Organisation National Mental Health Commission Out of Pocket (expenses) Opiate Substitution Program Opiate Treatment Program Pharmaceutical Benefits Scheme Personally Controlled Electronic Health Record Primary Health Network Royal Australian College of General Practitioners Socio-Economic Indexes for Areas South East Sydney Local Hospital District South Eastern Sydney Medicare Local Sydney Local Hospital District World Health Organisation Page 7 of 59

8 Executive Summary A three-step process is anticipated to build the policy framework for drug and alcohol planning and commissioning across the Central and Eastern Sydney Primary Health Network (CESPHN). The first stage is this detailed needs assessment that assesses health and service delivery needs, identifies service gaps and improvements and identifies a range of possibilities for action. The second step is the development of a regional operational drug and alcohol plan that commits to actions that can improve the treatment service system within the region. The final step is the commissioning process and associated framework that will seek to effectively disperse funds for system improvement. Key issues about CESPHN include its catchment area, potential growth and population. This PHN covers 16 local government areas and has a population of 1.4 million, making it one of the largest population coverages of any PHN in Australia. By 2031 the CESPHN region's population will reach more than 1.85 million, an increase of more than 25% from its current population, and the cultural diversity that is clearly identifiable is likely to increase further. Almost half (44.6%) of the region's population was born outside Australia, significantly higher than NSW as a whole, and more than one third (35.2%) identify as speaking a language other than English at home compared to 21% for NSW. 1 The area totals 632 square kilometres from the Pacific Ocean to Strathfield and from the Sutherland Shire to Sydney Harbour. This PHN catchment aligns with South Eastern Sydney Local Health District (SESLHD) and Sydney Local Health District (SLHD) boundaries, and also includes the St Vincent s Hospital Network, a separate entity contained within the SESLHD catchment. Finally the PHN also covers Lord Howe Island, off the coast of NSW. 2 This detailed Alcohol and Other Drug Needs Assessment for the CESPHN identifies characteristics that are unique to this region which must be considered when determining future commissioning of alcohol and other drug (AOD) services. In this region, alcohol is the primary drug of concern accounting for 61% of presentations and amphetamines second accounting for 10.7%. Key demographic and service attributes include: High number of homeless people which correlates with expected higher prevalence rates of alcohol disorders (37%) and other drugs (24%) High number of released prisoners who settle in this region upon release from prison. This cohort has an expected 11 times higher rate than the average population for AOD disorders High number of Lesbian, Gay, Bisexual, Transgender, Intersex, and Questioning (LGBTIQ) people, with an expected methamphetamine usage rates, and rates of injecting drug use that are up to four times the general population High prevalence (12%) of Aboriginal and Torres Strait Islanders utilising AOD outpatient services, yet only making up 0.7% of the population in the CESPHN catchment Exceptionally low number of pharmacies participating in the the provision of Opiate Substitution Treatment - less than 10% as compared to the state average of 30% Low number of GPs, out of the more than 2,000 practicing GPs actively engaged in supporting and referring patients with AOD needs Ibid. Page 8 of 59

9 Higher than average prevalence of AOD Disorders requiring hospitalisation within CESPHN Low number of specialists actively engaged in supporting/referring patients with AOD needs Low rates of co morbidity service provision (mental health and alcohol and drug) Lack of appropriate withdrawal and rehabilitation services for specific cohorts including aboriginal and Torres Strait Islanders, Culturally and Linguistically Diverse (CALD) people, people recently released from prison, youth, LGBTIQ and people with complex needs Lack of residential services appropriate for families / children (particularly women), and Very low rate of treatment services for alcohol and other drugs relating to counselling (15.9%), information and education (0.16%) and support and case management services (2.7%). Hence a significant number of referrals do not proceed beyond an assessment. These issues combined with national issues impacting provision of AOD services including: uncertainty and or short term funding for AOD service providers, especially in the community sector inadequate capital spending components in funding to enable the establishment of necessary infrastructure lack of provision of integrated service provision across a range of service sectors that address a person s full range of interdependent needs lack of clear accountabilities between LHDs and PHNs in relation to service provision and allocation of spending on AOD health needs Lack of detailed and easily accessible mapping of AOD needs, existing services and performance metrics Ageing AOD workforce, and Lack of AOD staff trained in mental health and AOD and providing dual diagnosis and service. In responding to this local CESPHN context and the national AOD situation, a detailed action plan has been developed to address these multiple issues. This document addresses 6 key areas, including: Governance and Oversight Service Capacity integrated service provision Populations with special considerations Clinical complexity and clinical pathways Population health interventions Program Infrastructure, workforce development and metrics By using the information detailed in this report, the CESPHN is well positioned to develop, implement and evaluate a comprehensive and regionally relevant AOD plan that involves relevant stakeholders, aligns with and complements other relevant primary health initiatives and focuses on the attainment of sustainable outcomes. This document provides a solid foundation for addressing and reducing the region s AOD needs. Page 9 of 59

