12th Annual Conference of the

International Society for the Study of Drug Policy (ISSDP)

Vancouver, Canada, 16-18 May 2018

Improving drug policy interventions for substance use disorders

by responding better to the multiple comorbidities of people who
use drugs
AUTHORS
David McDonald 1,2, 3, Carrie Fowlie3, Amanda Bode3, Anke van der Sterren3
1
Social Research & Evaluation Pty Ltd, Wamboin, Australia,
david.mdonald@socialresearch.com.au, ph. +61 2 6238 3706
2
National Centre of Epidemiology and Population Health, The Australian National University,
Canberra, Australia
3
Alcohol Tobacco and Other Drug Association ACT, Canberra, Australia, carrie@atoda.org.au,
ph. +61 2 6249 6358

ABSTRACT
The problem: People who access specialist alcohol and other drug (AOD) services have multiple risk
factors and comorbidities. However, we traditionally provide single responses to single problems. The
consequence is that, in both the health and criminal justice sectors, we fail to maximise the
opportunities that contacts with people who use drugs provide, and resources are not used optimally.
This is highlighted by recent research into the patterns of morbidity and mortality among people who
use drugs which demonstrates that risk factors other than drug use make significant contributions to
adverse health and social outcomes. This is seen in comorbidities as diverse as tobacco use, blood-
borne virus transmission, mental health, gambling, domestic and family violence, etc.

Policy responses: Key policy responses to this issue include addressing all substance use disorders
experienced by an individual, along with the comorbid conditions that relate to them; expanding
tobacco control initiatives to include individually-focused medical/pharmaceutical interventions
where this is not now done; and strengthening access to essential medicines.

Responding to the needs of the whole person: a case study: In the Australian Capital Territory,
Australia, drug policy workers and the specialist AOD treatment and harm reduction sectors have
collaborated to build into their work, as core business, components addressing a range of substance
use disorder comorbidities, particularly smoking cessation, hepatitis C treatment, mental health
interventions, and domestic and family violence interventions.

Conclusion: What we have learned from addressing a range of substance use comorbidities within the
specialist AOD treatment and harm reduction sectors is that:
1) this can be done within the existing health and criminal justice system infrastructure with relatively
small additional resource investments,
2) when dealt with systematically this can become part of the accepted core business of those sectors,
3) addressing the substance use disorder comorbidities, in this way, produces valued outcomes for
both service users and for service delivery staff and agencies, and
4) using a co-design approach, rather than having external drug policy bodies directing agencies and
staff to initiate change, is highly beneficial for all concerned.
ACKNOWLEDGMENTS
The authors acknowledge the commitment and expertise of the managers and staff of the alcohol,
tobacco and other drug sector in the Australian Capital Territory, and commend them on their
openness to innovation in the ways that they respond to the multiple needs of their service users.

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IMPROVING DRUG POLICY INTERVENTIONS FOR SUBSTANCE USE DISORDERS BY
RESPONDING BETTER TO THE MULTIPLE COMORBIDITIES OF PEOPLE WHO USE
DRUGS

This paper has its origins in the responses of some policy workers in the alcohol and other drug
(AOD) sector in Canberra, Australia to a small number of articles published online, ahead of print, in
international refereed journals, in 2017. It was one of those occasions in which a study carried out for
a worthwhile, albeit narrow, scholarly purpose produces findings that have much larger impacts than
the researchers initially anticipated—in this case impacts on the AOD treatment and support service
system across a whole jurisdiction (the Australian Capital Territory).

The first paper was titled ‘The contribution of health risk behaviours to excess mortality in American
adults with chronic hepatitis C: a population cohort-study’ (Innes, McAuley, Alavi, Valerio, Goldberg
& Hutchinson, 2017). The authors reminded us that people living with chronic hepatitis C virus
(HCV) infection have elevated risks of premature death. They set out to investigate the degree to
which the excess mortality is caused by (a) the biological consequences of chronic hepatitis C
infection compared with (b) a high burden of health risk behaviours. They found that ‘All [health risk
behaviours] were markedly more prevalent among individuals with [chronic hepatitis C] versus
individuals without. [Chronic hepatitis C] was associated with a 2.4-fold higher mortality rate after
adjustment for socio-demographic factors … At least half the excess mortality risk for individuals
with [chronic hepatitis C] in the US may be due to [health risk behaviours] rather than [chronic
hepatitis C]. The remedial response to hepatitis C must not neglect action on [health risk behaviours]
if it is to fully resolve the high mortality problem in this population’ (p. 97, our emphasis).

