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Standing Committee on Indigenous Affairs - 05/09/2014 - Harmful use of alcohol in Aboriginal and Torres Strait Islander communities

CONIGRAVE, Professor Katherine Margaret, Conjoint Professor, Addiction Medicine, University of Sydney

JACK, Mr Peter Darren, Associate Lecturer, Addiction Medicine, University of Sydney


ACTING CHAIR: We have appearing before us the discipline of addiction medicine at the University of Sydney. Welcome, Professor Conigrave and Peter Jack. Would you like to make some introductory remarks?

Prof. Conigrave : We thank you for the opportunity to appear before the committee. Peter and I have between us some 50 years of experience working in the alcohol and other drugs field, and this includes in urban, regional and remote settings. Peter has worked in residential rehabilitation and has worked in a variety of community services, including programs taking young offenders to work on the dog fence in South Australia through to adult prisoner support. I am an addiction medicine specialist, so I see patients, and I am also a public health physician. Alcohol related harms of course are a major source of concern to Aboriginal and Torres Strait Islander communities, and many communities have attempted to address these harms.

Worldwide research tells us that individuals who face past or current traumas are more likely to run into problems with alcohol. Also, a loss of a sense of control or a loss of connectedness can contribute to a person's risk of alcohol problems. We now also understand from research the neurobiological basis of alcohol dependence and that strong and sometimes overpowering desire to drink. This understanding has led to the development of relapse prevention medicines, which can greatly improve outcome. However, even with cutting-edge treatment, alcohol dependence remains a very difficult condition. It typically behaves as a chronic relapsing disorder, yet it is always left off the chronic disease agenda, and prevention and early detection lag behind the chronic physical disease agenda.

It is very important that policies relating to alcohol dependence are based on realistic expectations of outcomes. International studies show that less than half of individuals who complete residential detoxification can maintain continuous abstinence for the next 90 days. Yet without modern medicines or outreach support, this percentage can be as low as one in six. Given these figures, it is disturbing to see a criminal rather than a health perspective being used to manage alcohol problems, and this is most noticeable in the Northern Territory with the alcohol protection orders.

Also of concern is the expansion of mandatory treatment programs in a setting where there is very limited evidence for their effectiveness and when there is limited access to voluntary treatment. Currently over 40 per cent of prison inmates have evidence of alcohol dependence, based on surveys, but most prisons still do not offer comprehensive treatment for alcohol problems. Furthermore, based on US experience from justice reinvestment, the money spent on imprisonment would be far more effectively spent on programs to support families at risk and to increase opportunities for employment and resilience building among young people. Accessing treatment for alcohol dependence remains problematic. In rural New South Wales, individuals can travel six to nine hours to access residential services. Lack of child care or family-friendly services poses a challenge, and residential youth programs are scarce.

Furthermore, many services cannot accept individuals with complex physical or psychiatric problems, and this sort of complexity is more common among Indigenous Australians. Paradoxically, withdrawal management services and rehabilitation services are often separate, so patients can face a gap of several weeks after detox before they can access a rehab bed, during which time they often relapse to drinking.

Aboriginal community controlled services and Aboriginal staff have a unique ability to engage marginalised clients and to provide culturally appropriate care. However, historically Aboriginal-specific services have suffered from shortages of funding and lack of funding security which has then limited their ability to employ and maintain professional staffing and to ensure professional development.

Of course not all problem drinkers are dependent on alcohol, and broad based preventive initiatives are crucial. Controlling the accessibility of alcohol is the best proven way to reduce alcohol related harms. Taxation of course can reduce the availability of cheap, high-volume alcohol, which is a concern to many communities. Local alcohol supply controls can also be applied and they do not have to be discriminatory. Any community, white or black, urban or remote, can have alcohol restrictions applied, if they have a high burden of alcohol related harms, and that can range from limiting opening hours right through to full restriction on access to alcohol.

To ensure public confidence in decision-making around alcohol, it is important that donations from the alcohol industry are stopped. Also, communities and women, in particular, need to be supported to have a greater input in government consultation and in liquor licensing hearings.

In conclusion, there is a pressing need for bipartisan long-term action on alcohol, designed in partnership with communities to prevent ongoing harms from alcohol to Aboriginal and Torres Strait Islander Australians.

ACTING CHAIR: Would you like to add anything?

Mr Jack : Not particularly. I would like to answer some of your questions.

Prof. Conigrave : We wrote it jointly; I am just appointed spokesperson.