10 Introduction Purpose This paper provides an objective assessment, to the extent possible, of alcohol and other drug health and service needs within the geography covered by the Central and Eastern Sydney Primary Health Network (CESPHN). The impetus for this process is twofold. First the Commonwealth Government recently recommissioned Primary Health Networks (PHNs) across Australia with an increased remit with regard to local planning and service commissioning with an intent to get more effective local solutions and to enable better joined up care across sectors. Second, the Government Responses to the National Ice Taskforce, and the National Mental Health Commission Review, has led to a transfer of accountabilities for commissioning in Mental Health and Alcohol and Other Drugs to the new national network of PHN s. The Government response to the National Ice Taskforce Report 3 has included funds for new initiatives including $241.5 million in additional funding for PHNs to commission further alcohol and other drug treatment services to meet local need with a focus on culturally appropriate mainstream services and Indigenous-specific services. A three-step process is anticipated to build the policy framework for drug and alcohol planning and commissioning across PHNs. The first stage is a detailed needs assessment that assesses health and service delivery needs, identifies service gaps and improvements and identifies a range of possibilities for action. This document undertakes that task. The second step is the development of a regional operational drug and alcohol plan that commits to actions that can improve the alcohol and other drug treatment service system within a PHN region. The final step is the commissioning process and associated framework that will seek to effectively disperse funds for system improvement. There are 31 PHNs across Australia, with 10 based in NSW. Each PHN has unique geographical, demographic and service configuration characteristics that are relevant considerations for a policy and planning process. CESPHN Region The Central and Eastern Sydney catchment covers 16 local government areas and has a population of 1.4 million in the 2011 Census, making it one of the largest population coverages of any PHN in Australia. By 2031 the CESPHN region's population will reach more than 1.85 million, an increase of more than 25% from its current population, and the cultural diversity that is clearly identifiable is likely to increase further. Almost half (44.6%) of the region's population was born outside Australia, significantly higher than NSW as a whole, and more than one third (35.2%) identify as speaking a language other than English at home compared to 21% for NSW. 4 In general terms the LGA s covered by the PHN have relatively low levels of disadvantage on the Index of Relative Socio-Economic Disadvantage compared to NSW as a whole, however areas such as Botany Bay LGA have higher levels of disadvantage than the state average. 5 The age breakdown in the PHN is largely consistent with the state averages. 3 Commonwealth of Australia, Department of the Prime Minister and Cabinet, Final Report of the National Ice Taskforce SESLHD Health Services Plan Page 10 of 59

11 The area totals 632 square kilometres from the Pacific Ocean to Strathfield and from the Sutherland Shire to Sydney Harbour and also includes Lord Howe Island, off the coast of NSW. 6 The PHN catchment aligns with South Eastern Sydney Local Health District and Sydney Local Health District boundaries, and also includes the St Vincent s Hospital Network, a separate entity contained within the SESLHD catchment. The region covered by the PHN includes three major teaching hospitals, St Vincent s, Royal Prince Alfred and Prince of Wales, as well as a number of tertiary district hospitals and specialist acute facilities. Included amongst the specialist facilities are the Sydney Children s Hospital, the Sydney Dental Hospital, the Sydney Eye Hospital, the Royal Hospital for Women and the Forensic Mental Health Hospital run by the Justice and Forensic Mental Health Network. Each day over 21,000 people attend one of 652 general practices and over 1,200 people attend Emergency Departments in the CESPHN region. There are over 2,000 GPs, over 5,000 allied health professionals and nearly 500 community pharmacists. 7 There are five major community health centres in the Sydney Local Health District, eleven across the South Eastern Sydney LHD and St Vincent s provides outpatient clinic services and a range of specialist outreach services. Consultation and data gathering This needs analysis was undertaken subject to consultation with senior staff in the three Local Health Districts within the CESPHN, the peak body for Non Government Organisations (NGOs) in NSW and senior Commonwealth Government health officials. Data was sourced from each of the bodies consulted with, and from datasets identified by them but which they did not hold. Relevant publically available data sets were also accessed, including those sets managed by the PHN. Given the timeframes associated with this analysis the data accessed was not exhaustive and with a more extensive lead-in time, a larger and potentially more precise data gathering process could be undertaken in a follow up analysis in It is recommended that Commonwealth Health officials consult with state health officials, either through the Standing Council on Health, or through bilateral arrangements, to improve access to relevant state data. 6 Ibid. 7 Central and Eastern Sydney PHN, Draft Strategic Directions Document, October 2015 as Page 11 of 59

