Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697628856360.pdf (Australia)
AUSTRALIAN ASSOCIATION OF SOCIAL WORKERS Submission to the House of Representatives Standing Committee on Family and Community Affairs SUBSTANCE ABUSE IN AUSTRALIAN COMMUNITIES Contact: Ian Rentsch, Chief Executive Officer or Sarah Hordern, National Policy Officer Australian Association of Social Workers, PO Box 4956, Kingston, ACT 2604 PH: 02 6273 0199 FAX: 02 6273 5020 Email: aaswnat@aasw.asn.au CONTENTS 1.

INTRODUCTION 2.
INTRODUCTION 2.

RELATIONSHIP BETWEEN SUBSTANCE ABUSE AND SOCIAL AND ECONOMIC FACTORS 2.1 Substance Abuse and the Medical Model of Treatment 2.2 Substance Abuse, Pregnancy and Post Natal Care 2.3 Substance Abuse, Children and Young People 2.4 Substance Abuse and Domestic Violence 2.5 Substance Abuse and Elder Abuse 2.6 Substance Abuse and Indigenous Issues 2.7 Substance Abuse and Mental Health 2.8 Substance Abuse and Disability 2.9 Substance Abuse and Poverty 3.
GOOD OUTCOMES 3.1 Is “Harm Minimisation” Delivering?

3.2 Service Shortfalls 3.3 Good Practice Examples 4.

RECOMMENDATIONS 5.

REFERENCES 1.

INTRODUCTION The Australian Association of Social Workers (AASW) welcomes this inquiry into the social and economic costs of substance abuse to Australian Communities.

The AASW represents over 6,000 social workers, the majority of whom work in direct practice with disadvantaged and vulnerable individuals and groups within Australian society.
Substance abuse is seen by our members to be a major and complex problem that impacts on the lives of many of their clients.

This submission looks at the relationship between substance abuse and a range of other social issues, rather than focusing on the use and effects of particular substances.

One of the distinctive features of social work is the simultaneous dual focus social workers maintain; social workers work with individuals in the context of their environment.
This focus reveals the links between presenting problems and broader social inequities, such as poverty, social isolation and homelessness.

In fact people from “the lowest social stratum” are significantly over represented among substance abusers1.

There is a large body of opinion that argues when people have an adequate standard of living and positive social and personal relationships they are less likely to abuse drugs2.
Any comprehensive response to the problem of substance abuse must address the underlying needs and problems of individuals and communities.

Isolation, homelessness, unemployment, health (including mental health) and relationship issues must be targeted alongside targeting the use of any particular drugs3.
" In terms of what is meant by “substance abuse”, the AASW has chosen an inclusive definition; substance abuse is the use of tobacco, alcohol, prescription and illicit drugs in a way that causes harm to the user or others.
There can be no doubt that tobacco is responsible for by far the greatest health and economic costs of any drug used in Australia, followed by alcohol4.

Illicit drugs come a long way behind5.

Licit drugs accounted for over 96% of drug-related deaths and hospitalisations in Australia in 19976.
In addition perpetrators of anti-social behaviour (driving under the influence, being verbally or physically abusive, causing damage to or stealing property) were far more frequently under the influence of alcohol than under the influence of illicit drugs7.

Victims of these anti-social activities were more than twice as likely to be the victims of alcohol related incidents than to be victims of incidents related to other drugs8.
Yet surveys reveal that Australians are far less likely to associate those licit drugs with a drug “problem”9.

The AASW is confident that this Inquiry will confirm for the government the benefits of investing in the future.

Substance abuse is too complex an issue to be solved by one-dimensional quick fix proposals.

Prevention, support, education and treatment are the four strands of a holistic strategy that can truly reduce the costs of substance abuse to Australian communities.
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RELATIONSHIP BETWEEN SUBSTANCE ABUSE AND SOCIAL AND ECONOMIC FACTORS The AASW is concerned that the Standing Committee understand the complex inter-relationship between substance abuse and other significant social and economic issues.

Interpersonal problems with family and friends, difficulties at work, physical and mental health problems, mood disorders and suicidal ideation, financial problems and homelessness are commonly found to be a part of presentations of substance abuse.
If substance abuse is to be addressed in any coherent way it must be in the context of this much wider range of issues.

For example there is wide reporting of a strong correlation between substance abuse and domestic violence10.

In relationships where one or both partners abuse substances there is very often domestic violence11.

