Medicine & Health

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Now showing 1 - 8 of 8
  • (2021) Byrne, Bonita
    Background: Aboriginal and Torres Strait Islander people are more likely to abstain from alcohol than non-Indigenous Australians, however, they are more likely to experience harms related to their own or others’ alcohol use. Factors such as lower socioeconomic status and poorer access to appropriate services have been identified as potential risk factors for increased alcohol-related harms. Another potential factor that has not yet been explored in the published literature is lateral violence as a result of conflict in Aboriginal communities, and how that conflict contributes to alcohol-related harms. Aims: This research investigates the reasons why conflict exists in Aboriginal communities. It explores how conflict is associated with alcohol-related harms experienced by Aboriginal Australians. Methods: A narrative literature review using systematic search strategies was conducted to identify published literature on the association between conflict and substance misuse in Aboriginal communities in Australia. This review searched 14 databases. Abstracts were systematically screened against inclusion criteria. Next, qualitative interviews were conducted with nine Aboriginal Elders and community members to explore their lived experiences with conflict and alcohol-related harms in their communities and potential healing approaches to address this. Interviews were conducted using a yarning method in one-on-one interviews to elicit participants’ stories. A thematic analysis was conducted using inductive and deductive coding. Results: The literature review identified nine studies which considered conflict and its association with substance misuse in Aboriginal communities in Australia. The main factors that contribute to alcohol use, conflict and the association between the two were colonisation, lower socioeconomic status, remoteness and social identity. Key themes from participants’ lived experience with conflict and alcohol-related harms identified in the interviews were: breakdown of family and community due to colonisation and displacement, alcohol use in the community, and experience of racism. Key recommended strategies for healing included cultural programs and increasing respect for Elders. Conclusion: This study furthered our understanding of the effects of colonisation on Aboriginal communities today. It identified how the breakdown of family and kinship ties have contributed to conflict and alcohol-related harms experienced by Aboriginal communities. It points to potential ways to build resilience among Aboriginal communities and prevent alcohol misuse and conflict.

  • (2022) Bosworth, Rebecca
    Within prison, a high prevalence of people living with human immunodeficiency virus (HIV) and opioid use disorder exist. Return to opioid use is common among people released from incarceration. Regardless of incarceration length, an estimated 85% of individuals return to opioid use within one year. Return to opioid use is associated with significant harms. Methadone may reduce return to opioid use and benefit people living with HIV and opioid use disorder due to increasing antiretroviral therapy (ART) adherence, engagement with healthcare services and reducing the risk of HIV transmission. This thesis utilises data from Project Harapan, a pre-release methadone maintenance treatment (MMT) program conducted between 2010 and 2013 in Malaysia. The overarching aim of this thesis was to explore different aspects of the pre-release MMT program among a sample of 310 men living with HIV and opioid use disorder in Malaysia’s largest male prison. This thesis comprises four studies. The first study describes the association between knowledge and attitudes and the choice to initiate pre- release MMT. Uncertainty towards methadone may be associated with MMT-related hesitancy and lower proportions of men choosing to initiate pre-release MMT. The second study uses the behavioural model for vulnerable populations as a framework to explore the association between other factors connected to healthcare utilisation and the choice to initiate pre-release MMT. Findings suggest being of Hindu faith, being prescribed (yet not taking) ART, currently being on ART during incarceration and having a more severe craving for heroin were associated with lower proportions of men choosing to initiate pre-release MMT. The third study demonstrates the impact of pre- release MMT initiation on return to opioid use following release from incarceration. The findings reveal that reductions in opioid use in the first 12 months post-release may be associated with the initiation of pre-release MMT. With HIV-related mortality closely linked with people living with HIV and opioid use disorder, the fourth study reports on a global scoping review of HIV/AIDS, hepatitis and tuberculosis-related mortality among people who experience incarceration. Globally, it remains difficult to locate good-quality infectious disease-related mortality data for prisons. Given the paucity, we located data to suggest the highest number of reported deaths over a 20-year period were attributable to HIV/AIDS (n=3,305), followed by TB (n=2,892), HCV (n=189), HIV/TB co-infection (n=173) and HBV (n=9). Increased investment to improve the reporting of key mortality indicators is urgently required. This research resulted in one published manuscript, two accepted conference abstracts and three manuscripts awaiting submission post the conference embargo period. Thesis conclusions refer to men who experience incarceration in Malaysia in a study conducted between 2010 and 2013. Globally, evidence supports the effectiveness of pre-release MMT on reducing opioid-related harms yet given the paucity of such data among men living with HIV and opioid use disorder who experience incarceration in Malaysia, no such evidence existed, and the effectiveness remained unknown. Therefore, these findings make a significant contribution to the literature in relation to this previously hidden population. This thesis demonstrates that opioid-related harms can be reduced when individuals initiate pre-release MMT. Working towards optimising MMT uptake and supporting individuals to pursue effective treatment for opioid use disorder may prevent opioid-related harms and poor HIV treatment outcomes experienced by this vulnerable population.