12 Alcohol and other drug service mapping Overview There are three Local Health District run specialist alcohol and other drug programs in the region covered by the CESPHN, Sydney, South Eastern Sydney and St Vincent s, and a range of Non Government service providers. In addition, there are alcohol and other drug interventions provided by general practice and community pharmacy, and some residents of the PHN are able to access private treatment programs although in the main these are located outside the PHN boundaries. Finally, there are Community Drug Action Teams (CDAT s), organised by interested members of the community, who undertake population style interventions in the AOD area. Figure 1: Map of D&A service provision across PHN Page 12 of 59

13 The map above indicates 8 : NGO led drug health services (pink circle with white star centre), LHD led community drug health services (dark blue tear with white circle centre) Pharmacies who take part in the opioid treatment program (light blue circle with white star centre). The black dots on the map indicate train stations to demonstrate where services are in proximity to train lines. Table 1: Summary of Drug & Alcohol Services by LGA.9 LGA No. NGOs No. LHD led Drug Health Services No. Pharmacies in OTP Ashfield Botany Bay Burwood Canada Bay Canterbury Hurstville Kogarah Leichhardt Marrickville Randwick Rockdale Strathfield Sutherland Shire Sydney Waverley Woollahra Sydney Local Health District (SLHD) The SLHD has recently completed a Drug and Alcohol Strategic Plan that provides background on their service offering. The SLHD program provides the full suite of alcohol and other drug interventions with the exception of residential or day rehabilitation programs. It does provide community counselling and the associated components of rehabilitation that can be provided in that 8 Map and text taken from CESPHN baseline AOD needs assessment 9 Table taken from CESPHN baseline AOD needs assessment Page 13 of 59

14 setting. The services are provided at Canterbury, Concord and Royal Prince Alfred Hospitals (RPAH), and from community health centres at Redfern, Canterbury and Marrickville. A consultation/liaison service exists at the major hospitals and a telephone consult service is provided to Balmain Hospital. The SLHD AOD program has 127 staff and a budget of $13.5 million. 10 SLHD has an inpatient withdrawal unit located at Concord Hospital with twelve beds, access to six beds on the medical ward at RPAH, and access for co-admission to the short stay mental health ward at RPAH for complex co-morbid patients. The SLHD provides outpatient services for the Opiate Treatment Program (OTP) (also referred to as the Opiate Substitution Program (OSP)), medicated withdrawal and counselling services. Each of the major hospitals within the LHD provides an outpatient and counselling clinic and in addition there are specialist skills available for the treatment of Hepatitis C, pain management, for addressing drug use during pregnancy and for provision of services to clients entering treatment through the Magistrates Early Referral into Treatment (MERIT) program. The SLHD also has specialist services for those seeking assistance with cannabis disorders, provided on an outpatient basis. In summary the AOD services in SLHD are: 12 specialist withdrawal and stabilisation beds access to 6 general hospital beds for complex withdrawal Approximately 800 Outpatient Opiate Substitution Treatment places. 3 specialist Drug & Alcohol Outpatient Clinics Cannabis Clinic MERIT Program 127 FTE staff in total South Eastern Sydney Local Health District (SESLHD) SESLHD is currently undertaking its clinical service planning process for its alcohol and other drug Services that will provide more comprehensive mapping of its service resources. The services that it identifies that it provides includes: Withdrawal management services Hospital based liaison services Opiate Substitution Treatment Counselling and support services Chemical Use in Pregnancy Management Services Court Diversion Programs Cannabis Clinics 10 SLHD Drug & Alcohol Services Plan Page 14 of 59

