Gippsland Dual Diagnosis News

Gippsland Dual Diagnosis News Welcome to the second edition of the Gippsland Dual Diagnosis News! This newsletter will be produced quarterly by Belinda Norton, HYDDI clinician, and co-editor Jess Dickson, DD clinician. We value your contributions and suggestions for future newsletters. Please contact bnorton@lrh.com.au or jdickson@mindaustralia.org.au (part of the VDDI). Illicit pharmaceutical use Written by Belinda Norton, HYDDI clinician Prior to relocating to Gippsland, I worked in the Alcohol and Other Drug (AOD) sector in Canberra for 10 years. While much of the substance use issues are very similar to Canberra, I have noticed the prevalence of illicit use of pharmaceuticals in this area and workers have been interested to find out more information. Opioids, benzodiazepines, anti-psychotics, and methylphenidate are the most commonly misused prescription pills with people either doctor shopping or buying them off the street. Locally there have been reports of Seroquel tablets selling for $25 each and Opioids selling for $10 per mg. Codeine-based, over-the-counter medications like Nurofen Plus can also be an issue. Nurofen Plus has 200mg of ibuprofen and 12.8mg of codeine phosphate in each tablet, making it the strongest codeine tablet in Australia available without a prescription (MJA 2008). Autumn 2012 Volume 1, Issue 2 Inside this issue: Illicit pharmaceutical use p.1-3 Mind Australia - program profile p.4-5 Staff member profile: Jess Dickson p.6 Suicide in rural Australia p.7-8 Dual Diagnosis Training p.9 Training registration form p.10 Dual Diagnosis portfolio holder meeting dates p.11 The most commonly used licit opioids are: Morphine Sulfate: MS Contin, Anamorph, Kapanol Oxycodone Hydrochloride: OxyContin, OxyNorm, Endone Codeine Phosphate: Nurofen Plus, Panadeine Forte, Mersyndol. Less commonly used are: Fentanyl: Durogesic, Duragesic, Actiq Tramal Hydrochloride: Tramadol. 1

Other prescription drugs that are used are: Benzodiazepines: (diazepam, alprazolam) e.g. valium, Xanax Anti-psychotics: (Quetiapine) e.g. Seroquel Anti-Depressants: Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclic Antidepressants (TCA) Methylphenidate: Ritalin, Concerta Antihistamines: Unisom Zolpidem Tartrate: Stilnox (probably not that common - depends on region). People may doctor shop for a variety of reasons such as self-medicating for pain, anxiety, depression, heroin or other drug withdrawal, psychoactive effects or financial benefit. Sometimes they may exaggerate their symptoms, display aggression or acquire medication from family or friends. They also may go to different doctors and different pharmacies so they don t get recognised or they may alter or forge their prescriptions. In 2007, Diazepam 5mg tablets and codeine phosphate paracetamol 30mg/500mg were the most common medications recorded for doctor shopping (sourced from DCPC, 2007 Anex, 2011). Among illicit drug users, 69% report benzodiazepine use and 10% are injecting (sourced from the IDRS 2011 Anex, 2011). They use benzodiazepines to promote sleep, relieve anxiety post amphetamine type stimulant (ATS) use, increase effectiveness of other depressant use and/or manage mental health issues such as Post Traumatic Stress Disorder. Issues with the illicit use of pharmaceuticals are the interaction with other substances and the risk of overdose. The half-life of different pills can vary and people may feel the substance has left their system when it hasn t. There can also be issues with safe injecting as many illicitly used benzodiazepines are not water soluble making them dangerous to inject. Wheel filters are designed to filter out larger particles, which cause damage to the veins and should be used if injecting pills. Fentanyl Fentanyl, which has been referred to as the most powerful opioid known (approximately 80 to 100 times more potent than morphine), has long been used to treat cancer-related pain and has been listed on the Pharmaceuticals Benefits Scheme (PBS) since 1999. In 2006 its PBS listing was expanded to include treatment of non-malignant chronic pain in people who have developed some tolerance to other opiate based pain-management drugs. In Australia, fentanyl is classed as a controlled drug of addiction (Schedule 8), and is marketed as Duragesic (transdermal patches). There have been concerns mounting that there is increasing misuse of fentanyl patches through the following methods: Distilling fentanyl from patches for injecting drug use Distillate used to boost other illicit substances Distillate crystallised to resemble rock Smoking associated fentanyl derivatives Chewing and ingestion of patches Placement of multiple patches on the body. A Needle and Syringe Program (NSP) worker in a rural community has told the Anex Bulletin (2011, vol.10, iss.1) that some clients were reporting taking the patches and processing them to make an 2

