Alcohol Services Research Articles

New South Wales alcohol and other drug service providers' perceptions of the relative importance of client variables for determining treatment need.

This study examines alcohol and other drug (AOD) service providers' perceptions of the most important variables (client complexity and demographic) for determining treatment need and intensity of intervention. Online cross-sectional survey of N = 188 clinicians/service managers working in AOD services across metropolitan and regional/rural New South Wales, Australia. Participants ranked the importance of demographic and family factors, substance use, physical health, mental health, functioning and activities of daily living and youth-specific variables in identifying treatment need (five-point Likert scales). More than 90% of participants ranked 43 out 56 potential variables as 'very important'/'essential' in identifying treatment need. The 10 variables most ranked as 'very important'/'essential' were 'pregnant or breastfeeding' (95.2%), 'suicide/self-harm' (95.2%), 'overdose risk' (94.7%), 'abuse/neglect' (among youth/adolescent populations; 94.1%), 'mental health severity' (93.6%), 'dependent children' (93.1%), 'co-existing mental health concerns' (93.0%), 'hospitalisations due to mental health' (92.5%), 'child protection concerns' (among youth/adolescent populations; 92.2%) and 'disability' (91.5%). The 10 variables most commonly ranked as 'slightly important'/'not at all important' included 'citizenship' (63.3%), 'sex' (59.6%), 'country of birth' (54.8%), 'highest education' (50.0%), 'sexual orientation' (44.1%), 'relationship status' (33.5%), 'gender' (31.4%), 'transport' (28.2%), 'employment' (23.9%) and 'refugee status' (24.0%). Some ratings differed by geographic location (metropolitan vs. regional/rural) and job role (allied health worker, nurse, doctor or manager). This study provides insight into service providers' perceptions of treatment need and intensity associated with a range of client factors. It is a first step towards improvements in routine data collections that are used to inform treatment planning.

A Place of Last Drink Initiative: Effects on Various Types of Crime

Background Place of last drink (POLD) is a law enforcement strategy designed to decrease the service of alcohol to intoxicated patrons (i.e., overservice). When officers respond to an alcohol-related incident, they inquire about and record the place where the involved individuals last drank alcohol; this information can help identify licensed alcohol establishments that show a pattern of overserving alcohol. We evaluated the effects of a POLD initiative on various types of crime. Methods The POLD initiative was conducted in the state of Minnesota (USA). We compared 26 intervention jurisdictions to 26 matched comparisons. Outcomes were six crime measures (e.g., driving under the influence, violent, nonviolent). Predictors were levels of participation and implementation of POLD. We fit a separate Poisson regression model for each crime outcome and each predictor. Results In all models, we found little difference in crime rates between intervention and comparison jurisdictions. No effect on crime was observed for either participation or implementation levels of POLD. However, we found implementation levels were relatively low across jurisdictions. Conclusion This study adds to a very limited literature addressing the effects of POLD on public health harms such as crime. The particular POLD initiative did not appear to affect crime rates. We found POLD implementation levels showed considerable room for improvement and could help to explain some of the lack of effects of POLD on crime. More research is needed in additional localities and to assess whether specific aspects of implementation could help to strengthen POLD efforts.

Adapting Group Model Building for Mental Healthcare: A Participatory Co-Design Approach.

Countries around the world are experiencing both a growing need for mental health services and major gaps in the delivery of mental healthcare. The World Health Organisation's 2022 report on mental health emphasised co-designed and systems-level innovations responsive to the voice of those with lived experience. However, evidence for implementing such methodologies is sparse. Group model building (GMB), a participatory systems-based approach, has been used in various fields, but its application is limited within mental healthcare settings. It is recognised as a valuable tool for engaging stakeholders, including those with lived experience, in understanding and redesigning health systems and services. The participatory approach aligns with the mental health sector's shift towards co-design and person-centred care. This study assessed the acceptability of GMB as a method for co-design within mental healthcare, aiming to explore its potential for meaningful collaborative improvement and systems-level insights. Participants from a regional Mental Health and Drug and Alcohol Service (MHDAS) engaged in GMB workshops and focus groups. Eighteen individuals, including lived experience workers and healthcare professionals, provided feedback that informed adjustments to the workshops' design, language, timing and facilitation techniques, enhancing GMB's relevance for mental health co-design. The findings demonstrate the value and acceptability of the adapted GMB process in acute mental healthcare, marking a significant step towards evidence-based, person-centred service improvement. This study highlights the potential effectiveness of participatory methods in identifying and addressing systemic challenges, paving the way for future mental health reforms. Future work will focus on implementing and evaluating co-designed interventions, aiming for more inclusive and effective mental healthcare and advancing innovation and reform in the field.