15 Pain medication dependence services Needle and Syringe Exchange, and Co-morbidity management. The majority of SESLHD services are based in the Northern part of the sector proximal to the CBD, with sparse service provision in the Botany LGA, which is a high growth area. There is no designated detoxification unit in SESLHD although beds can be accessed at Sydney Hospital for withdrawals with complications, and St Vincent s provides a residential withdrawal service. There is a heavy emphasis on outpatient and ambulatory detoxification within the LHD. There is also a specialist drug and alcohol treatment centre, the Langton Centre, based in Surry Hills. SESLHD reports that there is no latent demand for Opiate substitution treatment, with manageable wait times, and good flow through to primary and community sector treatment for this group. St Vincent s Health Network St Vincent s provides inpatient treatment for alcohol and other drug problems through the Gorman House residential withdrawal unit, which is a 20 bed non-medicated withdrawal unit. This unit does not take complicated withdrawals involving likelihood of complex withdrawal symptoms, or in the presence of complex co-morbidity. In addition, St Vincent s operates the Rankin Court Treatment Centre, which offers community based treatment programs including: Assessment for opiate dependence Assistance with other drug and alcohol problems Commencement and stabilisation on medications for opiate dependence and Supervised reduction of opiate medications Daily supervised dosing and helping people move to community pharmacy dosing and private prescribers Assessment, referral and care coordination Crisis support and intervention Physical, mental and emotional health education and promotion HIV awareness information and education Referrals and ongoing consultations with specialised agencies and support services Mental health care and support Hepatitis C clinic St Vincent s also operates a number of unique services on a statewide basis including one of the few stimulant treatment programs and a number of telephone advisory services. Primary Care There are 38 pharmacies across the PHN region that are involved in the provision of Opiate Substitution Treatment. From the over 500 pharmacies that exist in the region, this is an exceptionally Page 15 of 59

16 low participation rate. The NSW state participation rate is approximately 30% of pharmacies involved in OST, whereas in CESPHN it is less than 10%. Strathfield and Woollahra LGA s have no pharmacies involved at all. Reasons for this low involvement require further interrogation, as pharmacy involvement is important for reducing overall patient congregation, normalising OST as part of medical treatment and increasing access for consumers. While there are over 2,000 GP s within the region, the number of these that are formally involved in specialist AOD treatment is likely to be low. Notwithstanding this, the majority would have to address alcohol and other drug problems in some form in their day to day practice, and as generalist practitioners should be expected to screen and brief assess for concerns. Therefore, while it is likely that only a handful are involved in the provision of OST or structured ambulatory detoxification, all GP s should be considered a potential part of the resource base to respond to problems, particularly for those requiring a brief intervention. Non-Government Providers There are a large number of Non Government Drug & Alcohol service providers in the region covered by the CESPHN. Some of these are broad spectrum psychosocial support providers with alcohol and other drug capacity and some are specialist AOD service providers only. The Sydney Medically Supervised Injecting Centre is a unique provider, with legislation preventing any other similar services. Table 2 below indicates the services in the region. Table 2: Non-Government AOA Providers in CESPHN Region (as provided by NADA). LHD Organisation Service South Eastern Sydney ACON Haymarket Foundation Odyssey House McGrath Foundation Salvation Army Salvation Army OASIS Youth Sydney Ted Noffs Foundation The Station Ltd Uniting Care Waverley Drug and Alcohol Centre Waverly Action for Youth Services Wayback Committee Womens Alcohol and Drug Advisory Centre Substance Support Service Haymarket Foundation Bourke Street Project Centre HIV/AOD Program Odyssey House Shop Front Alf Dawkins Detox William Booth House Youth Drug and Alcohol Program/Choices Program for Adolescent Life Management The Station Medically Supervised Injecting Centre Waverley Drug and Alcohol Centre Waverly Action for Youth Services WAYS Wayback Committee Jarrah House Detoxification Jarrah House Rehabilitation Sydney Alcohol and Drug Foundation NSW Kathleen York House Aftercare Kathleen York House Residential Kathleen York House Transition Page 16 of 59