injectable solution. Another worker in a regional city reported that at least one client had overdosed and was revived in hospital. One AOD worker said there was an increase in clients reporting fentanyl use, which followed a bit of a dry in morphine (from pills) availability about 18 months ago. Oxycodone Oxycodone prescriptions have increased significantly since 2000 as doctors feel more comfortable prescribing this for pain relief. Ms Amanda Roxburgh, senior researcher at the National Drug and Alcohol Research Centre, and co-authors conducted a study analysing trends in prescriptions for morphine and oxycodone, hospital separations for overdose, treatment episodes related to morphine or oxycodone, and the number of oxycodone-related deaths. They found that between 2002-03 and 2007-08, morphine prescriptions decreased by about 20 per cent compared with 152 per cent increase in prescriptions for oxycodone. Prescriptions for both were highest among older Australians. Ms Roxburgh said the study showed that treatment episodes for morphine remained stable, while those for oxycodone increased, and that 90 per cent of the 465 oxycodone-related deaths recorded during 2001-09 involved either the use of the drug in combination with other opioids, benzodiazepines and alcohol, or the contribution of concomitant medical conditions (AMA) Prescription Shopping Program The Prescription shopping Program (PSP) helps to protect the integrity of the Pharmaceutical Benefits Scheme (PBS) by identifying and reducing the number of patients obtaining PBS subsidised medicine in excess of their medical need. There are two elements to the PSP. The Prescription Shopping Information Service (PSIS) is available to registered prescribers 24 hours a day, seven days a week. It provides information on the prescription history of people identified by the program and is accurate up to the last 48 hours. There is also an alert service that will notify the doctor if they have prescribed to a patient of concern. Doctors need to be registered with this service to obtain information and the patient needs to have been identified as meeting the PSP criteria (DHS 2011). References Anex bulletin 2011 Volume 10, Edition 1. Retrieved on 19 March 2012 from http://www.anex.org.au/wp-content/uploads/2010/10/852-anex-bulletin-vol101_updated_spreads-2.pdf Anex 2011, Drugs and Crime Prevention Committee 2007, Retrieved on 21 March 2012 from http://www.anex.org.au/wp-content/uploads/2011/07/nicola-cowling-harmaceuticals-2011.pdf Australian Medical Association 2011, Medical Journal of Australia. Retrieved on 19 March 2012 from http://ama.com.au/node/7108 Medical Journal Australia 2008, Nurofen Plus misuse: an emerging cause of perforated gastric ulcer, Retrieved on 27 March 2012 from https://www.mja.com.au/journal/2008/188/1/nurofen-plus-misuse-emerging-cause-perforated-gastric-ulcer Department of Human Services, Medicare. Prescription Shopping Program Retrieved on 30 March 2012 from http://www.medicareaustralia.gov.au/provider/pbs/prescription-shopping/index.jsp#n10009 3

