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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

If you’re humble, you may not think you’re an ‘expert’ in anything – a practitioner perhaps, but definitely not an expert!

However, when it comes to being a witness in court, determining whether someone is an expert on a particular topic is crucial.

Here’s what you need to know.

 Expert witnesses

The general rule when it comes to witness testimony is that witnesses can only give evidence about something they directly saw, heard or otherwise perceived.

“I saw Mr Smith take the television” for example, or “I heard Mr Jones scream”.

Generally, as a witness, you must never infer things from your perceptions or offer an opinion.

“I saw Mr Smith take the television, intending to throw it at Mr Jones”, or “I heard Mr Jones scream, probably when he was hit by the television”.

It’s a slight but important distinction, one that comes with a number of exceptions.

One of those exceptions is expert testimony.

An ‘expert’, is able to given an opinion on matters if that opinion is wholly or substantially based on specialised knowledge gained through training, study or experience.

Are you an expert?

Health professionals can either be called to give ‘regular witness testimony’ or ‘expert witness testimony’ or sometimes a combination of both.

It’s important to be careful giving expert testimony that you are only inferring or offering an opinion on something based on your specialist knowledge.

For example, if you’re an AOD counsellor with no experience or training in family violence – offering an opinion on your client’s achievements in therapy is valid expert opinion, but whether your client is a risk of violence is outside your training, study or experience.

You can still be an expert witness, even if:

• Other experts in the field disagree with your conclusions.
• You have relied on another person’s data or work acquired through reading relevant literature and reports or through colleagues.

However, you should never claim to be an expert in something beyond your  training, study or experience – or if you’re not able to act objectively.

Expert witnesses are held go a higher standard than regular witnesses, they must ensure their testimony is not given merely to advocate for a particular party and they behave objectively.

Still confused?

360Edge will be running an online two-day workshop on the 7th and 14th July.

Join our clinical expert Paula Ross and legal eagle Jarryd Bartle for this practical workshop specially designed to assist practitioners to get court ready.

Key learning outcomes include:

• Knowing how to write case notes that are both clinically relevant and legally sound
• Describing the different types of courts and how they operate
• Knowing how to respond to a subpoena
• Feeling confident about appearing in court

BOOK NOW

As a result of the coronavirus outbreak, most practitioners are starting to conduct therapy sessions with clients remotely via videoconferencing.

Telehealth is a feasible treatment delivery option for therapy, but it does require some preparation to ensure you and your clients are comfortable with the change.

Here are 5 tips for conducting AOD therapy remotely!

Tip #1: Sort out your tech first!

Most complaints regarding telehealth relate to technical issues during sessions.

Therefore it’s incredibly important that practitioners do a few ‘test runs’ to ensure software is working effectively before a session.

You should also allow some time for the client to orient themselves with the tech to ensure both of you are comfortable with the process.

A rather common mistake is ensuring a good camera position: the client wants to see your face, not up your nose!

Tip #2: Quiet, private environments – on both sides!

Both clients and practitioners should undertake videoconferencing in a private environment free of distractions.

This may be difficult for some clients, so get creative! Let the client know  they should go to wherever they feel comfortable, even if it means conferencing via their car in the garage.

Tip #3: Have a back up option (have a few!)

Technical glitches in video and audio are bound to happen, therefore it’s crucial you have a number of alternative telehealth options at your disposable.

For example, videoconferencing software fails,  try something simple like FaceTime on the phone etc. In some circumstances sessions may need to be undertaken via audio only.

Whilst the key is to avoid technical issues, it’s just as important to be able to quickly switch to alternatives if problems do arise.

Tip #4: Telehealth your resources!

Providing therapy remotely should never mean a client misses out on the usual worksheets, handouts and activities of a face-to-face session.

Think of how you can adapt these activities online whilst still maintaining confidentiality. For example, GoogleDoc or DropBox may be useful to provide documents to a particular email requiring a password to access.

Tip #5: Involve your clients!

Telehealth is a new experience for both you and your client. Always check in to see how they are adapting to the change and brainstorm together ways to improve the delivery.

Consider emailing a summary or notes from the session to your client, so that they can feel that they were heard despite the physical distance.