17 Catholic Care Holyoake Co.As.It. Construction Industry Drug and Alcohol Foundation Glebe House Guthrie House Leichhardt Women's Community Health Centre Mission Australia Sydney Women's Counselling Centre Weave Youth and Community Services Inc WHOS Holyoake Family AOD Program Co.As.It. Foundation House Glebe House Guthrie House Leichhardt Women's Community Health Centre MA Centre - Drug and Alcohol Program Sydney Women's Counselling Centre WEAVE WEAVE Bush Circle WHOS Sydney Gunyah WHOS Sydney MTAR Men WHOS Sydney New Beginnings WHOS Sydney OSTAR2 WHOS Sydney Peppercorn WHOS Sydney RTOD WHOS Sydney Women's MTAR Service Utilisation Measures Region Wide Measures - General Hospital THE CESPHN has been provided with inpatient utilisation data broken down by Diagnostic Related Groups (DRG s), the groups used for determination of activity-based funding (ABF) to hospitals. This data is useful to identify absolute numbers of presentations related to drug disorders codes, and also to identify relative rates of presentation across PHN s when adjusted for population, age and sex. The table below captures absolute numbers for CESPHN and the relative utilisation rates for the available DRG codes. A relative utilisation rate of 100 would be average. A rate of more than 100 is above average, and less than 100 below average. The rankings below indicate where amongst the 31 PHN s CESPHN stands. The higher the ranking, the lower the utilisation rate, thus a ranking of 21 st indicates the PHN has a higher utilisation rate than 20 other PHN s. Table 3: CESPHN DRG presentations and relative utilisation DRG Disorder Code Presentations RU rate Ranking of RU Alcohol Intoxication Withdrawal st Drug Intoxication and Withdrawal th Alcohol Use Disorder and Dependence th Opioid Use Disorder Insufficient data* Page 17 of 59

18 Other Drug Use Disorder st Same Day Treatment alcohol th Same Day Treatment Drugs Last* Combined alcohol and drugs th * Data not available for all PHN s It is clear from these data that the prevalence of alcohol and other drug disorders requiring hospitalisation within CESPHN is substantially higher than the average across all codes. In the combined data CESPHN has the highest number of presentations in absolute terms and in relative terms the third highest. Some caution should be exercised here with interpretation as these figures are dependent upon the accuracy of the coding by clinical and administrative staff. It is noteworthy that the five PHN regions with the highest relative utilisation rates all have senior staff specialists in AOD in their regions and associated consultation liaison services that would boost identification and coding. Data has also been provided that allows for comparison within the PHN across its various sub regions. This information is presented in the table below across all AOD codes, as the data for individual codes us small and in many cases not collected across all sub regions. Table 4: D&A hospital utilisation by place of residence within CESPHN Sub-Region Relative Utilisation Separations Sutherland - Menai - Heathcote Canterbury - Central and Eastern Sydney Part Kogarah - Rockdale Hurstville Cronulla - Miranda - Caringbah Strathfield - Burwood - Ashfield Canada Bay Botany Sydney Inner City ,530 Eastern Suburbs - South Eastern Suburbs - North ,035 Leichhardt Marrickville - Sydenham - Petersham Grand Total ,862 Of note here is the relatively high utilisation rates of residents from the Botany and Eastern Suburbs South area within the context of the nearest specialist alcohol and other drug service being based in Surry Hills. Funded Specialist D&A Services While each LHD AOD service reports it activity in slightly different ways and with greater or lesser Page 18 of 59

19 detail in its data, the most effective way to assess its resourcing is with reference to the activity targets set in the LHD service agreement with the Ministry of Health. This document outlines what key activity is required in return for the budget provided to the Local Health District. The figures contained in the service agreement are based on the average level of activity for the last six years for each activity type, thus providing a relatively stable measure of overall performance over time. Table 5 below indicates the agreed targets for the alcohol and other drug program for each LHD that the Ministry designates have been resourced for the 2015/16 financial year. Table 5: Funded Ministry D&A Service Agreement Targets by LHD within CESPHN. Service Type SESLHD SLHD St Vincent s Total Inpatient and Outpatient Withdrawal Management (Closed Treatment Episodes) Counselling, Outpatient, Consultation/Liaison and Case Management (Closed Treatment Episodes) Opioid Treatment Program (Total numbers dosed or prescribed) Despite the funded targets above providing the most robust measure of LHD alcohol and other drug service resourcing the consultation process with senior LHD AOD staff highlighted some specific performance issues that were highlighted In Sydney LHD annual inpatient AOD separations have increased by approximately 40% between 2009 and This is effect would be captured by the six year averaging process in the service agreement, however if the trajectory continues without additional resourcing then resourcing will need to be accessed from elsewhere in the LHD or the service growth capped. In 2014/15 SLHD provided treatment to 815 persons on the OTP program, which is significantly in excess of their service agreement targets. In SLHD outpatient clinics provided 1,102 episodes of care in 2014/15, again in excess of activity targets. A proportion of these would be open episodes which would not be captured by the target, however this proportion was not identified. SESLHD provided data on their consultation liaison (C/L) service provision during the 2015 calendar year. Over that period there were 1,816 consultation episodes to patients being managed by other medical teams, with more than three quarters of these at Prince of Wales and St George Hospitals, and two thirds being aged between On average SESLHD provided 3.5 contacts to these people to assist with their overall management. The primary source of referral was the Emergency Department with 42.5%, followed by Mental Health with 22.5%. This is an example of the incompatibility of LHD data. Clearly these all cannot be episodes for the purposes of the service agreement targets, given how many there are. Some of these must be excluded for the purposes of Ministry data collection. This is an example of the importance of state health managed data and its potentially greater consistency across LHD s. The vast majority of C/L cases at SESLHD had alcohol as the primary drug of concern accounting for 61% of presentations, with amphetamines second although with only 10.7% of presentations. Page 19 of 59