Mind Australia Program Profile Mind supports people with mental illness in their recovery, to help them live well in the community, with or without symptoms. We work with people who have a range of often complex issues resulting from mental illness and their families and carers, and have been doing this work for over 30 years in Victoria. Gippsland Service team There are three services available in the Gippsland region. Services are funded by the Commonwealth Government and the Department of Human Services. Services that we offer are: 1.Gippsland Personal Helpers & Mentors Service (PHaMs) What the program aims to do The strength-based recovery focus of the service is to build on existing skills and attempt to foster activities that promote sustainable and meaningful participation within the community for people who are at risk of falling through the gaps. Who can access Gippsland PHaMs Gippsland PHaMs provides services to people aged 16 and over who are recovering from mental illness and reside in Gippsland. How to access the program The referral process is usually initiated by telephone. Referrals can be made to the program by a mental health service, other service providers, self-referral, a family member, friend or worker. Referral forms are provided for completion and applicants are required to attend an assessment interview before being offered a place at Gippsland PHaMs. Enquiries to Sarah Davies from 9.00am to 5.00pm Monday to Friday. Phone: 03 5134 6199 2. Wannik Gunyah What the program aims to do The staff at Wannik Gunyah work to provide young people with opportunities for positive changes. They support the young people in whatever way is necessary for them to develop a sense of belonging and self-worth. There is an emphasis on helping them deal with day-to-day tasks and preparing them for independent living including linking them into the community through education and employment. Wannik Gunyah also maintains and promotes family inclusive practices. Who can live at Wannik Gunyah 4

The residential program provides services to young people 16 24 years from the Gippsland Region. Wannik Gunyah is situated in a residential part of Traralgon and is made up of a small community of 10 young people. Clients can be in the program for a maximum of two years. Wannik Gunyah also offers a service for people aged 16 to 24 with Dual Diagnosis who have the skills to live in the community with outreach support. How to access the program Clients access the program by referral. The referral process is usually initiated by telephone. Then there is an informal visit to meet staff and other residents. Referral forms are completed before an interview and assessment date is confirmed. Enquiries to Kim Krieger 8.30am to 4.30pm, Monday to Friday. Phone: 03 5176 1800 3. Insight What the program aims to do The program has a home-based outreach service and day programs. The outreach service works with individuals who require support maintaining their mental health by working towards maintaining a safe environment, learning new skills, gaining greater access to the community, forming new relationships and increasing independence. The day program offers a variety of activities to enhance socialisation, learn new skills and increase community access. Programs on offer range from music, cooking, art, Fun Fridays and men s and women s groups. Who can access Insight Insight provides service to people with low-prevalence disorders or people seriously affected by mental health who are currently case managed or clinically supported and between the ages of 16 and 64. They must reside in the Latrobe or Baw Baw municipalities. How to access the program The referral process is usually initiated by telephone. Enquiries can be made by a mental health service, other service providers, self-referral, a family member, friend or worker. Referral forms are provided for completion by professional support and applicants are required to attend an assessment interview before being offered a place at Insight. Enquiries to Kim Krieger 8.30am to 4.30pm Monday to Friday. Phone: 03 5135 2555 5

Staff member profile: Jess Dickson How long have you worked for Mind? I commenced employment at Mind Australia as a Dual Diagnosis Outreach Support Worker on 6 December 2010. I am based at the Wannik Gunyah Program, a youth residential service in Traralgon. I remember the exact date. Being close to Christmas there were lots of activities and events being held, which was a great opportunity for me to meet my new co-workers, residents and develop youthspecific networks. From left: Jess Dickson, Teresa Wyntjes and Kevin Heatherington from Mind Australia What is included in your role as Dual Diagnosis worker? My role involves working with young people aged 16 to 24 years around mental health and substance use issues to provide support in managing symptoms, building resilience and re-engaging with the community and various activities/programs. What did you do before starting at Mind? I worked at Latrobe Community Health Service (LCHS) for four years in Drug Treatment Services (DTS). My roles included Post Withdrawal Links and Support and Alcohol and Drug Counselling. I was lucky enough in these roles to have opportunities in running a Community Rehabilitation Group and the Cautious with Cannabis program. Why did you choose this type of work? On completion of year 12 in 2002 I was undecided on a career path. I enrolled in Bachelor of Social Welfare at Monash University at the Churchill campus. On attainment of my degree, I was still unsure about which field of community services I wanted to work in. I undertook a 60-day student placement at LCHS in DTS and quickly became passionate about supporting people to make positive changes to reduce substance use issues. What s the best thing about your job? Every day presents a different challenge and is equally rewarding. I have met some amazing people and feel privileged to be involved in supporting their journey of recovery. What would you be doing if you didn t work for Mind? I cannot imagine what role I will have in the future. However, I do hope to continue working within the community health sector. 6

