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Keywords:

  • Alcohol;
  • Aboriginal;
  • Indigenous;
  • brief interventions;
  • primary health care;
  • residential treatment

Abstract

  1. Top of page
  2. Abstract
  3. Enhancing treatment
  4. The reviews
  5. Conclusion
  6. Acknowledgements
  7. References

Objective: To contextualise and provide an overview of two review papers – prepared as part of a larger research program – dealing with different aspects of the treatment of Indigenous Australians with alcohol-related problems.

Method: The papers were reviewed thematically and compared to identify key issues raised in them.

Findings: Together, the papers highlight the paucity of the evidence base for the provision of treatment for Indigenous Australians with alcohol-related problems. Among the key issues identified are: the need to engage with clients in culturally safe ways; practitioner, organisational and client barriers to engagement; the contexts in which Indigenous drinking and treatment take place; the need to develop rigorous methods of evaluation more appropriate to Indigenous cultural and service provision settings; and the importance of effective partnerships in the provision of services.

Conclusion: For those working in the field, the reviews direct attention to the need to review and interrogate our current practice. They also provide clear directions for future research.

To address high levels of alcohol-related harm among Indigenous Australians, the Ministerial Council on Drug Strategy endorsed a National Drug Strategy Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–2009, and a broad range of interventions has been undertaken.1,2 Treatment figures prominently in the Complementary Action Plan, and is provided in primary and secondary health care settings by both Indigenous-specific and mainstream services. In a survey of treatment services at the time of the 2001 census, the percentage of Indigenous clients (11%) was significantly higher than that of the total population (2.2%) and they were more likely to have presented for treatment for alcohol-related (as opposed to other drug) problems than their non-Indigenous counterparts.3 In the 2006/07, treatment in secondary care settings accounted for at least 33% of all expenditure specifically targeted at harmful alcohol and other drug use among Indigenous Australians.2

There is strong evidence for the efficacy of alcohol treatment among non-Indigenous Australians and comprehensive treatment guidelines have been developed.4,5 There has also been investment in Indigenous-specific alcohol treatment guidelines but these are constrained by the limited evidence base.6 While research into the treatment of alcohol-related problems among Indigenous Australians has been limited, it suggests that: interventions known to be effective in other populations cannot be assumed to be effective in Indigenous populations; the evidence for the effectiveness of treatment is equivocal; and the provision of treatment in primary health care settings is less than optimal.4,7 Furthermore, treatment is complicated by high levels of comorbid mental health problems that, in turn, contribute to greater impairment and disability, higher health and other costs in the community, and result in poorer treatment outcomes than among individuals affected by a mental health disorder or drug problems in isolation.8,9

Enhancing treatment

  1. Top of page
  2. Abstract
  3. Enhancing treatment
  4. The reviews
  5. Conclusion
  6. Acknowledgements
  7. References

To address knowledge gaps in this area, the Department of Health and Ageing funded the National Drug Research Institute (NDRI) to conduct a research program aimed at enhancing the management of alcohol-related problems among Indigenous Australians. The purpose of the program is not to develop novel interventions but to focus upon how interventions known to be effective in other populations can effectively be applied in Indigenous Australian contexts.

As part of this program, five research projects were commissioned, each focusing on one aspect of this challenge. Each project was specifically designed to be undertaken either by Indigenous community-controlled organisations or by such organisations in partnership with other health services or research institutions, to facilitate capacity building and sustainable outcomes. As part of proposal development, each research group prepared a stand-alone review of the literature. Two of these reviews follow and the others are being prepared for publication elsewhere.10,11

The reviews

  1. Top of page
  2. Abstract
  3. Enhancing treatment
  4. The reviews
  5. Conclusion
  6. Acknowledgements
  7. References

The starting point for the review by Shakeshaft et al. is the paucity of evidence for the efficacy of brief interventions in Indigenous populations – particularly in primary health care settings. Before canvassing the implications of this, they raise the key issue of the ethics of intervention in the absence of such evidence. They conclude that intervention is justified because efficacy has been demonstrated in non-Indigenous populations and because the potential to cause harm is remote. Shakeshaft et al. expand the focus on intervention per se to interrogate the literature to identify factors likely to inhibit uptake of brief interventions – including those associated with individual clinicians, organisations and patients.

The review by Taylor et al. is concerned with the provision of treatment in residential settings. They begin with a review of the evidence that indicates the need for an approach that recognises the contexts of Indigenous drinking (including urban contexts) and that is culturally safe. In the latter regard, they highlight some of the factors that detract from appropriate responses – including pressures on Indigenous community-controlled services and aspects of mainstream service provision – and they explore potential approaches to addressing these. As well as the need for inclusion of culture in treatment, they also highlight the need for consideration of cultural issues in the evaluation of interventions. Importantly, they consider the need for partnerships between Indigenous and non-Indigenous service providers – a need explicitly recognised in the Complementary Action Plan.