Integration of a facilitated access pathway for contraception into alcohol and other drug treatment services: A cohort study comparing metropolitan and regional settings.

Women who attend alcohol and other drug (AOD) services experience higher rates of unintended pregnancy, and access less contraception, than the general population. This study aims to observe contraceptive initiation and use after contraception services were offered at metropolitan and regional AOD services. Clinical staff were provided contraception education. One hundred women aged 16-49 were recruited from two services between 2017 and 2021. Women completed a questionnaire on their obstetrics and gynaecological history, pregnancy plans and contraception use. Women were provided education on contraception options and offered referral to a contraception pathway. The primary outcome was initiation of highly reliable contraception; secondary outcomes were the types of contraception initiated, and contraception use and pregnancy at 12 months. We compared the initiation of contraception across the two study sites. At baseline, 91% of women were not planning a pregnancy within 12 months, with 21% of these using highly reliable contraception. Of all women not planning a pregnancy, 28% initiated highly reliable contraception via the pathway (2% metropolitan, 51% regional, p < 0.001), with intrauterine devices being the most frequent method initiated (15%). At 12 months, 44% were using highly reliable contraception and 15% had recorded pregnancies. Contraception pathways for women in AOD treatment can improve initiation of highly reliable methods of contraception, although pregnancy rates were still high and there were large differences between the study sites. Care navigation and clinical champions are some potential facilitators to contraception access, and understanding additional barriers to access may be useful.

Voucher-based contingency management to promote treatment engagement in comorbid alcohol use disorder and alcohol-related liver disease: A pilot theory-informed qualitative study with service users.

Effective interventions for the management of alcohol-related liver disease (ARLD) remain a gap in clinical practice, and patients' engagement with alcohol services is suboptimal. Based upon the principles of operant conditioning, contingency management (CM) is a psychosocial intervention th at involves gradual, increasing incentives upon completion of treatment-related goals such as treatment attendance. A pilot feasibility trial was conducted with 30 adult patients recruited from an inpatient clinical setting. Consecutive sampling was used to recruit patients presenting comorbid alcohol use disorder (AUD) and ARLD. Participants were randomized to integrated liver care (ILC), receiving hepatology and AUD care, or ILC with a voucher-based CM intervention (intervention arm). A longitudinal qualitative approach was adopted to explore anticipated (Stage 1) and experienced acceptability (Stage 2). The Theoretical Framework of Acceptability (TFA) guided semi-structured in-depth interviews and deductive analysis. Thirty participants were enrolled in the pilot trial, and interviews were conducted with 24 participants at Stage 1 and seven at Stage 2. Over half of the cohort (54.2%, n = 13) presented decompensated liver disease, and an average of 179 units of alcohol were consumed per week. Overall positive views toward voucher-based CM were noted, and explanatory data emerged across five TFA domains (intervention coherence, ethicality, self-efficacy, perceived effectiveness, and affective attitude). The core aspects of the voucher-based CM intervention matched participants' preferences and needs. Participants regarded CM as having a symbolic value and strengthening the therapeutic alliance with healthcare providers. The data support the scope of voucher-based CM intervention to promote engagement with treatment services, and its potential to address the gaps in the care continuum in ARLD. The findings are of practical significance for developing person-centered, tailored interventions for this clinical population. The outcomes of this investigation can inform decision-making among stakeholders and healthcare providers and improve health outcomes for this clinical population.

Investigating the service utilization and pathways of patients with alcohol use disorders