Suicide in rural Australia As workers in the industry of Mental Health, Alcohol and Other Drugs, and/or Housing we are all aware of the risk of suicide with our complex clients. When clients with dual diagnosis issues are feeling suicidal, they are at higher risk of completing suicide when intoxicated, when their mental health issues are exacerbated or they have had previous attempts. There are often other contributing factors such as family violence, unemployment, history of trauma, and/or poverty, so when you combine these issues with homelessness, people can find it very difficult to see anything positive for the future. While some of our clients can present expressing suicidal ideation on many occasions, it is still important to ensure we have completed a risk assessment and appropriate intervention. Research suggests that 'rurality' living in a rural or remote location - creates a higher risk of suicide. Suicide rates for males in rural and remote communities have increased steadily over the past 20 years, with rates for young males consistently higher in small rural communities than in metropolitan and regional areas (Rural health promotion 2009). In 2010, 24% of all male deaths aged 15 to 24 years were due to suicide (ABS 2010). Possible factors contributing to higher rates in rural areas include isolation, rural poverty, increased risk-taking behaviour and access to lethal means (e.g. firearms). It has also been suggested that a culture of self-reliance, which does not encourage helpseeking behaviour, may be one of the most important contributing factors to youth suicide in rural areas. Rural Australia, in fact, has one of the highest rates of youth suicide in the world (Rural health promotion, 2009). The most recent statistics in Australia are from 2010 and are available from the Australian Bureau of Statistics (www.abs.gov.au) Some key facts related to suicide deaths in Australia: There were 2132 deaths from suicide registered in Australia in 2009, a rate of 9.7 per 100,000. In 2010 there were 2361 deaths from suicide, a rate of 10.5 per 100,000. While suicide is a relatively rare cause of death in Australia compared with other causes, it still remains a major external cause of death, accounting for more deaths in Australia than transport accidents. It is the tenth leading cause of death for males. For males the highest age-specific rates of suicide are for men aged 40 to 44. The rates then drop gradually until the age of about 70, after which they climb again. For women, there is less variation in suicide rates across the lifespan. Rates tend to increase slightly through the middle years and then decline for older age groups, however suicide deaths comprise a higher proportion of total deaths in younger age groups. It is difficult to estimate the rates of suicidal ideation, but studies suggest that around 11.9% of men and 16.6% of women in Australia will experience suicidal thoughts at some point in their lifetime. 7