Without wishing to detract from the thrust of Taylor and colleagues’ review, it is worth considering some of the debate around a supposed dichotomy between ‘harm minimisation’ and ‘abstinence’ (a position embraced by some treatment services and political commentators12). We contend that this dichotomy is a false one.13 A goal of any intervention is surely to improve the quality of life of individuals and others affected by alcohol consumption. Abstinence is clearly one means to achieve that goal – for some individuals and communities abstinence might be the cornerstone of any interventions. However, it is also important to reduce the risk of harm caused by those who continue to drink. Reducing the risk of injury to drinkers, reducing the risk of violence for families and communities and improving general health and quality of life are also important goals. Abstinence and harm minimisation goals are therefore complementary, not competing approaches.4,14

Conclusion

  1. Top of page
  2. Abstract
  3. Enhancing treatment
  4. The reviews
  5. Conclusion
  6. Acknowledgements
  7. References

The two papers review essentially different areas of the literature on alcohol treatment among Indigenous Australians. In general, they provide an overview of the field and gaps in the evidence base. In particular, they draw attention to key issues in provision of alcohol treatment services for Indigenous Australians. These include issues of: engaging with clients in culturally safe ways; practitioner, organisational and client barriers to engagement; the contexts in which Indigenous drinking and treatment take place; the need to develop rigorous methods of evaluation appropriate to Indigenous cultural and service provision settings; and the importance of effective partnerships.

For those working in the field, the reviews direct attention to the need to review and interrogate current practice. For the groups that prepared them, they chart a course for their specific research efforts. It is to be hoped that, in following this course, these groups of Indigenous and non-Indigenous researchers will take us forward in our endeavours to provide enhanced treatment for Indigenous people with alcohol problems.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Enhancing treatment
  4. The reviews
  5. Conclusion
  6. Acknowledgements
  7. References

We wish to thank members of the ‘Enhancing the management of alcohol-related problems among Indigenous Australians’ Program Advisory Committee for their contributions, and various researchers and practitioners who provided reviews of the proposals and draft literature reviews prepared by each of the participating project teams. The program and the individual research projects are funded by a grant to the National Drug Research Institute from the Australian Government Department of Health and Ageing. The National Drug Research Institute receives core funding from the Department of Health and Ageing.

References

  1. Top of page
  2. Abstract
  3. Enhancing treatment
  4. The reviews
  5. Conclusion
  6. Acknowledgements
  7. References
  • 1
    Ministerial Council on Drug Strategy. National Drug Strategy: Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–2006. Canberra ( AUST ) : National Drug Strategy Unit, Australian Government Department of Health and Ageing; 2006.
  • 2
    Gray D, Stearne A, Wilson M, Doyle MF. Indigenous-specific Alcohol and Other Drug Interventions: Continuities, Changes and Areas of Greatest Need. Canberra ( AUST ) : Australian National Council on Drugs; 2010. ANCD Research Paper No.: 20.
  • 3
    Shand F, Mattick R. Clients of Treatment Service Agencies: May 2001 Census Findings. Canberra ( AUST ) : Commonwealth Department of Health and Ageing; 2001. National Drug Strategy Monograph Series No.: 47.
  • 4
    Shand F, Gates J, Fawcett J, Mattick R. The Treatment of Alcohol Problems: A Review of the Evidence. Canberra ( AUST ) : Australian Government Department of Health and Ageing; 2003.
  • 5
    Shand F, Gates J, Fawcett J, Mattick R. Guidelines for the Treatment of Alcohol Problems. Canberra ( AUST ) : Australian Government Department of Health and Ageing; 2003.
  • 6
    Australian Government Department of Health and Ageing. Alcohol Treatment Guidelines for Indigenous Australians. Canberra ( AUST ) : Commonwealth of Australia; 2007.
  • 7
    Gray D, Saggers S, Atkinson D, Strempel P. Substance Misuse and Primary Health Care among Indigenous Australians. Aboriginal and Torres Strait Islander Primary Health Care Review: Consultant Report No. 7. Canberra ( AUST ) : Australian Government Department of Health and Ageing, 2004.
  • 8
    Hunter E. Mental health. In: ThomsonN, editor. The Health of Indigenous Australians. Melbourne ( AUST ) : Oxford University Press; 2003. Ch 6 p. 12757.
  • 9
    Hall W, Lynskey M, Teeson M. What is comorbidity and why does it matter? In: TeesonM, BurnsL, editors. The National Comorbidity Project: Workshop Report. Canberra ( AUST ) : Commonwealth Department of Health and Aged Care; 2001.
  • 10
    Shakeshaft A, Clifford A, Shakeshaft M. Reducing alcohol-related harm experienced by Indigenous Australians: identifying opportunities for Indigenous primary health care services. Aust NZ J Public Health. 2010;34(S1):415.
  • 11
    Taylor K, Thompson S, Davis R. Residential rehabilitation for Indigenous Australians: service challenges and inter-agency opportunities to enhance outcomes. Aust NZ J Public Health. 2010;34(S1):3640.
  • 12
    Apunipima Cape York Health Council and Cape York Partnerships [policy page on the Internet] Cairns (AUST): Cape York Institute for Policy and Leadership; 2002 [cited 2010 Feb 22]. Cape York Peninsula Substance Abuse Strategy. Available from: http://www.cyi.org.au/alcohol.aspx.
  • 13
    Lenton S, Midford R. Clarifying ‘harm reduction’ Drug Alcohol Rev. 1996;15:41113.
  • 14
    Babor T, Caetano R, Casswell S, et al. Alcohol: No Ordinary Commodity. Research and Public Policy. Oxford ( UK ) : Oxford University Press; 2003.