Abstract Background Process mining was widely used in healthcare settings to analyse patient pathways, providing insights about patient care and resource allocation. This study aimed to apply process mining to explore service utilization and pathways of patients with alcohol use disorders in receiving the community-based Drug and Alcohol Service to establish a baseline for evaluating improvement initiatives. Methods Patients’ encounters with the Drug and Alcohol Service and their direct care activities (i.e. Intake, Assessment, and treatment service activities) that occurred in these encounters were analysed to depict the actual pathways. Patterns were uncovered from these actual pathways using a process mining tool Disco. Patients with alcohol use disorders were divided into two groups—patients who use polysubstance and those who do not—to compare their service utilization and pathway patterns. Results Five hundred seventy-one patients with alcohol use disorders incurred 1447 encounters, comprising 13,974 activities. The top three actual pathways with at least three activities were: (i) pathway ‘Intake-&amp;gt; Withdrawal Management-&amp;gt; Withdrawal Management’ (170 (11.7%) encounters and 130 (22.8%) patients); (ii) pathway ‘Intake-&amp;gt; Adult Counselling-&amp;gt; Adult Counselling’ (161 (11.1%) encounters and 126 (22.1%) patients); and (iii) pathway ‘Intake-&amp;gt; Assessment-&amp;gt; Withdrawal Management’ (155 (10.7%) encounters and 129 (22.6%) patients). However, 313 (21.6%) encounters did not proceed beyond the Intake stage. When the patients started their pathways from Intake, their immediate next activities were frequently Withdrawal Management, Assessment or Adult Counselling. Compared to those who do not use polysubstance, patients who use polysubstance had a higher proportion of Intake (19.3% vs 11.8%, P &amp;lt; .001), Involuntary Treatment (4.0% vs 1.0%, P &amp;lt; .001) and Magistrate Early Referral into Treatment (6.4% vs .3%, P &amp;lt; .001), but a lower proportion of Withdrawal Management (31.2% vs 39.0%, P &amp;lt; .001) and Adult Counselling (27.8% vs 37.6%, P &amp;lt; .001). Conclusion This study contributes to an in-depth understanding of service utilization and pathways of patients with alcohol use disorders within the community-based Drug and Alcohol Service. Future studies should investigate their reasons for dropping out after Intake.

Detection and quantification of synthetic cannabinoids in seven illicitly sourced disposable vapes submitted by an individual presenting to a UK drug and alcohol service.

In the United Kingdom and internationally, synthetic cannabinoids (SCs) are a common adulterant in illicitly sourced vaping products. Recently, their use is increasingly being linked to severe health effects, particularly among children. Here, we aimed to conduct the first detection and quantification of SCs in illicit disposable vaping products. A cross-section of seven illicitly sourced disposable vape samples that were initially sold as cannabis products was submitted for analysis by a single individual presenting to a drug and alcohol service in the United Kingdom. Qualitative and quantitative analyses of these samples were conducted using nuclear magnetic resonance and gas chromatography/electron ionization-mass spectrometry. Qualitative analysis identified the SC 5F-MDMB-PICA in all seven samples, in the absence of any other pharmacologically active compounds. Quantitative analysis revealed that the median concentration of 5F-MDMB-PICA was 0.85 mg/ml (range = 0.59-1.63). The external appearance of these vape samples closely resembled regulated vaping products, and the presence of SCs was not identifiable by any labelling or packaging. The SC 5F-MDMB-PICA was detected at a median concentration of 0.85 mg/ml in seven disposable vapes which were illegally sourced in the United Kingdom, were mis-sold as cannabis products and closely resembled legal, regulated products.

Combining cohorts of prospectively collected and linked data to improve health after release from prison

BackgroundWhile people who experience incarceration have remarkably poor health profiles, undertaking research to inform evidence-based responses is complicated by difficulties of recruiting people in prison; high rates of socioeconomic marginalisation, study attrition; and legislative and financial barriers to linked data research. There are many advantages to pooling data from multiple studies involving people who experience incarceration, including greater statistical power and geographic and participant heterogeneity. However, there are also challenges that need to be addressed. MethodsWe combined four prospective cohort studies of adults released from prisons in four Australian states. Pre-release interviews, and validated screening assessments, were linked to primary care, medicine dispensing, hospital, alcohol and other drug treatment services, ambulatory mental health, ambulance, corrective services, and death records. Data were harmonised by team members reviewing variable definitions and categories within subject domains. ResultsThe combined cohort consists of 4,232 adults, including 1,544 Indigenous people and 905 women, with a median age of 31 years. Data linkage will enable a median of 9.3 years of prospective follow-up after release from incarceration. Differences in data structures, coding systems between and within datasets, changes over time, and grouping of records belonging to the same event were also addressed. ConclusionThis combined multi-site cohort study is an example of a complex, policy-oriented data linkage project. It was developed to underpin evidence-based, culturally appropriate interventions, health policy and service development for people who were incarcerated. This presentation will discuss the processes and pitfalls experienced while building a multi-sectoral, multi-jurisdictional data linkage project.

