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Microsoft word - aod position paper for board august 2013.docx

Position Paper - Alcohol and other Drugs
August 2013
The Inner South Community Health Service (ISCHS) is a major provider of primary health care services including alcohol and other drug (AOD) services, and has been for over 20 years. The service model is based on the social model of health. Principles of harm minimization are adopted in relation to all AOD work. 1. Purpose
This paper outlines ISCHS’s positions in relation to alcohol and other drugs (AOD). It includes positions on: 1. Reducing consumption through greater control of access and availability 2. Education and information provision 3. Access to quality treatment services. 4. The use and misuse of pharmaceutical products. The overriding principles of the paper relate to advocating for health and social approaches to reduce
harms including a right to access treatment and harm minimization strategies for the whole community
with a focus on strategies that are effective for marginalized groups. All policy and reform positions
adopted by ISCHS will be evidenced based.
Public health interventions are deliberately designed to maximize their effect by appealing to large but
relatively lower risk population groups- which means that public health success increases health
inequities (Bambra et al, 2010). Although ISCHS supports a public health approach, it equally
recognizes the inadequacy of some policies to fully benefit many of our marginalized clients.

2. Background

Thirteen percent of the Australian Burden of Disease and Injury in 2003 is directly accountable to the consumption of alcohol, tobacco and other drugs. Alcohol alone accounts for 60 deaths and 1500 hospitalizations weekly in Australia’ (NAAA 2011). ISCHS’s role as community health service incorporates health promotion. This includes working directly with local communities, in conjunction with influencing public health debates. Influencing the public health debates is crucial as there is a significant lobby within Australia who oppose effective public health debate and actions by attempting to categorize any such attempts as promoting a ‘nanny state’. The reality is those behind such campaigns normally stand to benefit from existing patterns of consumption which legislation, regulations, and education are seeking to change. As a public health organisation ISCHS provide an alternative view and seek to influence legislation and regulation, promoting a harm minimization approach, in line with recommendations of peak AOD groups, public health bodies and the needs of the local community. This position paper will provide a clear framework for the Board of Directors, management and staff, students and volunteers of ISCHS. Page 1 of 7
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3. Context
The National Drug Strategy 2010-2015 and the Victoria Whole of Government Strategy “Reducing the
Alcohol and Drug toll: Victoria’s Plan 2013-2017’ set the agenda for alcohol and drug management.
(See Appendix 1).

National and State health budgets are under considerable financial pressure and this pressure will
increase over the next 20 years. All levels of Government policy are framed on the effective provision
of prevention and harm minimization strategies to reduce the demand on health services and costs on
future budgets.
It is well recognized that AOD use is a major contributor to Australia’s ‘burden of disease’.
The ability to change drug use culture has been demonstrated through tobacco legislation, regulation
and education. This has proved to be an effective long term method for supporting prevention and
reducing harm.

ISCHS Context
The ISCHS service model is based on a harm minimization approach.
It is recognized that current National and State Strategies to regulation AOD have not had the same
benefit for all parts of the community. While rates of smoking have dramatically reduced among the
population, among disadvantaged groups smoking rates are up to 5 times higher than the population
average (Australian Preventative Health Agency 2013 p.2).
ISCHS has a strong commitment to delivering primary healthcare services, complimented by
advocacy on issues that influence the health and wellbeing of disadvantaged groups within the
ISCHS is a member of peak organisations focusing on AOD advocacy.
The focus of ISCHS advocacy will be in supporting the advocacy of member bodies. However, ISCHS
will advocate independently on relevant local issues, especially where more tailored strategies are
required to support change within disadvantaged groups.
ISCHS operates within the Social Model of Health (VHA)
ISCHS operates under the principles embodied in the Ottawa Health Promotion Charter (WHO).