This conclusion was reinforced by a paper ‘Cigarette smoking behaviors and beliefs in persons living
with hepatitis C’ (Shuter et al. 2017). Its abstract reads, in part (our emphasis):
Background and rationale. Tobacco use is common among persons living with hepatitis C
(PLHC), yet little is known about their smoking behaviors and beliefs. Modern hepatitis C
treatment offers a unique opportunity to intensively engage this population about other health
risks, including smoking.
Main results. … HCV+ smokers differed from HCV- smokers in having a higher prevalence of
illicit substance use, depression, and hypertension. PLHC smokers were highly motivated to
quit, with 52.5% stating an intention to quit within 30 days…
Almost a quarter (22.5%) believed that smoking ‘helped fight the hepatitis C virus’.
Conclusions. PLHC smokers have a high burden of psychiatric and substance use
comorbidity. They exhibit characteristics that distinguish them from uninfected smokers, and
many harbor false beliefs about imagined benefits of smoking. They are highly motivated to
quit but underutilize cessation aids. Without aggressive intervention, smoking-related
morbidity will likely mute the health benefits and longevity gains associated with hepatitis C
treatment. Research such as this may prove useful in guiding the development of future
tobacco treatment strategies.

The significance of this is that Australia is in the wonderful position of having a relatively fast, easy
cure for hepatitis C (direct-acting antiviral agents) available to all people living with HCV, as part of
Australia’s national health system. These (and other) studies have demonstrated, however, that the
high death rates among people living with hepatitis C infection are only partially explained by that
health condition. The use of tobacco, alcohol, and illicit drugs, along with insufficient physical
activity and poor diets, also need attention if the full benefits of the hepatitis C treatment are to be
realised.

To put it more directly, the potential benefits of HCV treatment—extending life expectancy by decades
among people previously living with HCV—are likely to be cancelled out by life-style risk factors,
especially tobacco smoking.

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The third article was an editorial with the challenging title ‘A call to action for treatment of comorbid
tobacco and alcohol dependence’ (Elvins & Kelly, 2018). It discusses a study of the effectiveness of
varenicline as a smoking cessation aid among alcohol-dependent people who had not expressed
interest in quitting smoking (O’Malley et al., 2018). The editors point out that:
Comorbid addictive disorders are associated with tremendous morbidity and mortality, yet
our knowledge base for their treatment remains very limited. No comorbid disorder is more
common than the highly harmful combination of nicotine dependence and alcohol addiction;
they literally go hand in hand …
A finding from the O’Malley and colleagues trial suggests that varenicline may be effective
for tobacco abstinence in smokers who do not endorse being ready to try to quit smoking.
Tobacco dependence will lead to premature death for half of smokers who are unable to
quit. Should we redirect our treatment strategy toward a proactive approach of
recommending treatment to all smokers, regardless of willingness to quit, while
encouraging behavior change—as we do already with patients with hypertension or type 2
diabetes? (pp. 121, 122, our emphasis).

In a rational world, one in which careful policy analyses underpin policy decisions, including resource
allocation, we could expect to see, in the AOD treatment service system, well resourced,
comprehensive attention to service users’ comorbidities, particularly their tobacco use. Unfortunately,
however, this is the exception rather than the rule. Across the world, our AOD treatment service
systems are poorly developed. It is something of irony that a great deal of research has been put into
developing treatment modalities that are both efficacious and cost-effective. An outcome is that, in
many nations, we have high quality AOD treatment interventions available, and they deliver highly
valued treatment outcomes (Public Health England, 2017). This largely occurs in the absence of well-
functioning treatment service systems at the local, regional and national levels (Ritter & Stoové,
2016).