EP421 - The multidisciplinary management of acute pancreatitis at a district general hospital – an NCEPOD audit

Abstract Aim To assess adherence to NCEPOD Acute Pancreatitis 2016 guidelines in order to optimise the multidisciplinary care of patients presenting with acute pancreatitis. Methods A retrospective case-based audit was conducted of the last 10 admissions with acute pancreatitis. Data on demographics, investigations and management were collected and audited against the NCEPOD evidence-based recommendations. Results The average age was 54 years (33-84) and 70% were male. The cause of the acute pancreatitis was identified as gallstones in 40%, alcohol in 30% and was unknown in the remaining 30%. All patients with alcoholic pancreatitis were referred to alcohol support services. 80% of all patients had significant co-morbidities at presentation: in 63% of patients these were well-controlled; of those uncontrolled, none received onwards referrals. Nutritional assessment only occurred in 10% of patients. Conclusions Our audit showed that we successfully identified a cause of acute pancreatitis in 70% of patients and involved alcohol services in 100% of alcoholic pancreatitis cases. This demonstrates good organisational infrastructure in managing these patients. However, despite the highlighted importance in the NCEPOD report, patients were not appropriately referred to dietitians or other medical specialities. We have therefore developed a series of multi-disciplinary team teaching sessions and an admission proforma to address these areas of the report and improve compliance. A second audit loop will be conducted to demonstrate impact.

Hepatitis C elimination: amplifying the role of primary care nurses in Australia.

Background Australia's commitment to eliminate hepatitis C by 2030 is underpinned by the mobilisation of the primary care sector. Primary care nurses are well placed to contribute to achieving elimination given their unique access to people with/at risk of hepatitis C and their person-centred approach to care delivery. This study examines the enablers to primary care nurse involvement in elimination efforts. Methods Primary care nurses involved in the care of people with/at risk of hepatitis C were recruited through two national nursing organisations. Participants provided verbal consent to participate in an electronically recorded, semi-structured interview. Interview data were transcribed verbatim, coded and analysed using a thematic analysis. Results Sixteen interviews were conducted with nurses working in general practice, community health, alcohol and other drug services, and custodial settings, with the findings framed using a social-ecological model. The study identified individual attributes, such as empathy and advocacy for clients deemed 'too hard for everyone else'. Interpersonal enablers included participants' ability to effectively communicate with clients and colleagues, and using trusted professional relationships to improve client access to care. Public policy that addressed community factors, including stigma and confidentiality, were seen as supportive. Conclusions This study identified the critical and varied role primary care nurses play in hepatitis C elimination. Effective scale up of hepatitis C care involves recognising the pivotal role of primary care nurses, which will help to create an enabling environment that supports nurses to work to their full scope of practice and enhance their contribution to the elimination response.

Opportunities and limits: exploring young people’s views of staff care in residential alcohol and other drug services

ABSTRACT Young people in residential alcohol and other drug (AOD) services build meaningful relationships with workers during their stays. In this paper we use an ethics of care framework to explore what young people said about care, how it was delivered and what they valued about it. Drawing on three waves of longitudinal interviews conducted with 38 young people over 12 months, we discuss our findings according to two overarching themes – opportunities enabled by care and limits to care. Young people’s descriptions highlight the potential for care to challenge stigma, enhance self-worth and wellbeing, enable respectful staff-client relationships, and foster positive relationships crucial for maintaining engagement. At the same time, young people described challenges around providing both individual and collective care, coproducing care in structured environments, and facilitating care as young people transition out of residential services. These findings shed light on the delicate balance between care provision and contextual constraints within AOD settings. This emphasises the need for ethical relationships built on clear communication, mutual respect, and ongoing forms of care. Recognising the value of care work, especially in transitions out of acute treatment services, is essential for reshaping funding approaches to prioritise meaningful and continuing care.

Sensitivity and specificity of Aboriginal-developed items to supplement the adapted PHQ-9 screening measure for depression: results from the Getting it Right study.