ACTING CHAIR: I am sure you did. I just want to know if you had anything you wanted to add. An issue, which is potentially current, is that the government has adopted a new funding model for Aboriginal and Torres Strait Islander programs in which you have got to bid competitively for these programs. Do you have any comments to make on that sort of approach and what it might mean for the Aboriginal community controlled health sector or the provision of the sorts of services you are talking about?

Mr Jack : You can get someone to compete for that, but it does not mean that the better competitor knows exactly what they are doing. You are getting people vying for Aboriginal money, and the AMS should be running the programs. We just cannot see it working. You might get the best player or applicant and they will secure that money but, in the end, you won't get any Aboriginal people attending that service, because they just won't be able to do it right. It is simple.

ACTING CHAIR: We have heard successive evidence about the importance of recognising the centrality of Aboriginal culture. And you would have heard our previous witness talk about the impact of racism. I am just interested in exploring the idea of how funding models might actually exacerbate those issues for Aboriginal and Torres Strait Islander people. It appears from what you have just said that you believe that is an issue.

Mr NEUMANN: You mentioned, Professor, about the shortages and security of funding. In my experience in dealing with Aboriginal and Torres Strait Islander organisations is that the funding often is for a pilot program for a year for which the paperwork is extraordinary and then it never gets renewed. Can you comment on that?

Prof. Conigrave : Peter could possibly comment even better than I can, because he has been directly affected. Do you want to comment?

Mr Jack : Every time something like a pilot program gets set up—like working on the dog fence program or taking young offenders out of the city and diverting them away from courts and detention—it works beautifully and then, 12 months down the track: 'Sorry, it was a pilot program. Away you go.' You can track the crime statistics. These kids haven't gone back into detention. They have not committed any more crimes and, as soon as they pull that money, bang: straight back into the lock-up. What the hell.

Mr NEUMANN: As a consequence of withdrawing the funding.

Mr Jack : Yes.

Mr NEUMANN: You mentioned donations from the alcohol industry. That was where you paused; you did not say anything further. By 'donations' what do you mean, Professor?

Prof. Conigrave : Last night I was looking at the Australian Electoral Commission site. In 2012, the year the banned drinker registry was canned, the Australian Hotels Association and affiliated associations I think donated $150,000 to each of the major Northern Territory political parties. The Australian Hotels Association and the alcohol industry are big political donors. I think as members of the public we have reason to worry whether this could be influencing decisions. Also we know that the alcohol industry has a lot of resources to go to Canberra to wine and dine with politicians. The local communities and health agencies do not have that sort of money so we have much less potential to get our views across.

Mr RAMSEY: Firstly, Peter, thanks for coming over to fix up the fence.

Mr Jack : No worries.

Mr RAMSEY: It will be in my electorate. It is good. I will make a comment before I get to a question. I do not think you should fear a competitive funding model.

Mr Jack : I do not fear it.

Mr RAMSEY: If you are doing a good job, you will win the money. When I go onto APY lands, over the course of a week I speak to over 100 organisations and every individual I speak to would be convinced of doing a really important and good job and will probably convince me the same, but collectively we are getting a worse result every year. Really I think we have to have some responsibility for the programs that are being paid for by the taxpayer. That was just a comment. What I am really interested in is your work in rehab centres. Earlier today I raised the fact that we are about to have our first regional Indigenous focused rehab centre open up in Port Augusta I think next month.

Mr Jack : Yes.

Mr RAMSEY: Kate brought up some figures about recidivism, if you like, to go back to alcohol. It was 50 per cent and even higher than that. What are the most effective things to get a lasting outcome with the work you have done in rehab centres? You can feel pretty right when you turn the person out the door, but what have you found that you do that gets the best results?

Mr Jack : The best results are when you have backup afterwards—after care and support workers. You supply people with some meaningful thing to do with their day, like employment, training, study or whatever.

Mr RAMSEY: Was the employment program you worked on that took people out to work on the dog fence part of the rehab work you have been doing?

Mr Jack : No, that was with the Aboriginal employment development branch at TAFE years ago in conjunction with family and youth community care in South Australia. It was a diversionary program to get the kids out on post-release, pre-release, early release.

Mr RAMSEY: Yes, I am aware of such programs.

Mr Jack : But again it was a trial program. It started working, the money got pulled and that was the end of it.

Prof. Conigrave : Another thing I have heard Peter and others say is that for a successful rehab you want the best of both worlds: you want the best cultural approaches and the best modern medicine. I have heard some of my Aboriginal colleagues talking about the benefits they have seen of naltrexone use in reducing alcohol consumption combined with men's groups and appropriate counselling. You do not have to have one or the other; you can have the best of both.