Women with substance abuse problems very often report a history of past sexual assault and/or sexual assault as a child12.
Abuse of children is more frequent in families where one or both partners are substance abusers13.

However the relationship is not one of simple cause and effect.

Substance abuse may be a causal or contributing (but never excusing) factor in some abusive situations.

In others substance abuse may be a coping mechanism for people attempting to deal with a history and/or current reality of abuse.
One hospital emergency department found that of the 9% of patients identified as having substance abuse as a major issue, only 19% did not have a range of concurrent psychosocial issues.
In other words 81% identified significant other problems, such as homelessness, violence, mental health issues and isolation14 276;+ !
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;;276"76( 2.1 Substance abuse and the medical model The AASW is concerned with the increasing medicalisation of any form of social discomfort.
Medication is prescribed for many problems that have a large socio-emotional component.

While statistical data on this type of substance abuse is difficult to find, anecdotal evidence from our membership suggests that it is a real and growing problem.

Significant numbers of children and adults are being prescribed stimulant medication to help in the management of ADHD, and there is an expanding usage of anti-depressant and anti-anxiety medication.
In some cases the medication is inappropriate and the issue is one of social difficulties, or grief, both of which respond as well or better to therapeutic and counselling interventions.

The AASW submits that there needs to be more attention paid to why people are unhappy or angry rather than using a chemical solution as the first option.

Case Study 1: Joanne (35) consulted her GP because she was having trouble sleeping, was increasingly irritable and was unable to stop her negative thought processes.
The GP was aware that Joanne had a number of stresses in her life including the recent death of her father.

However the GP did not have time to talk with Joanne at any length and referred her to a counsellor.

Joanne was unable to afford $100 per session with a private counsellor, and the GP suggested she try the Community Health Service.

Knowing it may take some time to access the service the GP also prescribed one of the new generation of anti-depressants to help Joanne get through this period.
When Joanne called the Community Health Service the duty officer was unable to offer her an appointment.

Since Joanne was already being treated for depression by her GP, and taking Aurorix, she did not fit the program’s requirements.

Unless she was in crisis or suffering a severe, ongoing mental illness Joanne would not be able to access their service15.
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2’’3##"(" 33$7(3(’’ 2.2 Substance Abuse, Pregnancy and Post Natal Care Hospitals have long been aware of the health risks associated with substance abuse during pregnancy.
Erratic attendance at antenatal clinics, frequent hospital admissions during pregnancy, complications due to substance withdrawal and increased need for neonatal intensive care services are some of the more obvious concurrent issues16.

Substance abuse during pregnancy can be highly risky for both mother and baby.

Substance abuse during pregnancy is also one of the indicators for subsequent child abuse and neglect17.
Since pregnancy can be a time when women are more likely to want to cease substance abuse and are therefore motivated to change, it is one of those “windows of opportunity” for intervention18.

The need to offer appropriate psychosocial management and support that can deal with issues such as relationship difficulties, violence and financial and housing problems was stated in a number of member’s reports19.
2.3 Substance Abuse, Children and Young People Substance abuse impacts on children and young people in several major ways.

Children who live in families where one or more care giver are substance abusers are at greater risk of physical and sexual abuse and neglect20.

Children often become the carers of their parents, which can have enormous emotional impact as well as depriving the child of many normal opportunities, such as attending school regularly, participating in extra-curricular activities etc.
In addition children who grow up in families where substance abuse occurs are more likely to use substances in hazardous ways themselves.
The AASW notes that the National Illicit Drugs Campaign, to be launched in July 2000, aims to provide information and education to parents to help ,?
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It is hoped that this campaign addresses the issue of parental modelling influencing children’s behaviour, and does not only focus on illicit drugs.

As shown above, it is the licit drugs that cause the greatest health and economic costs to our community, and amongst young people tobacco, alcohol and cannabis are the substances most likely to be identified in calls to Kids Help Line22.
The issue of inhalant abuse by primary age children was raised as a problem that goes far beyond petrol sniffing in indigenous communities23.

Inhalant abuse is found most often among younger children because aerosols are relatively easy to obtain.

Parent education about the risks involved, and the products used, needs addressing.

There can be no doubt that early intervention with families where substance abuse is negatively impacting on children offers great potential.
A recently publicised American study found that for every $1 spent on early intervention programs with families where neglect was an issue there was a $7 payback in terms of reduced pregnancies, drop out rates and substance abuse on the part of the children in those families24.