To determine the psychometric properties of an Aboriginal and Torres Strait Islander-developed depressive symptom screening scale. Prospective diagnostic accuracy study. Ten primary health care services or residential alcohol and other drug rehabilitation services in Australia that predominantly serve Aboriginal and Torres Strait Islander peoples. 500 adults (18 years or older) who identified as Aboriginal and/or Torres Strait Islander and were able to communicate sufficiently to respond to questionnaire and interview questions. Recruitment occurred between 25 March 2015 and 2 November 2016. Criterion validity of seven Aboriginal and Torres Strait Islander-developed items, using the adapted Patient Health Questionnaire 9 (aPHQ-9) and depression module of the Mini International Neuropsychiatric Interview (MINI) 6.0.0 as the criterion standards. The seven-item scale had good internal consistency (α=0.83) and correlated highly with the aPHQ-9 (ρ=0.76). All items were significantly associated with diagnosis of a current major depressive episode. Discriminant function and decision tree analysis identified three items forming a summed scale that classified 85% of participants correctly. These three items showed equivalent sensitivity and specificity to the aPHQ-9 when compared with the MINI-identified diagnosis of a current major depressive episode. Three items developed by and for Aboriginal and Torres Strait Islander people may provide effective, efficient and culturally appropriate screening for depression in Aboriginal and Torres Strait Islander health care contexts.

Long-term effects of an alcohol prevention program at licensed premises: a Swedish 20-year follow-up study.

In 1996, a multicomponent community-based alcohol prevention program in Responsible Beverage Service (RBS) targeting licensed premises was developed by STAD (Stockholm Prevents Alcohol and Drug Problems) and implemented in Stockholm, Sweden. The program consists of community mobilization and collaboration, training, and enforcement. Early evaluations have shown a significant increase in the refusal rates of alcohol service to intoxicated patrons, from 5% in 1996 to 70% in 2001, and a 29% decrease in the frequency of police-reported violence. A cost-effectiveness analysis showed a cost-saving ratio of 1:39. The program was institutionalized by a collaborative steering group consisting of community stakeholders. This study aimed to evaluate the long-term effects over 20 years of the RBS program. The indicator chosen was the rate of alcohol overserving to obviously intoxicated patrons at licensed premises in Stockholm. A 20-year follow-up study was conducted using the same procedure as the baseline and previous follow-ups. Professional male actors (pseudopatrons) were trained by an expert panel to enact a standardized scene of obvious alcohol-intoxication. In 2016, 146 licensed premises located in the central part of Stockholm were randomly selected and visited. A review of program implementation from its initiation 1996 was conducted, examining critical events, including commitment from key actors in the community, training of bar staff, and enforcement. At the 20-year follow-up, pseudopatrons were refused alcohol service in 76.7% of the attempts, which was at the same level (70%) as in the follow-up in 2001, thus indicating sustained effects of the RBS program. Compared with previous follow-ups, serving staff used more active intervention techniques in 2016 toward intoxicated patrons, such as refusing to take the order (56.9% in 2016 vs. 42.0% in 2001), and fewer passive techniques, such as ignoring patrons (6.5% in 2016 vs. 15.5% in 1999) or contacting a colleague (4.1% in 2016 vs. 25% in 2001). The sustained long-term effects of the RBS program are unique and can be explained by the high level of institutionalization of the multicomponent program, which is still ongoing in Stockholm. These findings can inform the dissemination of the program to other countries and settings.

Young people returning to alcohol and other drug services as incremental treatment

Young people who attend intensive alcohol and other drug (AoD) treatment commonly do so more than once. This paper aims to understand precipitators, enablers and barriers to young people's re-engagement in programs. Data come from a longitudinal qualitative study involving three waves of interviews with Australian young people recruited while attending intensive AoD programs (n = 38 at wave 1).We found that young people's ambitions for what they might achieve with a new stay and capacity to benefit from programs, evolved. Skills learnt in earlier stays or changed life circumstances often helped them achieve better outcomes subsequently. Ongoing contact with an AoD worker was the most important enabler to service re-engagement.Across the span of a year, we saw most young people in our study sample develop a stronger sense of wellbeing and control over substance use. While researchers tend to focus on evaluating outcomes associated with single stays at specific programs, young people think about their trajectories towards managing substance use and their lives as occurring more holistically, supported by engagements with a range of services. We argue that the notion of incremental treatment is useful in depicting the synergistic effects of service engagement over time.

Use of Transdermal Alcohol Sensors in Conjunction With Contingency Management to Reduce Alcohol Consumption in People With Alcohol Dependence Attending Alcohol Treatment Services: Protocol for a Pilot Feasibility Randomized Controlled Trial.