ACTING CHAIR: For a number of years now I have been trying to get my head around what is best practice. What do you need? I know we need place based responses and we have to look after specific populations, but what do you need? I think 40 per cent was the figure you used. How do we actually get to the 40 per cent? If we can get to the 40 per cent, then why cannot we do better? What sorts of things do we need to put in place to get there?

Prof. Conigrave : The best services around the world with the best funded programs around the world for severe alcohol dependence are still only getting 40 to 60 per cent remission rate at around three months. It is a difficult condition, which is why early intervention is so important.

You need multimodal treatment. In terms of Western, modern medicine—sorry, European-style medicine, if you like, or also Japanese-style medicine. You need a mix of relapse prevention medicines. You need skilled counselling, which might be cognitive behavioural therapy. There is growing interest in mindfulness based therapy and growing evidence of effectiveness of mindfulness based therapy. So it is not just a warm arm around the shoulder; it is actually very skilled counselling. There are group based approaches of the sort of thing Peter is talking about: providing people with alternative support outreach.

We know also from research into Aboriginal and Torres Strait Islander populations that people have to feel culturally secure to walk through the fence. I was involved in an analysis at the hospital where I work, which is a very big, very well staffed hospital. We were not getting a single Aboriginal person coming through the door voluntarily asking for help with alcohol. We were getting an awful lot coming through the door with alcohol related seizures, alcohol related brain damage and alcohol related cirrhosis. So we started working with the AMS—with Brad Freeburn, the head of the drug and alcohol unit at the AMS Redfern—and looking at what we could do better. When we started to have an Aboriginal women's group run jointly by an Aboriginal staff member and a non-Aboriginal staff member, we started to get more people coming in and engaging with counselling. We have been working with a number of Aboriginal community controlled agencies, and our original detox centre has gone from having very few Aboriginal people to, recently, five in one week. So I think the Aboriginal controlled agencies do have a particular ability, as Peter has said, to access community. There is the trust there. If we can get partnerships between Aboriginal and non-Aboriginal and support Aboriginal agencies, I think we can gradually do better.

ACTING CHAIR: Let's assume they have had some early intervention and people's awareness being raised but we find someone or people who need residential rehab. Does residential rehab actually deliver an outcome which is better than non-residential rehab? Do you have step-down facilities to accompany it? Do you have long-term support post the residential rehab? What is the model?

Prof. Conigrave : It is horses for courses. If someone has milder alcohol dependence, they may well be suitable for a home detox, so we are currently working with Illawarra AMS, who are setting up a home detox program. But some people have withdrawal seizures. A lot of Aboriginal people we see with alcohol problems have a lot of background traumas—childhood trauma, for example—which has left them with mental health issues, and therefore they are not suitable for home detox and need residential care to be able to stop drinking. We do not automatically go to rehab if someone seems like they can cope in the outside world with support. We will offer relapse prevention medicines, groups et cetera, and they will try at home. But, if they have a really difficult home environment or a history of years and years of relapses and it is judged not to be realistic, they might need a period of three months or more of rehab. So it is channelling people into what they need. Is that a fair comment?

Mr Jack : Yes. You need to deal with more than that one person because the whole family has the problem. The father, the mother and the children all need to be working on it.

Prof. Conigrave : I think this is a really good point. It is a known prognostic factor; the number of drinkers around you influences your likelihood of continuing drinking. There was that recent highly publicised case of the man in the Northern Territory who had an alcohol protection order put on him. My understanding of it is that he was plucked out of the long grass and told he had to stop drinking or else he would end up in jail. Presumably, he was not drinking alone, because that is not how drinking happens. How realistic is it to pluck him out, say, 'Stop drinking' and then pop him back with all the other drinkers?

Mr Jack : Yes. And I do not think taking people's children off them for their drug and alcohol issues is going to benefit them. Most people will go: 'You've got my kids. You can get nicked now. I'll just go for it. I'll grog on till I'm gone.' You have to work with people and families.

ACTING CHAIR: Obviously FASD is now something that is, thankfully, being thought about and addressed in some places. What do we do about educating and intervening early so that young women and young blokes understand the implications of alcohol and other drugs?

Mr Jack : Like you have the 'quit smoking tobacco' workers in communities around Australia, you can have a FASD worker go and work with pregnant young girls.

ACTING CHAIR: Sadly, the funding has been cut—

Prof. Conigrave : You want to work with young girls before they get pregnant, too.


Mr NEUMANN: It has all been cut.