ISCHS Position

Supporting health, social and planning approaches to reduce harm related to alcohol use including Taxing alcohol products according to the level alcohol they contain (volumetric alcohol taxation); Phasing out of alcohol promotion from times and placements which have high exposure to young people aged up to 18 years; Reduction in the availability of alcohol through more effective control of new outlets, and through reduced trading hours. Increased awareness through education of what constitutes harmful drinking and binge drinking, and increased understanding of the harms. Increased awareness of the risk and protective factors for foetal alcohol syndrome. Page 2 of 7
U:\CEO\Board\Board Papers 2013\Aug\AOD Position Paper for Board August 2013.docx Access to quality and timely treatment for all alcohol misuse, including addiction. Strengthening prevention efforts in populations with a high prevalence of smoking, including Aboriginal and Torres Strait Islander people and people with mental illness. Reducing exceptions to smoke-free workplaces, public places and other settings. Providing greater access to a range of evidence-based cessation services and supports including access to a broad range of approved nicotine replacement products at subsidized prices, but fully subsidized provision and dispensing to people on low incomes. Illicit Drugs
Timely access to assessment and drug treatment services. Improved access to injecting equipment, including 24 hour vending machines, and the funding of a 24 hour drug injecting facilities in areas of high illicit drug use. A Victorian harm minimisation trial involving the prescribing of heroin to people addicted to heroin. Reduced numbers of users coming into contact with the justice system through decriminalisation of possession of personal use quantities of all illicit drugs. The provision of drug treatment programs and access to clean injecting equipment in all prisons. Immediate access to post release AOD support and treatment programs for people with AOD histories exiting prison. Pharmaceutical Drugs
Implementation of a systematic monitoring system of prescriptions for pharmaceutical drugs to better inform how prescribed drugs are used, in conjunction with the existing Prescription Shopping Program established to monitor prescribing to individuals. Dispenser access to the Prescription Shopping Program. Commonwealth funding for pharmacotherapy dispensing fees for substitute drugs such as methadone, buprenorphine and naltrexone. Review of the self-regulation system of marketing and promotion of prescribed medicines, which is currently managed through a self-regulatory code of conduct administered by Medicines Australia, the Peak body for the pharmaceutical industry. Ensuring people who misuse pharmaceutical drugs can receive treatment and care which is informed by evidence. Page 3 of 7
U:\CEO\Board\Board Papers 2013\Aug\AOD Position Paper for Board August 2013.docx Appendix 1. Evidence