One of the results—perhaps an inevitable one—of failing to establish well-functioning treatment

service systems in the AOD field is that we have a host of individual treatment agencies largely
treating single problems with single solutions. People living with opioid use disorders are treated with
methadone or buprenorphine. People living with methamphetamine use disorders are treated with
cognitive behavioural therapy. People with alcohol use disorders are treated with counselling and
perhaps naltrexone. The reality is, however, that almost all of these treatment service users have
multiple comorbidities, and prominent among them is the one that contributes most greatly to
morbidity and mortality: tobacco smoking.

THE COMORBIDITIES
Which comorbidities are found within the service users of our AOD treatment service systems? There
are many, and the limited research that quantifies their relative impacts, such as the Innes et al. (2017)
study cited above, provides valuable insights. Among the comorbidities that we observe among the
service users of the Australian Capital Territory drug treatment agencies are the following:
• Tobacco smoking
• Use of illicit drugs other than the primary drug of concern
• Non-medial use of pharmaceutical products
• Domestic and family violence
• Physical health problems including HCV, cardiomyopathy, neoplasms, etc. (elsewhere
HIV/AIDS)
• Mental health problems especially anxiety, mood disorders and PTSD
• Gambling
• Homelessness/housing stress
• Unemployment and underemployment
• Physical inactivity
• Unhealthy diets
• Etc.

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But which comorbidities do we respond to? The excellent reference source, in the series Oxford
Specialist Handbooks, Addiction medicine (2nd ed.) (Saunders et al. 2016), contains a chapter titled
‘Ongoing management of substance use disorders’. The chapter contains a section titled ‘The ten key
components of management’ (pp. 107-12), and one of those components is ‘Identification and
treatment of comorbid disorders’. That sounds fine, but the discussion that follows is limited to
comorbid mental health disorders, without careful consideration of the significant range of other
comorbidities such as those listed above. This is not intended to be a criticism of the authors and
editors of the Handbook, rather it illustrates what is the norm across the AOD treatment service
system.

POLICY RESPONSES
Where are we now with respect to policy responses to multiple comorbidities?
• As mentioned above, we tend to treat single substance use disorders with single treatment
modalities.
• Too often, treatment service users must prove to the treatment agencies’ staff that they are
worthy of being provided with care.
• Treatment staff tend to decide what treatment response is best for the service user, rather than
engaging in collaborative decision-making.
• We tend to focus our responses on the issues that are most proximate to harms linked to
people’s drug use rather than to their broader and deeper needs.
• The whole person tends to be invisible in our treatment service systems.
• The treatment systems tend to operate as forms of social control over people who use drugs,
and over behaviour of which the powerful in society do not approve.

In some jurisdictions, the linked issues of drugs, drug use, people who use drugs, and societal
responses to all of these, are increasingly being discussed through the framings of human rights and
public health (in contrast to criminal justice system approaches) (e.g. Csete & Wolfe 2017; Lines et
al. 2017). Finally, after decades of promoting a failed ‘war on drugs’ approach, even the United
Nations now appears to be moving in this direction (e.g. Commission on Narcotic Drugs, 2018;
United Nations General Assembly, 2015). A set of drug treatment system policies that explicitly
reflects a human rights and public health orientation would necessarily be one which focuses on the
needs of the whole person, including their multiple comorbidities. Treatment systems would be
service user-focused, rather than service provider-focused.

In such a framing, key policy responses would include addressing all the substance use disorders
experienced by an individual, along with the comorbid conditions that relate to them; expanding
community-wide tobacco control initiatives to include individually-focused medical/pharmaceutical
interventions where this is not done sufficiently now; and strengthening access to essential medicines
for use in AOD treatment, including opioid substitution treatment medications.