2.4 Substance Abuse and Domestic Violence The links between substance abuse and domestic violence are well documented.
A Queensland Domestic Violence Task Force Study found that women living with domestic violence had higher rates of alcoholism and chronic tranquilliser use and were nine times as likely to abuse drugs when compared to women from non-violent homes25.
A National Drug and Alcohol Research Centre study of women with alcohol and other drug problems found that 75% had a history of sexual or physical abuse $’’!
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Once again the relationship between substance abuse and other social problems is complex.

While popular images often blame violent behaviour on substance abuse, the AASW submits that substance abuse can never be held responsible for an individual’s own decisions about how they interact with others.

The disinhibiting effects of drugs and alcohol do not excuse acts of violence or intimidation.
In addition (as the statistics above indicate) substance abuse is very often a means for the victims of domestic violence to self medicate the pain associated with their intimate relationships.

2.5 Substance Abuse and Abuse of Older People Substance abuse is a key indicator in the abuse of older people, both in Australia and overseas27.
A Queensland social worker who deals with, on average, two new cases of elder abuse each week estimates that 20% of cases involve the abuser having a drug or alcohol problem28.

As the following case studies show older people are often less able to escape the abusive situation because the abuser may be their only “carer”.

Case Study 2: A younger man took an older man with an alcohol problem to live at his home.
The young man claimed a Carer’s Pension, a Carer’s Allowance and controlled the older man’s bank book.

The younger man drank heavily and occasionally let the older man drink too, after which he was punished for drinking.
Some punishments involved being locked in the garage, ,/ *’" ’(73#/""9, :<""#"’"
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The older man was severely physically, emotionally and financially abused and his needs were neglected.

Efforts are being made to establish him in new accommodation.

His alcoholism continues to be a problem29.

Case Study 3: A domestic violence situation existed for many years.

The husband would drink and hit his wife.

He had a stroke and became dependent on his wife.

She did not place him in a nursing home.

She kept him at home and beat him daily30.


Domestic violence can turn into elder abuse when there is a change in the power relationship between a couple, brought about by an age related change in one or the other.

2.6 Substance Abuse and Indigenous Issues The relationship between substance abuse and indigenous issues is beyond the scope of this submission to deal with adequately, and it is related to the trauma experienced by Aboriginies throughout white settlement.
However it is a matter of extreme concern to the AASW and we hope that the Inquiry will seek out balanced reporting of the topic if it is not already covered in other submissions.
Of particular concern is the fact that although indigenous adults are less likely to report drinking alcohol than other Australians they are more likely to be hospitalised and/or die from conditions which are indicators of substance abuse31 One program that is worth examining is the Living With Alcohol Program (LWA) in the Northern Territory32.
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The program combined a levy on alcoholic drinks (based on their alcohol content) with an increase in treatment, education and preventative activities, in particular a public education campaign supporting enforcement of drink driving and liquor licensing laws.

The new programs were totally funded by the levy.


It would appear that the program was very successful and has been credited with a 31% reduction in alcohol related road deaths, a 29% reduction in the number of alcohol related accidents and an 18% reduction in the per capita consumption of alcohol33.

2.7 Substance Abuse and Mental Health There is a high correlation of substance abuse with mental health problems.
The 1997 National Survey of Mental Health and Wellbeing of Adults found that 31% of people with a substance abuse disorder had another major mental disorder, such as anxiety or an affective disorder34.

Once again the relationship between disorders is not clear cut.

Certain types of substance abuse can lead to mental health problems, eg alcohol use resulting in alcohol related brain damage, cannabis use precipitating early psychosis.
But more often substance abuse is a type of self- medication for people who have not received appropriate support and treatment for their mental health problem.

Young people may in fact prefer to identify themselves as substance abusers than as mental health patients35.

Severe social phobia may lead to depression and be self- medicated with alcohol use36.

Harm is a relative concept.


While there can be no doubt that tobacco is responsible for by far the greatest costs of any drug used in Australia, it may also have some therapeutic use.
Mental Health workers report clients 00/ 0%>"7#*< + >"7#$)):
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2.8 Substance Abuse and Disability Many of the issues referred to in section 2.5 (Abuse of Older Persons) are similarly problematic in the area of disabilities.

Disability and substance abuse are linked in two particular ways.

Some disabilities are a result of violence associated with substance abuse38.
People living with disability can be more vulnerable to abuse or violence linked to substance abuse, either because the abuser is their only “carer” or because they depend on the abuser to help them care for another.