There is a body of local and international research that both identifies the harm caused by illicit and
licit drugs including alcohol, along with a broad range of evidence supporting the effectiveness of
treatment and prevention strategies.
Alcohol consumption accounted for 3.3 per cent of the total burden of disease and injury in Australia
in 2003; 4.9 per cent in males and 1.6 per cent in females. (NHMRC)
Most Australians who drink alcohol do so at levels which have few adverse effects. However, any
level of drinking increases the risk of ill-health and injury. (NHMRC)
Alcohol is second only to tobacco as a preventable cause of drug-related harm in Australia. Risky use
of alcohol has serious personal, social and economic consequences (ADF).
The AERF (Alcohol Education Rehabilitation Foundation) estimates the toll from the use of alcohol at
$36 billion annually in Australia (Danny Rose, The Age 24th August 2010), including 70,000 victims as
a result of alcohol related assaults, 24,000 of these related to domestic violence (
The consumption of alcohol was estimated to cost Australian society $15.3 billion, in 2004–05 (Collins
& Lapsley 2008a).
In relation to our Community Health catchment, estimates derived from the 2008 Victorian Population
Health survey indicated alcohol consumption at levels considered to be at high risk to health across
the ISCHS catchment compared to the Victorian average (Social Health Atlas of Australia, 2013).
Alcohol pricing and taxation (NAAA website)
International scientific evidence consistently shows that alcohol consumption and harm are influenced
by price. Alcohol taxation, as a means of increasing the price of alcohol, is one of the most effective
policy interventions to reduce the level of alcohol consumption and related problems, including
mortality rates, crime and traffic accidents.
Alcohol marketing and promotion (NAAA website)
Alcohol marketing and promotion contributes to young peoples’ attitudes to drinking, starting drinking
and drinking at harmful levels. Much of this marketing has the effect of reinforcing the harmful drinking
culture in Australia. We urgently need comprehensive reform of the alcohol advertising regulatory
arrangements. The National Preventative Health Taskforce recently recommended that in a staged
approach, alcohol promotions should be phased out from times and placements which have high
exposure to young people aged up to 25 years.
Alcohol availability (NAAA website)
There is heightened concern in communities across Australia about the increased availability of
alcohol, primarily caused by the deregulation of liquor control laws. In many of our major cities and
regional centres, the link between high densities of alcohol outlets and alcohol related violence has
been the focus of significant public attention and concern. Similarly, there is strong evidence that
extending the trading hours of alcohol outlets results in increases in alcohol-related problems. Other
evidence indicates that a reduction in these hours can contribute to a reduction in these same
In this context, there is a need to reassess approaches to alcohol availability and enforcement of
legislation. NAAA considers that treating alcohol like an ordinary commodity and prioritising market
competition over public health will continue to exacerbate Australia’s harmful drinking culture.
Additionally, there is a need for national guidelines on alcohol outlet density and opening hours.
Page 4 of 7
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Smoking is a leading cause of preventable death and disease in Australia (National Tobacco
Strategy). In Australia in 2003, tobacco use was responsible for 7.8% of the burden of disease.
Smoking was the cause of 15,551 deaths (42 a day) in 2003. It was responsible for 20.1% of the
disease burden due to cancer, and 9.7% of the disease burden due to cardiovascular disease
Collins and Lapsley ( estimated that in 2004–05 the total cost of smoking in Australia
was $31.5 billion. It was considered that this study underestimated the actual costs.
In 2007/2008, 23% of males aged over 18 years, and 19% of females smoked. Smoking rates for men
and women are continued to drop (down from a peak of 72% for men, and 31% for women).
However, people living in the most socioeconomically disadvantaged areas were twice as likely to
smoke as people living in the most advantaged areas (AIHW). This is supported by the data from the
ISCHS client survey in 2009, which indicated 35% of clients interviewed smoked daily (nearly twice
the Australian average).
Bonevski and Baker (2012) give current rates of smoking in high prevalence communities as: 50% of
Aboriginal Australians, 37% of single parents, 73% of homeless people and people with other drug
disorders, 66% of people with a mental illness and 60% of people accessing welfare aid from non-
government agencies such as Anglicare and the Salvation Army and 85% prisoners smoke.
ISCHS advocacy builds on a continuation and strengthening of the current successful National and
State Strategies, to ensure we further reduce the percentage of people still smoking, with a focus on
strategies that will be effective with marginalized groups and communities.
Illicit Drugs
Illicit drug use accounted for 2.0% of Australia’s total burden of disease in 2003. Much of this harm is
related to unintended outcomes of drug use or public policy. For example, twenty five percent of this
burden of disease is related to Hepatitis (AIHW), which can be contracted by risky injecting practices,
particularly the sharing of injecting equipment. Continued and improved access to injecting equipment
is critical to reduce harms associated with drug use.
The social cost of illicit drug use in Australia was estimated at $8.2 billion in 2004–05, including costs
associated with crime, lost productivity and healthcare (AIHW).