RESPONDING TO THE NEEDS OF THE WHOLE PERSON: A CANBERRA CASE STUDY

Examples exist of policy work having been undertaken to adapt AOD treatment service systems to
attend to service users’ multiple comorbidities, and to focus more on the whole person. We have had
leadership roles in initiatives of this type in the Australian Capital Territory (the ACT), a jurisdiction
with a population of some 415,000, located in inland south-eastern Australia (see
https://www.act.gov.au/browse/about-act ). The ACT has one city, Canberra and, as the ACT’s name
suggests, it is the seat of the Parliament of the Commonwealth of Australia. Canberra has ten
specialist AOD service agencies, both government and non-government (NGO), delivering 34
different AOD programs. All but one of these organisations are NGOs. The top four principal drugs of
concern for clients seeking treatment and support for their own drug use are (in descending order of
frequency) alcohol, methamphetamine, cannabis, and heroin (Australian Institute of Health and
Welfare, 2017).

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In recent years, ACT drug policy workers and the specialist AOD treatment and harm reduction
sectors have collaborated to build into their work, as core business, components addressing a range of
substance use disorder comorbidities, particularly the provision of smoking cessation, mental health
interventions, direct acting antiviral medications for the treatment of hepatitis C, and domestic and
family violence interventions. We describe each of these briefly, and explicate the co-design process
that has underpinned their development.

Smoking cessation
Some 82% of people accessing specialist AOD services in the ACT self-identify as tobacco smokers,
in contrast to 10% of the general ACT population. In the ACT, the AOD sector has responded to these
unacceptably high rates by initiating and participating in a collective and planned program of tobacco
management activities, including:
• developing clear service-wide tobacco management policies and guidelines
• supporting AOD workers to quit or reduce their own tobacco use through the provision of free
nicotine replacement therapy (NRT)
• reviewing clinical processes to more explicitly embed smoking cessation practice in screening
and assessment
• providing free NRT and intensive smoking cessation support to service users alongside
existing AOD treatment, and
• building capacity among AOD workers in providing this targeted smoking cessation treatment
and support (ATODA 2016).

By building on their existing strengths, ACT specialist AOD services hope to both increase rates of
smoking cessation and improve AOD treatment outcomes by delivering targeted and intensive
smoking cessation interventions alongside other drug treatment. Integrating effective smoking
cessation support within AOD treatment leverages off the existing treatment and support expertise,
and requires comparatively minimal additional investment in treatment and training. Through this
collective body of work, smoking cessation has become core business of the specialist AOD services
in the ACT.

Mental health interventions

The co-occurrence and complexity of mental health problems among people experiencing AOD issues
is well documented (e.g. Teesson, Slade & Mills 2009), and acknowledged among AOD service
providers. In 2008, the Australian national government funded NGO AOD services for multiple years
to build capacity to respond to AOD and mental health issues concurrently. Funding flowed
predominately to AOD service delivery agencies, with some funding allocated to AOD peak agencies
(for coordination and support). Within the ACT, activities focused on:
• Annually implementing a validated fidelity instrument: the Dual Diagnosis Capability in
Addiction Treatment (DDCAT) Index tool.
• Implementing a routine expectation of mental health screening using standardised and formal
instruments. This screening could then inform assessment and treatment planning processes,
allowing services to structure treatment programs based on the severity of the issue identified
– including shared care with specialist mental health services.
• Establishing policies and procedures for Suicide Risk Assessment.
• Undertaking resource-effective shared training that established competence across the entire
workforce.

The approaches were designed specifically with AOD settings and clinical approaches in mind, and
are now integrated as assumed minimum components and core business of AOD service delivery.

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Direct acting antiviral medications
The ACT AOD sector has partnered with the local Hepatitis organisation to define and advocate for
responses to hepatitis C in AOD settings. This includes, with the support of the AOD peak body,
developing and endorsing a statement of priorities across all specialist ACT AOD services that
acknowledges the unique role, and access to affected communities, specialist AOD services have.
Blood-borne virus education and prevention activities have been embedded across AOD services:--
89.9% of service users in the ACT reporting improved knowledge of prevention of blood borne virus
transmission as an outcome of attending the service (ATODA 2016).