Case Study 4: Jane (28) is the mother of Ben (7) and Will (5).

Will has a degenerative condition that means he is confined to a horizontal position and is only able to move one finger and talk.

Will disclosed to his school teacher that Jane’s de facto partner, Rick, is violent.
In fact Rick hits Ben around the head and has also hit Jane when he has been drinking.

Jane says she has to continue living with Rick because she needs his assistance in lifting Ben, and taking some shifts through the night to turn and toilet Ben39.

2.9 Substance Abuse and Poverty There are clear links between substance abuse and poverty.
30% of patients presenting at a major regional hospital with substance abuse issues as their primary issue required immediate material support 0*72D#’’4’)
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Substance abuse disorders were found to be relatively high among unemployed people, affecting 19% of unemployed men and 11% of unemployed women41.

Boarding houses frequently provide low standard accommodation for people suffering from substance dependencies, with chronic substance abuse often resulting in homelessness42.

Alcohol related brain damage affected more than 18% of the boarding house residents in a 1996 study43.
The study also found that supported accommodation for people with alcohol related brain damage and elderly people with current substance abuse behaviours was urgently needed44.

It is more difficult for people on low incomes to adopt harm minimisation strategies.

For example Nicorettes and nicotine patches are inaccessible to many low income smokers because of the their cost.

3.
3.

GOOD OUTCOMES The AASW submits that the general principals of harm minimisation, which include abstinence, are the most effective ways to achieve positive, cost effective outcomes in the area of substance abuse.

Substance abuse policy will work best if it is part of public health policy, not part of criminal justice policy.
Policies that are people focused, that enable people to lead healthy lives, that respect human dignity and human rights are far more effective than those that stigmatise, stereotype and marginalise clients.

In particular the AASW supports the ADCA’s Drug Policy 2000, which suggests ten key areas for reducing drug related harm in Australia.
This is a carefully researched and pragmatic document that offers government a clear direction and achievable, measurable outcomes in addressing substance abuse in Australia.
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In many ways harm minimisation is delivering “good outcomes”.

Australia is well regarded internationally in terms of our record in reducing the costs of substance abuse and our comparatively humane approach to individuals’ substance abuse problems.
However there are some short comings, or gaps, in the range of services and programs currently offered to combat the harm caused by substance abuse.

For example in the area of drink driving it seems that the benefits delivered by random breath testing in the 1980’s have been eroded during the 1990’s, with 20-25% of men admitting to drinking and driving in a recent National Drug Strategy Household Survey45.
The gaps in service that have been identified by social workers in direct practice are outlined in the following section (3.2) of this submission.

3.2 Service Shortfalls Many AASW members reported difficulty in accessing services for clients with substance abuse issues.

Some reported intake waiting times to services being too long.

By the time a place was available clients had lost the motivation to engage with the program offered.
Services need resources and flexibility in timing interventions to take advantage of the motivation for change cycle.

 Others reported that service delivery models are often too restrictive.
For example drug and alcohol services are often mandated to work on substance abuse issues only; if the client has concurrent issues such as being a perpetrator or victim of violence, or having a mental health issue they will often be referred to another service, which in turn will be unable to address the substance abuse.

 Related to this is the inability of some services to deal with substance abusers in the context of their environment.
Staffing and resource issues prevent exploration of the wider structural and %8$5(B%B relationship issues which so often need to be addressed if long term change is to be maintained.
A number of reports from members highlighted the lack of adequately trained workers to work with complex, multi problem cases.

Many mainstream service providers feel anxious about their ability to deliver the level of care these clients require46.

For example disability is often left out of core training in domestic violence training packages47.

 While acknowledging the need for highly skilled workers specialist services may not attract the full range of clients they might hope to attract.
For example clients may experience a greater sense of stigma and marginalisation from attending a specialised program, which in itself will be de-motivating.

3.3 Good Practice Examples The Ante-Natal Day Stay Program at John Hunter Hospital has reduced the average number of inpatient admissions during pregnancy of drug and alcohol dependent women by 50%48.
This program has had very positive appraisal from the women participating, with the individualised nature of the program being highly appreciated.

 The Chemical Dependency Unit (CDU) of the Royal Women’s Hospital in Melbourne provides state wide education, training and mentoring to increase the skill levels of professional staff in hospitals throughout Victoria.
AASW members report positive results from intensive rehabilitation programs that include work training, living skills and behaviour management in conjunction with direct attention to the actual substance abuse.

