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When it comes to alcohol and other drugs, we are passionate about evidence-based policy because we think we should do what is effective. We frequently make public submissions to inquiries into measures to respond to alcohol and other drug issues.

• Submission to Royal Commission into Victoria’s Mental Health System,  20 June 2019
• Submission to Northern Territory Select Committee on Harm Reduction Strategy for Addictive Behaviours, 7 September 2018
• Submission Regarding Social Services Legislation Amendment (Drug Testing Trial) Bill 2018, 3 April 2018
• Submission Regarding The Criminal Code and Other Legislation Amendment (Removing Commonwealth Restrictions on Cannabis) Bill 2018, 22 May 2018
• Submission to the Victorian Parliamentary Inquiry into Drug Policy, 4 September 2017

Addressing a person’s alcohol and other drug and mental health problems doesn’t need service or systems integration. The evidence for integrated care is limited, but there is evidence that meeting the diverse needs of clients improves both retention and outcomes.

Within-service holistic wrap-around client care

Providing wrap around services that address a person’s medical, educational, and mental health needs in alcohol and other drug treatment improves retention and treatment outcomes.

Holistic, wraparound client care should be routine in both mental health and alcohol and other drug settings. Providing this kind of holistic care wherever the client has made first contact seems to be more effective than service integration.

Health professionals in each sector need to understand the types of co-occurring problems they may each face and what is within their capacity to respond to.

Improving collaboration between services

Currently, the alcohol and other drug and mental health sectors work primarily on a loose coordination approach in which individual practitioners from different sectors work together to get the best outcomes for clients. The downside to this approach is that it relies on the good will of individual practitioners to engage in shared care arrangements, and service users can fall through the gaps.

Improving relationships between agencies and encouraging collaboration in the form of structured case conferencing, agreements on collaboration of services or co-location of professionals could improve responses, without the need for major structural or cultural change.

Co-locating services

Colocation, in which multiple services are geographically located together, has been shown to facilitate working relationships and referral pathways, and therefore client outcomes.

Co-locating behavioural health providers in community health centres, for example, seems to increase screening for alcohol and other drug problems by primary care providers, improves referral to specialist alcohol and other drug treatment.

Where to from here

There appears to be no benefit in integrating AOD and mental health services. It is complex and expensive to achieve, and unlikely to achieve the expected client outcomes.

Alternative options, which are probably less costly and do not require major disruption to sector or organisational culture are likely to achieve better outcomes.

Step 1: Within each service, improve holistic assessment and wraparound care
Step 2: Between services, improve formal collaboration structures and processes
Step 3: Co-locate rather than integrate

Given the lack of evidence for integration, we should put more effort and funding into linking up services more effectively and more formally.

Co-occurring mental health and alcohol and other drug problems are common among people attending both treatment services.

There are a number of ways in which alcohol and other drug problems intersect with other mental health disorders, primarily:

• The use of drugs may change the structure and function of the brain that leads to symptoms of other mental health disorders. For example, neuroscience studies have shown that long term methamphetamine use depletes the dopamine and serotonin systems, both required for the regulation of mood, potentially leading to symptoms of depression.
• Alcohol and other drugs may be used to relieve distress of mental health symptoms, sometimes referred to as ‘self medication’
• Comorbidity may emerge from shared genetic or socio-economic predisposing factors, such as poverty or trauma.

The presence of more than one disorder can complicate treatment significantly. There is evidence that relapse from one disorder can trigger relapse from the other so there is general agreement among professionals that both disorders need to be addressed.

For many conditions, just providing good alcohol and other drug treatment reduces symptoms disorders, especially for the more common mental health problems of anxiety and depression.

So it is critical that treatment providers outside the specialist alcohol and other drug sector are well trained in assessment, brief intervention and effective referral of alcohol and other drug problems.

But it also means that if alcohol and other drug workers just provide good drug treatment, many of the mental health issues of our clients will reduce to more manageable levels.

Professor Nicole Lee is 360Edge’s Director and an international leader on alcohol and drug policy and practice.

Read more about our team here.

The USA-led push to view alcohol and other drug problems as a ‘brain disease’ was in part to try to provide a counter to the prevailing moral view at the time.

But, while the use of alcohol and other drugs clearly has a (mostly temporary) impact on the structure and function of the brain, there is no evidence that an alcohol or other drug problem is a brain disease in the same way that Huntington’s or Parkinson’s are diseases of the brain, for example.

The fact that relatively few people who use drugs develop a problem with them is also evidence that it is not a brain disease.

We still can’t distinguish between the brain of someone who is dependent on alcohol or other drugs and someone who is not. broader social determinants of health, such as low socio-economic status, lack of education, homelessness, and unemployment; as well as early trauma and mental health issues.

The social consequence of viewing alcohol and other drug dependence as a function of the interaction between an ‘addictive brain’ and a specific drug is prohibition. We either need to eliminate drugs from society (and hence more law enforcement is needed) or we need protect the brain from drugs (and hence abstinence is required). But emerging research shows that a prohibition approach is not effective in reducing harms or use.

The reality is there are many complex factors that impact on the development of alcohol and other drug issues, including family history; socio-demographic factors and

Alcohol and other drug problems are more aligned to the definition of a mental health issue, with multiple factors in both their development and maintenance. We don’t typically refer to mental health disorders as a ‘disease’, even though there is evidence that there is associated impact on the structure and function of the brain.

Our Director, Professor Nicole Lee, discusses the current debate regarding the ‘brain disease’ model of addiction further in a ‘Viewpoints’ article in The Conversation here.

It is #MentalHealthWeek and that provides a unique opportunity to discuss the commonalities and important differences between the mental health and AOD sector.

Alcohol and other drug use has historically been seen first as a moral deficit, and then a criminal issue, and only relatively recently has there been a broader shift in thinking about it as a mental health issue.

But understanding where alcohol and other drug problems fit into mental health is not straight forward.

Not all alcohol and other drug use is problematic. Very few people go on to develop long term problems (overall the estimate is around 10%), so our understanding of alcohol and other drug use as a mental health issue only applies to the end of the use spectrum where people are experiencing significant problems.

Taking that further, alcohol and other drugs have another unique dimension to them.

Most people with depression and anxiety don’t enjoy those feelings, even when they are not at the problematic end of the spectrum. Alcohol and other drugs on the other hand…

With alcohol and other drugs, use does not equal problems. So we need to take a broader view that encompasses both a health and a human rights perspective.

Unlike most other clinical health areas, our AOD service sector spans prevention, harm reduction and tertiary intervention. Sometimes that means we aren’t all peas in a pod, but it is also one of the strengths of the sector.

We philosophically view alcohol and other drug use on a continuum, and understand that merely (non-problematic) use of a drug does not necessarily constitute a problem.

Jim Orford’s idea of alcohol and other drug problems as an ‘excessive appetite’ captures the idea nicely – use is generally fun and purposeful, and only becomes a problem when it is excessive.

So while some alcohol and other drug problems might be viewed from mental health perspective, the issues for our sector are much broader. Under some circumstances alcohol and other drug use might be viewed as a mental health problem but they shouldn’t be integrated into the mental health system.

In many ways it maintains the stigma around (especially illicit) drug use by perpetuating the idea that use is a mental health issue.

Professor Nicole Lee is 360Edge’s Director and an international leader on alcohol and drug policy and practice.

Read more about our team here.