Prof. Conigrave : Yes. I do not think there has been that same grassroots level work on alcohol, not since the Living with Alcohol program in the Northern Territory, which was very successful. There is also often this assumption that lack of knowledge is the only thing. Levels of knowledge are improving but the worst foetal effects happen with alcohol dependence. There is a real lack of availability of treatment services, particularly if a woman has other children and it is very hard for her to access care.

ACTING CHAIR: There are no support structures.

Prof. Conigrave : Also, a lot of treatment rehabs and detoxes will not take pregnant women.

ACTING CHAIR: Are you aware of a program that is operating with congress in Alice Springs?

Prof. Conigrave : Yes, I was involved in the early stages.

ACTING CHAIR: What is your view on that sort of program?

Prof. Conigrave : I was involved in the very early stages. I think it is based on a very good principle. They have exactly what Peter was talking about—a lot of outreach workers to do outreach care. They are actively going out and engaging with people. They are trying to link them with medical care. That is my understanding. At least as I saw it in the early days, it was being set up on good principles.

Mr NEUMANN: I have a question in relation to advertising. What particularly gets me is the number of men who do not show any degree of responsibility with respect to their partners and drinking. They have drink available in the home. Australians love sport. They watch AFL. I am a Queenslander who is still grieving over the State of Origin! I am just amazed at how we have seen the normalisation of gambling associated with sport. You have the Tooheys Blues playing the XXXX Maroons in the State of Origin. It is a normalisation of a culture of drinking.

Mr Jack : How many times do you drink while you are running around playing footy? You do not. So why advertise it at the footy? It is crazy.

Mr NEUMANN: You see sporting stars in tracksuits with the name blazoned on.

Mr Jack : Yes. It makes no sense.

Mr NEUMANN: It makes no sense.

Prof. Conigrave : There is an appalling loophole in the alcohol advertising regulations. I think it is also a worry that sportspeople are always used as role models for young Aboriginal people and then they have the big VB logo on their chests that they are required to wear if they want to be part of the team.

ACTING CHAIR: What relationship, if any, do you have with the alcohol industry?

Prof. Conigrave : Me?

ACTING CHAIR: Yes, your organisation.

Prof. Conigrave : I had a glass of wine last Saturday night! That is the extent of it. We have been very careful—

ACTING CHAIR: I did not mean they were a funder or that sort of thing. I am interested to know if they have had any contact with you on how they might act more responsibly to address the issues of concern you are talking about.

Mr NEUMANN: There are warning labels and all those sorts of things, and the so-called two-year trial at the moment.

Prof. Conigrave : Outside my university role, I am involved with FARE, the Foundation of Alcohol Research and Education. In that capacity, I have been very actively involved in lobbying. Even before I joined FARE, I tried to challenge the alcohol industry. I remember some years back some of us wrote an open letter expressing concerns about the fact that DrinkWise had 50 per cent industry funding. All of us who signed that open letter got individual legal letters threatening legal action. So, yes, I had been actively involved in expressing concerns about the industry long before I joined up with FARE.

ACTING CHAIR: I appreciate that, and I knew that. One of the issues worth confronting is getting the industry to respond.

Prof. Conigrave : Yes. I should say that there are good parts of the industry, too. They are not all bad. It is not like the smoking industry. But I think we have to be realistic: their job is to make profits for their shareholders. They would be failing their shareholders if they did not try to increase alcohol consumption. Whereas we know, not just for the Aboriginal population but for the whole population, on average, we have to reduce alcohol consumption.

ACTING CHAIR: Yes. It is a good public health issue—

Prof. Conigrave : It is.

ACTING CHAIR: and a good public health response.

Prof. Conigrave : Can I just make a comment. Peter was talking about the child protection issues, and it came up in the questions to Laverne; I see it with my patients. I do not think anyone would deny there are certain parents where you must—

Mr Jack : You must take them.

Prof. Conigrave : Yes, where you must take the kids. But occasionally you see slightly quixotic decision-making and the goalposts changing, and I think it is those sorts of things that really lead to frustration and distress in the community. We sometimes see decisions being made about alcohol treatment or about drug treatment where you have non-clinicians making recommendations on treatment.

ACTING CHAIR: Thank you for your contributions. We thank you very much for your submission. We have very much enjoyed the interaction and, most importantly, your very wise counsel. You will get a copy of the Hansard to check, to make sure that we have not fluffed it! I am sure we have not. If you want to submit any more evidence to us, you are quite welcome to do so.

Prof. Conigrave : Thank you.