In 2016 a new generation of direct-acting antiviral medications for hepatitis became available through
the Pharmaceutical Benefits Scheme. They can be prescribed by a GP, are more effective, easier to
take and have fewer side-effects (NSW Users and Aids Association). This has created new
opportunities for AOD services to provide on-site services, or facilitate links to off-site supports for
screening, engagement, prevention, harm reduction, treatment and monitoring.

While still early in the process, ACT AOD services have begun to embed hepatitis C treatment
alongside AOD treatment and are undertaking activities to advocate for, and implement initiatives that
will use, AOD settings to engage people living with chronic hepatitis C. This is occurring at the same
time that we are consolidating our evidence based harm reduction efforts to prevent new infections.

Domestic and family violence interventions

Harmful AOD use is a major risk factor for using and/or experiencing violence generally, and
domestic and family violence (DFV) specifically. This means that AOD workers have an important
role, and AOD services are ideal settings, to detect DFV and to intervene sensitively and
appropriately. Despite this, advice to guide specific practices in responding to DFV in AOD work has
been lacking.

As part of a broader policy focus on DFV, the ACT Government in 2017 engaged the ACT AOD
sector (through the AOD peak organisation) to undertake a rigorous and comprehensive co-design
process with specialist AOD services and DFV stakeholders, clinicians, consumer representatives,
researchers and policy workers to design a program of work. As part of this, three Australian-first
tools were developed that aim to provide more effective responses for people who use AOD in
harmful ways and either experience and/or use DFV. The tools enable specialist AOD services to
benchmark practice and to delineate and articulate worker roles, and provide clinical and practical
guidance to the AOD sector to prevent and respond to DFV. The approach borrows from the learnings
the sector gained with embedding responses to mental health morbidity into AOD services.

A key factor for success was the ACT Government empowering the AOD sector to use its expertise to
respond to the sub-population specific needs of people who accessing AOD services and make a
system-wide plan for change, rather than taking a top-down approach. As a result, the approaches and
tools developed are evidence-based, fit-for-purpose and feasible within AOD settings.

The ACT AOD sector’s co-design approach

The ACT AOD sector has adopted a co-design approach whereby programs and their deliverables are
produced with the intensive involvement of the key stakeholders who will enact and benefit from the
outcomes. Co-design has been central to the development and implementation of a range of integrated
programs within the ACT AOD sector that address substance use disorder comorbidities, such as
those described above.

The co-design approach has successfully harnessed the sector’s common values and goals, and has
pulled together the specific expertise and resources brought by each partner to benefit the collective
activity. Through this collective activity, the AOD sector maintains its strength and cohesion to move
forward together to deliver quality outcomes to service users.

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Through a co-design approach, the AOD sector has identified issues of concern facing the sector, and
maintained ownership of the solutions. The products of co-design are, thereby, fit-for-purpose,
relevant, workable, and have maximum benefit to specialist AOD services and service users.
Furthermore, co-design enables the sharing and pooling of resources in both the production and
implementation of the programs/outcomes. This includes not only financial resources, but also refers
to sharing skills and intellectual resources, and to building collective capacity and knowledge across
the sector.

CONCLUSION
We have learned several things, in recent years, from our experiences in Canberra with addressing a
range of substance use comorbidities within the specialist AOD treatment and harm reduction sectors.
These include the following:
1) Expanding and adapting AOD treatment and support services to incorporate attention to a range of
comorbidities can be done, within the existing health and criminal justice systems’ policy frameworks
and infrastructures, with relatively small additional resource investments.
2) When dealt with systematically, this can become part of the accepted core business of those
sectors. This applies in both the government and NGO AOD service agencies.
3) Addressing the substance use disorder comorbidities, in this way, produces valued outcomes for
both service users and for service delivery staff and agencies.
4) Using a co-design approach, rather than having external drug policy bodies directing agencies and
staff to initiate change, is highly beneficial for all concerned. Although it takes time and commitment
on the part of the participants, it delivers buy-in to the change process, and leads to the creation of
approaches to comorbidity that are fit-for-purpose. It helps to generate, within the sector, a strong
understanding and culture of change management and how to deliver it (which can then be mobilised
to new priorities and issues)

Dealing with the comorbidities as part of core business helps the AOD sector to achieve the stated
(but not sufficiently frequently attained) outcomes of therapeutic interventions, namely reduced
harmful drug use, improved physical and mental health, and improved social functioning. This
happens when we go beyond simply treating the presenting substance use disorder, defined in terms
of a drug or (commonly) the most prominent drug among people who are poly-drug users.