20 The SESLHD Health Services Plan indicates that in the five year period from 2005/6 to 2010/11 the Drug & Alcohol service provided 4.4% of the 2.7 million Non admitted Patient Occasions Of Service (NAPOOS) within the LHD, or approximately 118,800 NAPOOS. 11 If a small amount of growth in activity is assumed each year, this would mean by 2010/11 there was approximately 25,000 NAPOOS in that year. NAPOOS have no particular time requirement and can include consultations on the ward. Linking NAPOOS to the closed episodes of non-admitted care measured in the service agreement, is problematic. SESLHD have identified a particular cohort of patients with alcohol and other drug problems who are frequent attenders at ED and utilise a significant amount of resources. In a study at Prince of Wales Hospital they identified that 62 AOD patients were accounting for 9% of all Emergency Department presentations at the Hospital. By 2022 SESLHD is projecting, 950 separations for alcohol and other drugs per annum and 3,286 bed days. Two thirds of this activity is expected in the Northern part of the LHD. They are also projecting NAPOOS to grow to 2.6 million per year in 2021/22 and if AOD retains 4.4% of this figure then this would equate to approximately 115,000 NAPOOS per year. This would seem unlikely however without substantial new state investment, and the number should be viewed with caution until captured by concomitant resourcing in a service agreement. St Vincent s indicate that they are generally able to meet demand for the Opioid Treatment Program and for residential withdrawal services. Primary Care Access to locally relevant MBS data that could identify involvement of general practitioners in alcohol and other drug treatment has not been able to be accessed for this analysis. While an estimate of the involvement of pharmacists in OTP was provided, the data does not indicate the numbers who are accessing these pharmacies. Data in relation to GP involvement and pharmacy involvement may be accessible from the NSW Ministry of Health but not in the available time frames. Involvement of general practice in a formal shared care sense is traditionally low. Studies have investigated this and intimated that there are barriers preventing GPs from becoming more involved in treatment including 12 : a perception that GPs do not have a mandate to enquire about their patients drug and alcohol use; lack of adequate training as undergraduates and postgraduates scepticism and pessimism about treatment effectiveness perceived patient resistance discomfort discussing substance misuse time constraints, and a perception that drug users are chaotic and non-compliant 11 SESLHD Health Services Plan Sourced from McEvoy B. Addiction and addiction medicine: exploring opportunities for the general practitioner. Med J Aust 2008; 189 (2): Page 20 of 59

21 It would not be unlikely that similar findings could be applied to community pharmacy, along with complaints about the impact on the amenity of their businesses associated with treatment support for addiction medicine clients. This analysis is unable to make any statements regarding primary care AOD activity within CESPHN at this point in time. Non Government Organisations NADA, the NSW peak body for alcohol and other drug NGO s, is able to provide localised data by PHN on activity provided by local NGO s for the 2014/15 financial year. Drawing from the NADA database for the region covered by the CESPHN, the following demographic data has been made available. Table 6: Demographic data on NGO service utilisation for CESPHN 2014/15 Client Type Description Count Percent Other's drug use Own drug use Total Sex Count Percent Not stated/inadequately described Male Female Total Age Range Count Percent under 10 years years years years years years years and over Total Indigenous Description Count Percent Aboriginal and Torres Strait Islander origin Aboriginal but not Torres Strait Islander origin Neither Aboriginal nor Torres Strait Islander origin Page 21 of 59