Wearable technology for objective, continuous, and reliable alcohol monitoring has been developed. These are known as transdermal alcohol sensors (TASs). They can be worn on the wrist or ankle with the sensor pressed against the skin and can measure sweat vapors being emitted from the skin, to record transdermal alcohol concentration (TAC). Previous studies have investigated the accuracy and acceptability of the available TAS brands, but there has been little research into their use in people with alcohol use disorders (AUD). This feasibility randomized controlled trial aims to explore the feasibility, strengths, and limitations of using a TAS to monitor alcohol consumption in individuals in treatment for AUD with or without contingency management (CM) to promote abstinence or low-level alcohol consumption. The target sample size is 30 (15 randomized to each group). Participants will be recruited through poster adverts at alcohol services. Both groups (control and CM) will wear the TAS (BACtrack Skyn) for 2 weeks in the context of their usual treatment, meeting with the researcher every other weekday. In the last meeting, the participants will complete a postwear survey on their experience of wearing the TAS. The CM group will also receive small financial incentives for low or no alcohol consumption, as measured by the TAS. On days where the TAC peak is below a set threshold (<115.660 g/L), CM group participants will be rewarded with a £5 (US $6.38) voucher. There are financial bonuses if this target is achieved on consecutive days. The researcher will monitor TAC for each day of the study at each research visit and allocate financial incentives to participants according to a set reinforcement schedule. The first participant was enrolled in June 2023, and the last in December 2023. Data analysis is underway and is estimated to be completed by June 2024. A total of 32 participants were enrolled. Most TAS brands have had limited application in clinical settings, and most studies have included healthy adults rather than people with AUD. TAS has the potential to enhance treatment outcomes in clinical alcohol treatment. The accuracy, acceptability, and feasibility of TAS for people with AUD in clinical settings need to be investigated. This is the first study to use TAS in specialized alcohol services with diagnosed AUD individuals currently receiving treatment from a south London alcohol service. ISRCTN Registry ISRCTN46845361; https://www.isrctn.com/ISRCTN46845361. DERR1-10.2196/57653.

Cognitive impairment among alcohol treatment service users in South Wales: an exploratory examination of typologies of behaviour, impairment, and service attendance.

Alcohol dependence is a global issue with many negative consequences, including alcohol-related brain damage (ARBD). Assessment of the sociodemographic and cognitive characteristics of individuals with confirmed or suspected ARBD presenting to alcohol services warrants further investigation. This study retrospectively examined rates of cognitive impairment using Montreal Cognitive Assessment (MoCA) data from 300 adults who visited three alcohol support services. We demonstrate that 55.3% of the sample had significant levels of cognitive impairment. Females' cognitive performance was disproportionately negatively affected by historical alcohol use relative to males. The analysis identified four categories of participants, and the majority had a long history (+10 years) of alcohol use and were still actively drinking. Those taking part in active treatment for ARBD or practising abstinence demonstrated lower levels of cognitive impairment. Additionally, prior access to specialised ARBD care was associated with higher MoCA scores. This research has identified a range of key service engagement, sociodemographic and cognitive characteristics that could be used to optimise support for those with alcohol dependence, whilst also highlighting some critical questions to be addressed in future research.

Improving assessment and management of suicide risk among people who inject drugs: A mixed methods study conducted at the Medically Supervised Injecting Centre, Sydney.

People who inject drugs are 13 times more likely to die by suicide than the general population. Guidelines for responding to risk in this population are limited. Harm reduction services attended by people who inject drugs require targeted strategies to address the complexities of suicide risk among this population. Co-design, engaging health professionals and people with lived experience informed the study. Mixed methods were used to understand the experience of managing suicide risk among clients attending the Medically Supervised Injecting Centre (MSIC) in Sydney. A survey was administered to assess staff confidence in managing risk. Focus groups were conducted with health professionals and MSIC clients to explore experiences of suicide management, response and opportunities for improvement. Half (N = 17) the MSIC staff surveyed reported over 10 years' experience working with this population. Confidence in managing suicide risk was low. Three key themes emerged from focus groups (N = 17): (i) Autonomy and the need to involve clients in the assessment process; (ii) Trust between clients and health professionals, and transparency in decision-making; and (iii) System barriers, described by health professionals as inadequate referral pathways for clients in distress, and by clients as negative experiences of care, including involuntary admission and not receiving medication (e.g. methadone). Revised assessment guidelines and a tailored safety plan were developed. These resources are also suitable for other alcohol and other drug services. The challenge in managing suicide risk in harm reduction services is balancing duty of care with staff-client relationships and client engagement.