It produces an orientation that facilitates a focus on the drug use that is the most significant cause of
morbidity and mortality in AOD treatment populations: tobacco smoking.

It focuses attention on our sector’s scope of practice: what we can and cannot do within the specialist
AOD sector. It serves as an enabler of an expanded scope of practice, while maintaining our core
specialist approaches and competencies. Having attention to significant comorbidities as core business
for the sector does not undermine the goals of substance use disorder interventions. Rather, it helps us
to realise our secondary objectives better, without detracting from the primary objectives of the
services.

Remember where we started this paper:

• At least half the excess mortality risk for individuals living with chronic hepatitis C may be
due to health risk behaviours rather than chronic hepatitis C.
• ‘Without aggressive intervention, smoking-related morbidity will likely mute the health
benefits and longevity gains associated with hepatitis C treatment’.
• ‘Tobacco dependence will lead to premature death for half of smokers who are unable to quit.
Should we redirect our [AOD] treatment strategy toward a proactive approach of
recommending treatment to all smokers, regardless of willingness to quit, while encouraging
behavior change—as we do already with patients with hypertension or type 2 diabetes?’

The challenge has been presented to those of us with responsibility for policy work in the AOD
treatment service system, the challenge of dealing with the whole person, of addressing diverse

8
comorbidities (especially tobacco smoking), rather than focusing mainly or entirely on a single
presenting problem. We have described important, productive steps taken in this regard within
Canberra’s AOD specialist treatment and harm reduction service sector to deliver more integrated
care to achieve optimal treatment outcomes for the people we are there to work with.

REFERENCES
Alcohol Tobacco and Other Drug Association ACT (ATODA) (2016). Service Users’ Satisfaction
and Outcomes Survey 2015: a census of people accessing specialist alcohol and other drug
services in the ACT. ATODA monograph series no. 4. Canberra: ATODA.

Australian Institute of Health and Welfare (2017). Alcohol and other drug treatment services in
Australia 2015–16, Canberra: AIHW.

Csete, J., & Wolfe, D. (2017). Seeing through the public health smoke-screen in drug policy
(Commentary). International Journal of Drug Policy, 43, 91-95.
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Commission on Narcotic Drugs (CND) (2018). Removing stigma as a barrier to the availability and
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Innes, H., McAuley, A., Alavi, M., Valerio, H., Goldberg, D., & Hutchinson, S. J. (2017). The
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hepatitis C: a population cohort-study. Hepatology, 67(1), 97-107, doi:10.1002/hep.29419.

Lines, R., Elliott, R., Hannah, J., Schleifer, R., Avafia, T., & Barrett, D. (2017). The case for
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O’Malley, S. S., Zweben, A., Fucito, L. M., Wu, R., Piepmeier, M. E., Ockert, D. M., . . .
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NSW Users and Aids Association (NUAA), Hepatitis C Treatment and Support, website, viewed 19
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Public Health England (2017). An evidence review of the outcomes that can be expected of drug
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Ritter, A., & Stoové, M. A. (2016). Alcohol and other drug treatment policy in Australia (editorial).
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Shuter, J., Litwin, A. H., Sulkowski, M. S., Feinstein, A., Bursky-Tammam, A., Maslak, S., . . .
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Teesson, M., Slade, T., & Mills, K. (2009). Comorbidity in Australia: findings of the 2007 National
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United Nations General Assembly (2015). Human Rights Council, Thirtieth session, Agenda items 2
and 8: Annual report of the United Nations High Commissioner for Human Rights and
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