  • (2022) Colledge-Frisby, Samantha
    People who inject drugs (PWID) experience a range of clinical harms that contribute to morbidity and increase their risk of mortality. The literature has largely focused on the epidemiology of blood borne viruses (BBVs) in this population; however, other mental and physical conditions affect PWID that significantly impact quality of life. There are gaps in our understanding of the clinical profiles of PWID beyond the risk of BBVs which this thesis aims to address. This thesis employs various study designs to broaden our understanding of the clinical profiles of PWID. Firstly, three systematic reviews were conducted to synthesise the evidence and generate estimates of injecting frequency, non-fatal overdose, and mental health problems (i.e., depression, post-traumatic stress disorder [PTSD], suicidality, and non-suicidal self-harm) among PWID. Second, latent class analyses were performed using cross-sectional data from a national sentinel sample to examine profiles and correlates of PWID reporting recent injecting-related injuries and diseases (IRID). Finally, a large, linked cohort of people engaged in opioid agonist treatment (OAT) from 2001 to 2017 in New South Wales was analysed to examine the impact of OAT on hospitalisations for injecting-related diseases. Several key findings emerged from this thesis. Findings from the systematic reviews indicated that most PWID are injecting daily or more frequently and approximately one in five have experienced a recent non-fatal overdose. Fewer studies were identified that assessed mental disorders and self-harm among PWID; however, pooled estimates across studies suggested that perhaps nearly half of PWID have current severe depressive symptomology, and 22.1% have previously attempted suicide. The latent class analyses identified risk factors that may contribute to PWID experiencing more severe and multiple IRID, namely recent needle re-use and thrombophlebitis. Finally, there is a modest protective association between OAT retention and injecting-related diseases; however, hospitalisations for these diseases are increasing. These findings highlight several important areas for future research, and for clinical and public policy action. Namely, when we consider the healthcare needs of this population, we must consider this broad spectrum of pathology. Continued research into effective interventions that improve PWID health as well as expanding accessibility of existing interventions are crucial future steps.

  • (2023) Raichand, Smriti
    Background: Teratogenic medicines when used in pregnancy increase the risk of foetal defects. The doses above which these risks increase are published for some medicines including four antiepileptics. Among antiepileptics, valproate is associated with the highest risk of foetal harm. It is, therefore, important to understand the utilisation of teratogenic medicines among pregnant women and women of child-bearing age. Study 1 in this thesis measured the prevalence of teratogenic medicine utilisation before and during pregnancy. Study 2 estimated utilisation of teratogenic antiepileptics as average daily doses (ADDs) dispensed to women of child-bearing age. Study 3 examined valproate utilisation in pregnancy, factors associated with continuation in pregnancy, and recent trends in women of child-bearing age. Methods: In Study 1 and Study 3 we used linked administrative health records, which contained pregnancy-related details and mothers’ health service use, including dispensed prescription medicines. The cohorts comprised concessional beneficiaries who gave birth in New South Wales in 2004-2012. To examine medicine utilisation among women of child-bearing age (Study 2, Study 3) we used medicine dispensing records for 10% of the Australian population in 2012-2020. We presented prevalence as percentages and n per 1000 women, ADDs as mg/day, and associations as odds ratios (ORs). Results: The prevalence of teratogenic medicine utilisation at any time during pregnancy was 2.0%, steadily decreasing from first trimester through to birth. Teratogenic antiepileptics (carbamazepine, lamotrigine, and valproate) except phenobarbital, were dispensed at ADDs below the published high-risk dose thresholds, to women of child-bearing age. Prevalence of valproate utilisation was 5.2 in 1000 pregnant women, and approximately 24% continued use in pregnancy. Having a diagnosis of epilepsy (OR 10.2, 95% CI 5.7-18.4) was significantly associated with valproate continuation in pregnancy. Valproate utilisation among women of child-bearing age decreased from 5.8 to 3.5 per 1000 women in 2013-2020. Conclusions: Taken together, our findings on teratogenic medicine use among pregnant women, antiepileptic ADDs among women of child-bearing age and valproate exposure in these populations suggest that Australian prescribers and patients were aware of the potential harms posed by these medicines.