It is difficult to estimate how many non-fatal suicide attempts occur, since many are not reported. However studies suggest that 43,000 to 44,000 Australians make a non-fatal attempt each year. The percentage of deaths attributable to suicide is much higher among Aboriginal and Torres Strait Islander people (about 4.0%) than non-indigenous Australians (about 1.4%). Suicide is the sixth leading cause of death of Aboriginal and Torres Strait Islander Australians. Suicide is more concentrated in the earlier adult years for Aboriginal and Torres Strait Islander people than for the general Australian population, with recent data indicating the highest rates for both males and females in the 15 to 24 year age group. One quarter of suicides in Australia occur among people who have migrated to Australia, with 60% of these being from non-english speaking countries. However, rates vary according to country of origin, gender and age. People in any form of custody have suicide rates more than three times higher than the general population. Suicide mortality rates in Gippsland over five years (2003-2007) by Local Government Area are as follows: LGA Males per 100,000 Females per 100,000 Wellington 21.5 4.6 Latrobe 19.8 4.9 Baw Baw 16.2 6.2 South Gippsland 16.0 2.8 East Gippsland 14.6 5.0 Bass Coast 14.2 6.2 Gippsland 17.7 5.0 Victoria 11.9 3.6 When suicide is suspected, the case is referred to the Coroner for investigation. If the Coroner is not satisfied that all criteria are met (death due to unnatural causes, actions are self-inflicted and person had the intention to die), the death will be deemed accidental or undetermined depending on Coroner s findings (Response Ability). In 2010 there were 8318 people who died as a result of an external cause. Of these, 2361 were considered to be intentional self-harm, 5382 were accidental death and 683 were undetermined intent (ABS 2010). It can be particularly difficult to distinguish accidental death from suicide in the cases of drug overdoses and car accidents. This raises the possibility that actual suicide rates may be higher than reflected in published statistics. If you are experiencing issues with depression and/or suicidal thoughts please call Lifeline on 13 1114 References: Department of Health 2011 Suicide Mortality Rates, retrieved on 20 March 2012 http://docs.health.vic.gov.au/docs/doc/65c570b5d31681d4ca25787700084985/$file/hci109.pdf Australian Bureau Statistics 2010, 3303.0 Causes of Death, Australia, 2010 retrieved on 19 March 2012 from http://www.abs.gov.au/ausstats/abs@.nsf/products/7993a7cbaedfe462ca2579c6001b644a?opendocument Response Ability, Overview of suicide in Australia, retrieved on 20 March 2012 from http://www.responseability.org/site/index.cfm?display=134569 State Government of Victoria, 2009 Rural health promotion retrieved on 20 March 2012 from http://health.vic.gov.au/ruralhealth/promotion/index.htm 8

Dual Diagnosis Training 2012 Gippsland Dual Diagnosis Training is designed primarily for staff working within the clinical mental health, Alcohol and Drug and PDRS Sectors within Gippsland Dual Diagnosis Screening and Assessment A one-day training session on dual diagnosis screening tools, how to use and interpret them Warragul: Wednesday 18 th April 9.00 4.30 Sale: Tuesday 26 th June 9.00 4.30 Traralgon: Thursday 23 rd August 9.00 4.30 Comorbid substance use and anxiety A half-day session that will focus on occurrence of and strategies for the treatment of co-occurring substance use and anxiety Traralgon: Thursday 7 th June 12.00 4.30 Comorbid substance use and depression A half-day session that will focus on the occurrence of and strategies for the treatment of co-occurring substance use and depression Traralgon: Wednesday 18 th July 12.00 4.30 Effects of Alcohol and Drugs on Psychotropic medication A half-day session that explores the interaction of AOD and psychotropic medication, contraindications and things to look out for Bairnsdale: Wednesday 20 th June 12.00 4.30 Korumburra: Thursday 13 th September 12.00 4.30 Traralgon: Thursday 6 th December 12.00-4.30 AOD pharmacotherapy A one-day training session covering current options for substitution and maintenance medication for use with substance-dependent people including information on accessing pharmacotherapy, contraindications and implications for dual diagnosis clients Warragul: Wednesday 23 rd May 9.00 4.30 Traralgon: Monday 22 nd October 9.00 4.30 Mental Health Risk in AOD settings This half-day session looks at how to assess mental health risk in AOD settings, common presentations and how to handle them, a guide to the clinical mental health system as well as tips on managing chronic risk such as self harming and risk associated with personality disorders Traralgon: Thursday 26 th July 12.00 4.30 Harm minimisation and relapse prevention in dual diagnosis Includes an overview of harms associated with dual diagnosis, features of relapse and strategies to assist your clients to reduce this harm and avoid relapse Warragul: Wednesday 29 th August 9.00 4.30 Sale: Wednesday 5 th September 9.00 4.30 Brief Interventions and therapeutic guiding principles of Dual Diagnosis A one-day session focussing on therapeutic interventions to assist your client to move through the stages of change Sale: Tuesday 30 th October 9.00 4.30 Warragul: Wednesday 28th November 9.00 4.30 Working with clients in pre-contemplation A one-day practical session that will focus on the challenges of working with clients in pre-contemplation and strategies to assist in change Traralgon: Wednesday 12 th September 9.00 4.30 Working with Aboriginal people with a dual diagnosis A one-day session to explore key strategies for working with indigenous people that includes considerations of family, community and environment Traralgon: Wednesday 21 st November 9.00 4.30 VENUES: TRARALGON: Latrobe Valley Community Mental Health, 20 Washington St, Traralgon WARRAGUL: Petit Centre, West Gippsland Health Service, 31-35 Gladstone St SALE: Sale Community Mental Health, Cnr Palmerston and Cunningham Sts BAIRNSDALE: Monash School of Rural Health, McKein St KORUMBURRA: Community Mental Health Service, 4 Gordon St, Korumburra To apply for any of the above training sessions, please complete and send the attached registration form to GAshton2@lrh.com.au or fax to 5658 1294. For enquiries please phone Gillian on 5658 1501. 9