22 Not Stated Torres Strait Islander but not Aboriginal origin Total Unsurprisingly given the nature of the treatment provided and its target cohort of those with severe dependence the majority of treated individuals are in the adult age range. The small numbers in the under 10 age range are likely children being treated in a family setting with their parents who have a drug use disorder. It is noteworthy that approximately 13% of all clients are Aboriginal, which is disproportionate to the representation in the population. Table 7: Source of referral to NGO s for CESPHN region Source of Referral Count Percent Self Family member/friend Residential alcohol and other drug treatment agency Court diversion Other criminal justice setting Other Non-residential alcohol and other drug treatment agency Family and child protection service Other non-health service agency Not stated/inadequately described Medical officer/specialist General practitioner Non-residential community health centre Education Institution Other hospital Psychiatric hospital Other residential community care unit Non-residential community mental health centre Police diversion Residential community mental health unit Workplace (EAP) Medically supervised injecting centre Total Page 22 of 59

23 Self-referral is the commonest form of referral in the D&A field although it often fails to recognise the assistance or direction provided to individuals prior to their efforts to make contact with the service. Very few people enter treatment without some form of social impetus, or adverse social event, and this is often the genesis for a self-referral concomitant with advice from a knowledgeable party, who is not identified within the data. Most noteworthy is the very small proportion of clients referred from general practice into treatment. This suggests little provision of ambulatory withdrawal within a treatment plan that then links to rehabilitation. This could be representative of low participation by general practice in treatment provision, or a reticence to refer to rehab after the provision of primary care treatment, or both. Table 8: Treatment types by drug type provided for CESPHN NGO s Main Treatment when Alcohol Count Percent Rehabilitation activities Assessment only Withdrawal management (detoxification) Counselling Support and case management only Information and education only Consultation activities Total Main Treatment when Methamphetamine Count Percent Assessment only Rehabilitation activities Withdrawal management (detoxification) Counselling Support and case management only Information and education only Total Main Treatment when Cannabis Count Percent Assessment only Rehabilitation activities Withdrawal management (detoxification) Counselling Support and case management only Information and education only Other Total Page 23 of 59

24 Main Treatment when Heroin Count Percent Rehabilitation activities Assessment only Withdrawal management (detoxification) Counselling Support and case management only Maintenance pharmacotherapy (Opioid) Total Assessment and rehabilitation feature as the predominant treatment types, which is consistent with the relative volumes of resources for each treatment type within the NGO sector. The data does not tell much, other than that a significant proportion of referrals go no further than an assessment, which raises a question regarding either the utility of the criteria for entry to services, or the knowledge of referring parties about the nature of the assessment criteria, or a mixture of the two. Table 9: Primary Drug of Concern for CESPHN NGO s Principal Drug of Concern Count Percent Alcohol Amphetamines Cannabinoids Heroin Benzodiazepines, nfd Opiate Pain Medications Methadone Cocaine Gambling Nicotine Buprenorphine incl suboxone MDMA/Ecstasy All others Not Stated Total This data is also unsurprising, given that many NGO services deal with clients who have substantial disorders, and as such the drugs with the higher dependence profiles are the most prevalent. It is noteworthy that amphetamines presentations exceed cannabis and heroin combined, a situation that would not have been the thought likely as recently as 10 years ago. Page 24 of 59

25 Population Measures of Need Prevalence Data The first step in preparing an analysis of need is to ascertain the population prevalence of the disorders to be responded to, in this case drug and alcohol dependence and misuse disorders. There are many papers that have attempted to measure the prevalence of drug and alcohol disorders in general terms using extrapolations of usage data. Alcohol and other drug disorder usage rates are highly susceptible to supply side characteristics for any given drug however, and distortions in supply side characteristics can lead to substitution of use patterns and subsequent disorder prevalence calculations at any given point in time. This can be demonstrated by heroin utilisation and dependence data from the late 1990 s, during a time of considerable oversupply, that manifested in higher overdose rates, ambulance callouts, and presentations to treatment services, than is seen currently or was seen in the 1980 s. However, it is not uncommon to observe drops in usage data for one drug alongside concomitant increases in use for another. The most appropriate source of data for general prevalence rates, and the source used by state health planners, is the Australian Burden of Disease (AusBoD) study. 13 It is also the source used for the National Drug and Alcohol Services Planning (DASP) tool under development by the Intergovernmental Committee on Drugs (IGCD). The national DASP process is being used by Local Health Districts and state health Departments to undertake planning for Drug & Alcohol service need. The recently released Western Australia Mental Health and Drug & Alcohol plan relies heavily on the DASP modelling for its assumptions of service need and associated policy responses. Given its widespread recognition by Governments within Australia it is appropriate to use in the current context. AusBoD looks at diagnosable illness as its basis for prevalence rather than usage rates, which is the primary data source of the National Drug Strategy Household Survey. The estimated number within a standard 100,000 person population with a diagnosable alcohol or other drug disorder estimated by AusBoD is contained within the following table. Table 10: Epidemiology of drug and alcohol problems 15 Drug Type Age Prevalence Alcohol ,061 Alcohol ,355 Alcohol 65+ 1, Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD. The Burden of Disease and Injury in Australia PHE 82. Canberra: Australian Institute of Health and Welfare, Western Australian Mental Health Commission. The Western Australian Mental Health and Alcohol and Other Drug Services Plan as on March 22, Based on the AusBod study (see 5 above) and sourced from the draft technical manual associated with the National DASP project. Page 25 of 59