  • (2023) Bharat, Chrianna
    Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, morbidity and mortality in this population remains higher than that of the general population. There is a need for innovative approaches to monitor and improve the quality use and safety of available medicines, and to better understand risk factors impacting adverse outcomes in this population. In this thesis, routinely collected administrative data on people with opioid dependence in New South Wales (NSW), Australia, were used to investigate medicine use, including Opioid Agonist Treatment (OAT), opioid analgesics, and other psychotropic medicines. Studies in this thesis examined novel methodological approaches to evaluate medicine exposure and quantify risk, both observed and predicted. This thesis used a diverse range of data sources, including controlled drug registries and pharmaceutical claims databases, linked with health service use and mortality records; and implemented a range of statistical methodologies, including generalised estimating equations, Cox proportional hazards models, and deep learning algorithms. Specifically, this thesis aimed to: (i) estimate retention in OAT and identify person, treatment, and prescriber characteristics that are associated with retention; (ii) develop, evaluate and compare models predicting OAT cessation risk at entry to treatment; (iii) examine trends in opioid analgesic utilisation during periods in and out of OAT; (iv) review methods for generating exposure periods from pharmaceutical dispensing data; and (v) evaluating the all-cause and cause-specific mortality risk associated with opioid analgesics, benzodiazepines, gabapentinoids, and OAT. The first study found retention in OAT to be affected not only by characteristics of the person and their treatment, but also of their prescriber, with longer prescribing tenure associated with increased retention of people in OAT. The results from the second study indicated time-to-event prediction models may be limited in their ability to identify individuals at high cessation risk on entry to OAT. Of the methods used in model development, machine learning approaches performed similarly to traditional statistical methods. In the third study, people with opioid dependence were found to have high rates of recent psychotropic medicine utilisation at the time of opioid analgesic initiation, and reduced opioid analgesic dispensing while engaged in OAT. The fourth study describes a novel method for generating medicine exposure periods from dispensing claims data, developed especially for application to medicines with complex and variable dosing regimens. Finally, in the fifth study, benzodiazepines and gabapentinoids appear to increase mortality risk when used in combination with opioid analgesics, although the risk may be reduced when engaged in OAT. This thesis demonstrates the utility of person-level data linkage and innovative analytical methods to generate real-world evidence about the use and outcomes of prescribed medicines among people with opioid dependence. Awareness of harms in clinical settings and evaluating outcome risk during medicine use would give clinicians the ability to understand who needs prevention and treatment services, ensuring efforts and resources are targeted towards those most at-risk. These represent important strategies for improving quality medicine use and reducing harms among people with opioid dependence.

  • (2022) Watchirs Smith, Lucy
    Background Although new technologies bring many benefits, there is also concern that sexting, internet pornography, meeting partners online and new contraceptive technologies may be fuelling the spread of sexually transmitted infections (STIs) and unintended pregnancies. This thesis considers several current issues affecting Australians' sexual and reproductive health, focusing on young people. Methods Drawing on data collected during a national health survey conducted in 2012–13 among 20 091 participants aged 16–69, I investigate these topics using a whole population epidemiological approach. I also undertake a systematic review and meta-analysis of the relationship between sexual behaviours and exposure to sexually explicit websites (SEW) and sexting among young people. Results The systematic review included 14 cross-sectional studies; pooled findings linked some STI risk behaviours with exposure to SEW and sexting. However, several variables suggestive of being more sexually active or having a pre-existing interest in sexual activity also correlated with SEW and sexting exposure. Similarly, the strongest correlate of meeting a sexual partner online was higher sexual partner numbers. Analysis of contraception and condom use found that almost all (95%) of the women used a form of contraception at their last vaginal intercourse; however, only half (49%) were protected from STIs by condoms or dual contraception. Conclusions Interpreted collectively, the studies in this thesis tend to support the argument that individuals use new media platforms to satisfy their pre-existing interests. These findings underscore the nuanced and potentially nonlinear relationships between new technologies, STIs and unintended pregnancies among young people.