Our advocacy approach to illicit drugs is driven by the understanding that often the harm associated
with illicit drug use is a direct result of the environment in which drug use occurs, as well as the
harmful effects of the actual drugs. Our advocacy focuses on the health needs of people using illicit
drugs, rather than the illegal nature of their drug use. This response should not be interpreted in any
way to support illicit drug use, but as a health service, our focus is on reducing harm, rather than law
enforcement. The paper supports decimalization of drugs to reduce criminal behavior and allow
greater support and engagement of people engaged in drug use.
Page 5 of 7
U:\CEO\Board\Board Papers 2013\Aug\AOD Position Paper for Board August 2013.docx However we also acknowledge the harms associated with all drug use (whether illicit or licit), and at
all times support and encourage people to make healthy life choices, which includes abstinence,
reduction in consumption, and safer methods of using.
There is growing evidence of the misuse of pharmaceuticals in Australia with a focus on opioids and
benzodiazepine, where considerable harm is occurring.
There are two categories of people misusing opioid or benzodiazepine medications. There are those
who intentionally misuse, and there is likely to be a large number of Australians using these
medications as prescribed but where such prescriptions do not represent a quality use of those
medicines (NCETA p. 4).
People from either group may have been using these medications for some time and, in the case of
benzodiazepines in particular, withdrawal from them may be very difficult.
The number of Australians who recently used pharmaceuticals for non-medical purposes increased by
more than 100,000 between 2007 and 2010 (from 640,000 to 770,000). Painkillers/analgesics were
used for non-medical purposes by 2.7% of this population in the past 12 months and 1.4% of those
aged 12 years or older had used tranquillisers or sleeping tablets for non-medical purposes over this
period (NCETA p. 5).
The 2010 National Drug Strategy Household Survey (AIHW, 2011) found that 7.4% of Australians
aged 14 years and over had ever used painkillers/analgesics, tranquilisers, steroids,
methadone/buprenorphine or other opioids (not including heroin) for non-medical purposes in their
lifetime. Of these 4.2% of these had done so in the past 12 months, up from 3.7% in 2007.
The number of deaths associated with the misuse of pharmaceutical drugs in Victoria in 2012 was
304, compared to our state road toll of 282. VAADA
There is a need for a coordinated medication management system in Australia to provide on-line, real
time information for prescribers, pharmacists and regulators concerning the medication prescription
and dispensing histories of patients. This was one of the major recommendations of The National
Centre for Education and Training on Addiction (NCETA) report on Pharmaceutical drug misuse
problems in Australia: Complex issues, balanced responses (2011), along with improved access to
injecting equipment, and dispenser (pharmacists) access to the Prescription Shopping Program, to
help them identify people at risk of overusing prescribed medications.
The report also raises concerns in relation to marketing of pharmaceutical drugs. ‘The marketing of
pharmaceuticals is an important way in which companies stimulate demand and generate high
turnover’ (Choice, 2008 as quoted in the NCETA report p.95). The interest of the community and the
interest of the companies do not necessarily align, with over use being one of the potential outcomes.
On a different issue, the issue of pharmacy prescribing fees for people on substitute therapies such
as methadone remains an inhibitor for many in relation to the effectiveness of this treatment. Normal
dispensing fees range from $5 to $7 a day and it can be more expensive. The removal or reduction in
these fees would enhance access and therefore the effectiveness of the program, especially for
people on low incomes.
The recommendation regarding the need for appropriate and accessible treatment and care for
people misusing pharmaceutical drugs comes from a recommendation from the Public Health
Association Australia (2010). This client groups needs often relate to a range of issues including pain
management and need to be targeted.
Page 6 of 7
U:\CEO\Board\Board Papers 2013\Aug\AOD Position Paper for Board August 2013.docx References
Australian Preventative Health Agency (2013). Promoting a healthy Australia.
Bambra et al. (2010) Reducing health inequalities in priority public health conditions: using rapid
review to develop proposals for evidence based policy.
Billie Bonevski and Amanda Baker JUL 23, 2012 Smoking is a social justice issue. Crikey. Retrieved

Collins & Lapsley (2008a). The costs of tobacco, alcohol and illicit drug abuse to Australian society in
2004/05. Australian Department of Health.
Commonwealth of Australia. (2012). National Tobacco Strategy.
Lawn. S. (2008) Tobacco control policies, social inequality and mental health populations: time for a
comprehensive treatment response Australian and New Zealand Journal of Psychiatry; 42:353

NAAA. (2011). Alcohol tax reform is a major public health and social policy issue
Nicholas, R., Lee, N., & Roche, A. (2011). Pharmaceutical Drug Misuse in Australia: Complex
Problems, Balanced Responses. National Centre for Education and Training on Addiction (NCETA),
Flinders University, Adelaide.
Public Health Association Australia (2010). Pharmaceutical Drug Misuse Policy
Page 7 of 7
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