Ultimately delivering therapy remotely will succeed or fail on the strength of the practitioner/client relationship.

In the harsh politics surrounding alcohol and other drug use, there is often an expectation that AOD practitioners should ‘push’ clients to change even when they don’t want to. But behaviour change without motivation is coercion and very few people make major life changes when pushed.

A more effective (and ethical) approach is to get people ready to change through motivational interventions.

Motivational interviewing (MI) is a skill many health professionals have encountered, but very fewer have mastered.

It is not simply about ‘meeting a client where they are at’. Nor is it about accepting all that a client says at face value. Motivational Interviewing is a technique designed specifically to increase readiness for change.

The process of MI can sometimes be difficult for practitioners, as it requires some degree of detachment from the outcome. And we get into this profession to help people achieve outcomes! It takes some deep self reflection for practitioners to be able to recognise when their own beliefs about outcomes are influencing their practice. Whose outcome are you working towards, yours or the client’s?

Decades of research has found that people make better life choices if practitioners provide a space for them to reflect and chart their own course. Through purposeful talking, practitioners can fully respect client autonomy whilst helping them enact changes which work best for them.

Only through autonomous decisions, not ‘carrots and sticks’ is meaningful life change possible.

Are you considering FebFast? Considering cutting down on your alcohol consumption?

Here is what you need to know.

How alcohol works

It doesn’t matter what type of alcohol you drink – or even whether you mix drinks – the effects are basically the same with the same amount of alcohol.

Alcohol’s effects include reducing activity in the part of the brain that regulates thinking, reasoning and decision-making, known as the prefrontal cortex. Alcohol also decreases inhibitions and our ability to regulate emotions

When you drink alcohol it goes into the stomach and passes into the small intestine where it’s quickly absorbed into the bloodstream.

If you have eaten something, it slows the absorption of alcohol so you don’t get drunk so quickly. That’s why it’s a good idea to eat before and during drinking.

It takes your body about an hour to metabolise 10g, or one standard drink, of alcohol. However, everybody breaks down alcohol at a different rate, so this is just a rough estimate.

Health effects

Australians love their alcohol, exceeding many other countries in terms of consumption. However, very few people understand the negative health effects of regular alcohol consumption.

Recent research has shown there is a clear link between drinking alcohol and a number of health conditions. These include at least seven cancers (liver, oral cavity, pharyngeal, laryngeal, oesophageal, colorectal, liver and breast cancer in women); diabetes; liver disease; brain impairment; mental health problems; and being overweight or obese.

Some previous research suggested low levels of alcohol might be good for you, but we now know these studies were flawed. Better quality studies have found alcohol does not offer health benefits.

Binge drinking, where a large amount of alcohol is consumed in one session, can also cause immediate harms including accidental injury, ‘blackouts‘ and in some cases death.

For some people, alcohol consumption can also impact their mental health provoking periods of depression or anxiety.

Harm reduction

No level of alcohol consumption is ‘safe’, but reducing how often and the amount you drink  can reduce the risk of harm.

New draft alcohol guidelines recommend healthy Australian women and men drink no more than ten standard drinks a week and no more than four on any one day to reduce their risk of health problems.

The guidelines also note that for some people – including teens and women who are pregnant or breastfeeding – not drinking is the safest option.

Signs you may need to cut back

Are you:

• drinking every day or nearly every day? Daily drinking is associated with dependence
• drinking more than the recommended limits? Drinking more than two drinks on any day is associated with long-term health problems
• needing to drink more to get the same effect? This indicates growing tolerance to alcohol and is an early sign of dependence
• having difficulty taking a break or cutting back, or drinking more than you intended to? These are signs that you have less control over how much you drink
• finding that drinking is interfering with day-to-day activities on a regular basis, for example being late for work because you have a hangover?
• noticing your well-being is affected, for example, you get feelings of anxiety or depression during or after drinking, or you have trouble sleeping? Alcohol can be relaxing while you are drinking, but it can make anxiety, depression and sleep problems worse
• doing things while you are drinking that you later regret?

If so, it’s time to reassess your drinking. This online assessment tool may help.

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.