Client and stakeholder perceptions of a novel, nurse practitioner-led alcohol and other drug ambulatory withdrawal service.

Despite recommendations for ambulatory withdrawal programs appearing in many contemporary alcohol and other drug treatment guidelines, to date there have been few studies exploring such programs from client and service stakeholder perspectives. The aim of this study was to explore both individual and service stakeholder perceptions of a nurse practitioner-led ambulatory withdrawal service on the Gold Coast, Queensland, Australia. Data were obtained from three groups: clinicians with knowledge of the service (n = 6); relatives of clients who had used the service (n = 2); and clients who had used the service (n = 10) using a Qualitative Descriptive design. Saldaña's (Saldaña, The coding manual for qualitative researchers. 2013) structural coding framework was used to analyse and code data into themes, with the study reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al. Int J Qual Health Care 2017;19:349-57). Participants noted advantages of the nurse practitioner-led ambulatory withdrawal service, including rapid availability of admission to the service and a person-centred approach. Compared with other ambulatory withdrawal options, clients valued the ability to remain in their own environment, however participants suggested greater follow-up after withdrawal, with the potential of a home visiting service for greater client engagement and treatment retention. Findings provide evidence to suggest that nurse practitioner-led ambulatory withdrawal services are an acceptable option for a proportion of clients who need rapid access to services when they wish to make changes to their alcohol and/or other drug use. Furthermore, they can provide person-centred care for comorbid physical and mental ill health occurring in addition to psychosocial issues associated with alcohol and/or other drug use.

Understanding cultural inclusion in alcohol and other drug services in New South Wales, Australia and assessing the acceptability of a cultural inclusion audit.

Cultural inclusion and competence are understood at the most basic level to be the practice of considering culture so as to provide effective services to people of different cultural backgrounds. In order to work better with clients from diverse backgrounds, alcohol and other drug (AOD) services need to offer a service that is designed to be accessible to all people, where systems in place operate in a way that considers different cultural needs. This research aimed to assess the extent to which non-government AOD services in New South Wales are positioned to support cultural inclusion as well as to evaluate the acceptability of a cultural inclusion audit across four AOD sites. The research adopted a mixed methods approach comprising of a pre-audit online survey (n = 85) designed to assess AOD services' attitudes and practices towards cultural inclusion, and in-depth interviews that were conducted with nine AOD service staff and four cultural auditors to explore the acceptability of a cultural inclusion audit process. Findings from the survey indicate cultural inclusion practices are limited. Interview data highlight that while staff are not fully aware of what appropriate cultural inclusions entails, they are receptive to and want a cultural inclusion program. The study illustrates the benefits of implementing a cultural inclusion audit process aimed at raising awareness of what cultural inclusion entails. Including a cultural inclusion service audit is likely to enhance AOD service provision to culturally and linguistically diverse groups and thereby improve treatment outcomes.

Does a place of last drink initiative affect the likelihood of alcohol sales to obviously intoxicated patrons?

Although the sale of alcohol to obviously intoxicated patrons (i.e., overservice) is illegal in 48 U.S. states, the likelihood of overservice at bars and restaurants has exceeded 80% across multiple studies, states, and decades. Place of last drink (POLD) enforcement is one proposed strategy to address alcohol overservice. When law enforcement agents respond to an alcohol-related incident, they ask the individuals involved where they had their last alcoholic beverage. POLD information is recorded and ideally systematically reviewed to identify locations that are frequently places of last drink. Law enforcement or other agencies may follow up with or penalize the alcohol license holder at these locations. We compared the likelihood of overservice in communities conducting POLD with communities that did not conduct POLD in Minnesota. Pseudo-intoxicated patrons acted out signs of obvious intoxication while attempting to purchase alcohol at 396 bars and restaurants in 26 communities conducting POLD and 26 comparison communities. We calculated rates of alcohol sales to the pseudo-intoxicated patrons overall and in POLD communities versus comparison communities. The overall sales rate to the pseudo-intoxicated buyers was 98%. Rates of sales were 99% at establishments in POLD jurisdictions and 97% in comparison jurisdictions. There were no common characteristics, such as perceived gender/age of the server/bartender or crowdedness of the establishment, among the seven establishments that refused alcohol service. Our study shows that, as currently implemented in Minnesota, POLD does not reduce the overservice of alcohol at a jurisdiction level. More research is needed to identify interventions that yield sustained reductions in the overservice of alcohol.