2012 Gippsland Dual Diagnosis Education and Training Registration Form To register for any dual diagnosis training, please complete the form below and fax to (03) 5658 1294 or email to GAshton2@lrh.com.au Name: Current position: Organisation: Postal Address: Telephone: Dietary Needs: Email: Discipline: Postcode: I would like to register for the following education sessions; Dual Diagnosis Screening and Assessment Warragul 18 th April 9.00-4.30 Sale 26 th June 9.00 4.30 Traralgon 23 rd August 9.00 4.30 AOD pharmacotherapy Warragul 23 rd May 9.00 4.30 Traralgon 22 nd October 9.00 4.30 Dual diagnosis brief interventions and therapeutic guiding principles Sale 30 th October 9.00 4.30 Warragul - 28 th November 9.00 4.30 Effects of Alcohol and Drugs on psychotropic medication Bairnsdale 20 th June 12.00 4.30 Korumburra 13 th September 12.00 4.30 Traralgon 6 th December 12.00 4.30 Working with clients in pre-contemplation Traralgon 12 th September 9.00 4.30 Mental Health risk in AOD settings Traralgon 26 th July 12.00 4.30 Co-morbid substance use and anxiety Traralgon 7 th June 12.00 4.30 Co-morbid substance use and depression Traralgon 18 th July 12.00 4.30 Harm minimisation and relapse prevention Warragul 29 th August 9.00 4.30 Sale 5 th September 9.00 4.30 Working with Aboriginal people with a dual diagnosis Traralgon 21 st November 9.00 4.30 Upon receipt of your application form an email will be sent to confirm your place in the training. If you do not receive this email please contact the dual diagnosis worker on 0438 358 676. 10

Dual Diagnosis portfolio holder meeting dates 2012 Orbost/Bairnsdale Sale/Yarram Latrobe Valley/Warragul Bass Coast/ South Gippsland Venue: SNAP Bairnsdale Room 137 Sale PMH LVCMHS Washington St Wonthaggi Community Mental Health Thursdays Tuesdays Thursdays Tuesdays Time: 11am - Time: 1pm - 2pm Time: 2pm - 3pm Time: 2pm 3pm 12noon April 19 April 24 May 31 May 29 May 3 May 22 June 21 June 19 June7 July 19 July 24 July 5 July 24 Evaluations Due to some Dual Diagnosis Portfolio holder meetings having low attendance rates, an evaluation of the current portfolio meeting model was conducted recently with the members from Latrobe Valley/Warragul. We are still waiting on final evaluation results, however, so far some suggestions have included having an educational focus, quarterly meetings, reflective practice component and email correspondence between meetings. We will inform you of the outcome when the results are finalised. 11