26 Drug Type Age Prevalence Amphetamine Amphetamine Amphetamine Benzodiazepine Benzodiazepine Benzodiazepine Cannabis Cannabis ,765 Cannabis Opioids Opioids Opioids As such for every 100,000 people in a broadly representative population the DASP predicts: 8,838 will have an alcohol use disorder. 646 will have a methamphetamine disorder 465 will have a benzodiazepine misuse disorder 2,300 will have a cannabis misuse disorder 793 will have a non medical opiate (including heroin) misuse disorder. Translating this to the current and future populations of the CESPHN provides the following general assumptions regarding drug and alcohol misuse prevalence. Table 11: CESPHN estimated population prevalence of drug disorders at 2016 and 2031 Drug Disorder Type Standard Pop Rate Pop Prevalence Pop Prevalence Alcohol 8, , ,503 Methamphetamine 646 9,690 11,951 Benzodiazepine 465 6,975 8,603 Cannabis 2,300 34,500 42,550 Non medical opiate ,895 14,671 Total 13, , ,278 Page 26 of 59

27 It is also important to anticipate the particular age breakdown of likely presentations to assess the need for particular configurations or modalities of service delivery. The table below provides an age breakdown of presenting disorders within three main age cohorts. Table 12: Age representation in drug disorders in a general population. Age Cohort Standard Pop Rate across all disorder types CESPHN Population Prevalence 2016 CESPHN Population Prevalence Years ,740 31, Years , , Years ,960 30,784 The above numbers are of course, representative of all population groups as they would appear on an average basis within the general population. If a particular geography has an over-representation (above average) of a particular high, or low, prevalence group then that requires some reweighting. Within a given 100,000 population higher concentrations than average of certain sub groups increase the prevalence rates of the above disorders: The homeless population has been estimated to have vastly higher prevalence rates, as high as 37% for alcohol disorders and 24% for drug misuse disorders. 16 Those who are released from prison have much higher (approximately 11 times the general population) 17 prevalence rates of disorders and have a 3.5 times risk of death upon release than the general population. 18 It has been estimated that the majority of prisoners in NSW originate from, and return to, just 10 suburbs. 19 The LGTBI community has some estimates of drug usage rates substantially above the general population but little data is available on dependence disorders. Nonetheless methamphetamine usage rates, and rates of injecting drug use are up to four times the general population. Indigenous populations have complex patterns of usage and disorder prevalence which will be addressed at a later point in the paper. Assumptions about a general linear relationship with higher prevalence rates of disorders associated with higher population concentrations are not necessarily correct, however it is likely that there is an increased treatment need. Consideration will be given to the contribution of particular sub-groups to population prevalence rates in CESPHN, along with recommended responses, later in this analysis. 16 Fazel S, Khosla V, Doll H, Geddes J (2008) The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis. PLoS Med 5(12): e225. doi: /journal.pmed Butler T, Andrews G, Allnut S, Sakashita S, Smith NE, Basson J. Mental disorders in Australian prisoners: a comparison with a community sample. Aust N Z J Psychiatry Mar;40(3): Ingrid A. Binswanger, M.D., Marc F. Stern, M.D., Richard A. Deyo, M.D., Patrick J. Heagerty, Ph.D., Allen Cheadle, Ph.D., Joann G. Elmore, M.D., and Thomas D. Koepsell, M.D. Release from Prison A High Risk of Death for Former Inmates N Engl J Med 2007; 356: January 17, 2011 DOI: /NEJMsa Community Restorative Centre NSW statistics. Page 27 of 59