  • (2023) Economidis, George
    Background and aim: Child abuse and neglect notifications, substantiations, and subsequent child removals have increased in high-income countries in recent decades. In Australia, the New South Wales (NSW) Government has invested in two family- based therapy programs (Multisystemic Therapy for Child Abuse and Neglect [MST- CAN] and Functional Family Therapy - Child Welfare [FFT-CW®]) to reduce rates of child physical abuse and neglect among high-risk families and increase the number of children who remain safely with their families. This thesis examines the implementation of these programs into routine service delivery in NSW and their preliminary outcomes. Methods: Chapter 2 comprises a systematic review of the effectiveness of family-based therapy programs in reducing rates of child abuse and neglect, compared with alternative programs/usual care. Chapters 3-6 comprise an evaluation of the implementation of MST-CAN and FFT-CW® in NSW since 2017. Chapters 3 and 4 report on interviews with policy and program experts, and focus group discussions with service providers, to understand the enablers and barriers of implementing MST-CAN and FFT-CW® in NSW. Chapter 5 proposes an adaptation to the scoring system of a well-validated framework for quantifying themes represented as enablers and barriers to service delivery. Chapter 6 is an observational study that aims to describe out-of-home care (OOHC) and child protection notification outcomes among families participating in MST-CAN and FFT-CW® in NSW. Results: Chapter 2 shows family-based therapies may reduce rates of child abuse and neglect, although methodological limitations of published studies mean their effectiveness remains unclear. Chapters 3 and 4 identified that key enablers to implementing MST-CAN and FFT-CW® in NSW were their therapeutic and strengths- based approaches, FFT-CW® itself and the analytic approach of MST-CAN. Key barriers were the referral and adaptation process, staff recruitment and retainment, and data collection issues. Preliminary data suggest lower rates of OOHC may be associated with completion of FFT-CW®. Conclusions: The methodological rigour of studies evaluating the outcomes of family- based therapies requires improvement. Additionally, adaptation, referral, data and cultural considerations associated with implementing MST-CAN and FFT-CW® in NSW require revision if investment in these programs is continued, alongside ongoing monitoring of their outcomes and costs.

  • (2023) Bruno, Claudia
    Quality (or rational) use of medicines is embedded in Australia’s National Medicines Policy to ensure that patients receive appropriate treatment without harm. Still, clinical trials often exclude priority populations that are at greater risk of medicine-related harm, resulting in limited evidence to guide real-world prescribing in such populations. This evidence gap has led to considerable variation in prescribing and concerns about the appropriate use and safety of psychotropic medicines. Through exemplar studies using real-world data, this thesis generates evidence to address the quality use and safety of psychotropic medicines among people with mental health and neurodevelopmental disorders, children, and pregnant women. The first three studies (Chapters 2-4) use Australia-wide dispensing data and linked data to address several concerns around attention-deficit/hyperactivity disorder (ADHD) medicine use in Australia. Key findings include: (i) that school children who were the youngest in their school grade were more likely to use ADHD medicines than older students in most Australian jurisdictions, except in New South Wales where children often delay school start for one year; (ii) ADHD medicine use doubled in Australia between 2013 and 2020, with largest increases among young females. However, this level of use remains below the prevalence of ADHD; (iii) in 2021, changes to populations eligible for publicly subsidised lisdexamfetamine led to increased use among adults and improved access for those previously ineligible for publicly subsidised treatment. These results informed ongoing government inquiries into ADHD and treatment in Australia. The fourth study (Chapter 5), using register data from the Nordic countries, found that antipsychotic use during pregnancy did not increase the risk of child neurodevelopmental disorders or learning difficulties. These findings will assist clinicians and women managing mental illness during pregnancy and demonstrate the benefits of global collaboration. The findings of this thesis are of public and clinical interest and have both local and international implications. The thesis demonstrates the utility of real-world data to address and promote quality use of medicines and safety in priority populations. The thesis also considers the challenges of using real-world data in evidence generation and explores how appropriate study designs, global collaboration, and open science may help overcome these challenges.