 Motivational interviewing, which makes use of the motivation for change cycle is reported by members to deliver positive results.
%,1(6’4;$’’H# ’’ %*’4 A member from South Australia reports greater success in working with men who have been perpetrators of violence when using a “Manhood” style of work rather than the traditional feminist model49.
4.

RECOMMENDATIONS a.

Substance abuse will be addressed most effectively if policy development is part of public health policy rather than criminal justice policy.

b.

Health promotion, screening for risk factors, targeted interventions that focus on support and education must be central to any future policy initiatives.

c. One model alone will not be effective, what is needed is a range of educational, supportive and therapeutic services that target particular risk groups within our community.
d. Traditional treatment options have targeted the highly dependent substance abuser.

Intervention at an earlier stage in a person’s substance use can prevent them from developing serious problems later on.

e. Relapse within the first year of treatment is very common50.

Support programs with a focus on employment, accommodation and lifestyle need to be available to all people who have accessed therapeutic treatment programs.
f. The provision of holistic service delivered by highly skilled workers is still not common enough.

Collaborative approaches, using staff and other resources from different agencies need to be encouraged.

g. Mainstream services need to be encouraged to up skill staff and address organisational culture so that the needs of substance abusers can be met more effectively.

h. Data on treatment outcomes needs to be made readily available to clinicians, especially those who work in poorly funded services.
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5.

REFERENCES Alcohol and other Drugs Council of Australia, Drug Policy 2000: A New Agenda for Harm Reduction, (Consultation Draft), Alcohol and other Drugs Council of Australia, Canberra, 2000.
Alcohol and other Drugs Council of Australia Library Posting, 10/4/00 Australian Bureau of Statistics Crime and Older People, Australian Institute of Criminology Conference, 24 February 1993 Australian Bureau of Statistics, National Survey of Mental Health and Wellbeing of Adults, Australian Bureau of Statistics, Canberra, 1998.

Australian Bureau of Statistics, The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, Australian Bureau of Statistics, Bulletin 4704.4, 1999.
Australian Drug Foundation, Laws, Australian Drug Foundation Website, www.adf.org.au Australian Drug Foundation, Treatment, Australian Drug Foundation Website, www.adf.org.au Australian Institute of Health and Welfare, 1998 National Drug Strategy Household Survey: First Results, Australian Institute of Health and Welfare, Canberra, August 1999 Commonwealth Department of Health and Aged Care National Illicit Drugs Campaign Strategy Synopsis, Population Health Division, Commonwealth Department of Health and Aged Care, Canberra, 2000.
Connell, Belinda & Dowling, Lyn, People of a Lesser Life: Residents Living in Private “For Profit” Boarding Houses, Dowling, Hunter Joint Enterprise Boarding House Project, July 1996.

John Hunter Hospital, John Hunter Hospital Alcohol and Drug Enhancement, John Hunter Hospital, April 2000.

Kids Help Line, Drug and Alcohol Use in NSW, Kids Help Line, Queensland, 1999.

McDonald, L., and Collins, A., Elder Abuse and Neglect; A discussion Paper, Health Canada, 1998.
Mendes, Philip, Safe Injecting Facilities and the Politics of the Drug Debate, Unpublished paper, 2000.
NSW Health, NSW Health Domestic Violence Policy Discussion Paper, NSW Health, October 1999 Office of Ageing, Department of Family Services and Aboriginal and Islander Affairs Abuse of Older People in Queensland, Office of Ageing, Department of Family Services and Aboriginal and Islander Affairs, November 1997 Sadler, Paul, “Patterns of Elder Abuse”, Crime and Older People, Australian Institute of Criminology Conference, 24 February, 1993.
Sobsey, Dick, Violence and Abuse in the Lives of People with Disabilities: The End of Silence Accepted?, Paul Brooks Publishing, Baltimore, 1994.

Social Work Department, John Hunter Hospital, Substance Abuse Presentations, Report prepared by the Social Work Department, John Hunter Hospital, NSW, for the AASW, May 2000.
The Public Health, Safety and Economic Benefits of the Northern Territory’s Living With Alcohol program 1992/3 to 1995/6, Report commissioned by the NT Government’s Living With Alcohol program, September 1999.

This submission also benefited from information supplied from AASW members who work in direct practice with clients affected by substance abuse.