1. Ground Zero
An Advocacy Project
On behalf of Pharmacotherapy clients
A right; to participation, empowerment and
involvement.

2. Acknowledgements
This project is a collaborative one and we would like to express our appreciation and
thanks to all contributors who gave freely of their time and assistance towards it. We
would also like to thank the Tasmanian Polytechnic, Diploma of Community Services
staff for their advice, mentoring and guidance over the last 2 years. The hope is that we
have assisted in progressing policy, procedures and positive discourse surrounding
consumer led advocacy in the ATOD sector.
Bucaan Community House.
The Link Youth Health Services
Anglicare Tasmania
Aboriginal Health Service
Mission Australia (Chigwell)
ATI (Aron Perkins)
North Hobart Pharmacy (Amcal)
TasCAHRD
Bridgewater Community House and NSP
Pharmacist (anon)
3 sector workers (anon)
The Honourable Scott Bacon, ALP member for Denison
Andrew Wilkie, MHR, Denison
Office of the State Health Minister
.

3. Preface
This work is copyright and apart from any use as permitted under the Copyright
Act 1968, no part may be reproduced by any process without permission of
Tasmania Polytechnic or the authors of this document. The opinions expressed in
this document are those purely of the authors and not those of TasCAHRD or
Tasmania Polytechnic

4. Table of Contents
SECTION PAGE
Preface ii
Abbreviations iv
Definitions vi
EXECUTIVE SUMMARY vii
Recommendations ix
1.0 Introduction 1
1.1 Background 1
Table 1 PAR vs. CR 1
Graph 1 Number of Active Opioid Substitution Therapy 4
Patients per Annum, Tasmania, 2000-2012 4
Table 2 Number of clients, by sex, pharmacotherapy type,
state and territory 4
Figure 1 Accidental Addict 5
1.2 Methodology 6
Table 3 Organisations referred to by respondents 6
2.0 Literature Review 9
Graph 2 Number of Opioid & Opioid Plus BZD-related Deaths in
Tasmania per Annum 11
Graph 3 Oxycodone Deaths in Aus 12
Figure 2 Dope is top drug worry 13
3.0 Community Profile 14
Graph 4 Rapid Uptake of OxyContin Prescribing 14
Graph 5 Methadone Prescribing in Tasmania vs. AUS 15
Figure 3 Deadly epidemic fears over common painkiller 16
Graph 6 Opioid Prescribing is Escalating 17
Figure 4 Drug hauls skyrocket 17
Graph 7 S8 Authorities per Annum in Tasmania 1989-2012 18
Table 4 Perceived need for Specialist Alcohol, Tobacco,
and Other Drugs in Tasmania 18
Figure 5 Our state of Dependence 19
4.0 Outcomes 20
Figure 6 How to reduce opioid overdose deaths in Australia 20
Figure 7 Oprah Quote 21
5.0 Summary 22
6.0 Appendix 23
6.1 Appendix I – Letter from DHHS 23
6.1 Appendix II – Survey Flyer 24
6.2 Appendix III – Survey 25
7.0 References 28

5. Abbreviations
ADS Alcohol and Drug Services
AIDS Acquired Immune Deficiency Syndrome
AIVL Australian Injecting and Illicit Drug Users League
ATDC The Alcohol, Tobacco and other Drugs Council of Tasmania
ATOD Alcohol Tobacco and other Drugs
ATI Advocacy Tasmania Inc.
BMJ British Medical Journal
CALD ` Culturally and Linguistically Diverse
CHF Consumers Health Forum of Australia
CSO Community Service Organisation
DHHS Department of Health and Human Services (Tasmania)
DSM Diagnostic and Statistical Manual of Mental Disorders
EMCDDA The European Monitoring Centre for Drugs and Drug Addiction
EU European Union
GP General Practitioner
HMA Healthcare Management Advisors
ICD International Classification of Disease
IDU Injecting Drug Users
KE Key Expert
NGO Non Government Organisation

6. NMDS National Minimum Data Set
NOPSADC National Opioid Pharmacotherapy Annual Data Collection
NPPPDO National Pharmacotherapy Policy for People Dependent on Opioids
PAR Participatory Action Research
PSAC Polytechnic Student Advocacy Class
PSB Pharmaceutical Services Branch
CGP Royal College of General Practitioners
RCPSYCH Royal College of Psychiatrists
TasCAHRD Tasmanian Council on Aids, Hepatitis and Related Diseases
TOPP Tasmanian Opioid Pharmacotherapy Policy
TUHSL Tasmanian users Health and support League
WHO World Health Organization

7. Definitions
Closed Treatments: (HMA 2008, pg 26) states, “a period of contact, with defined start
and end dates, between a client and a treatment agency”.
Dependence: The DSM criteria refer to ‘abuse’ rather than misuse. Both the DSM and
the ICD refer to ‘dependence’ rather than using the term ‘addiction’, which is generally
regarded as unclearly defined and often used more to label than describe behaviours,
(Parrish 2011, pg. 192)
Drug: McDonald, D (2012 pg 5), quotes the (NDS) definition of ‘drug’ as stated:
The term ‘drug’ includes alcohol, tobacco, illegal (also known as ‘illicit’) drugs,
pharmaceuticals and other substances that alter brain function, resulting in changes in
perception, mood, consciousness, cognition and behaviour.
Health: as adopted by WHO ‘Health is a state of complete physical, mental and social
well being, not merely the absence of disease or infirmity’.
Opioids:
Opioids include both natural and synthetic opiates. They are either a natural compound
derived from the opium poppy or a synthetic compound that act on opiate receptors. Due
to the fact that they have an analgesic effect they are used in the medical profession.
Since they are addictive their use can lead to drug dependence. This dependence can
occur with pharmaceutical opioids as well as illegal opioids. Some of the common types
of opioids are as follows: Codeine; Heroin; Morphine; Oxycodone; Percodan; Demerol;
and Darvon. AIHW 2012
Pharmacotherapy client: A person receiving pharmacotherapy treatment for either
opioid maintenance or withdrawal management (detoxification) from a prescriber (AIHW
2012).
Policy: McDonald, D (2012 pg 5), outlines this term from Althaus, Bridgman and Davis
(2007) “A statement of government intent, and its implementation through the use of
policy instruments”.
Polydrug Use:
‘Is the use of more than one drug or type of drug by an individual, often at the same time
or sequentially and usually with the intention of enhancing or countering, the effects of
the drug’ (Hinton 2008 pg 25)
Recovery: The RCPSYCH and RCGP (2012 pg10), explains (HM Government, 2010)
definition of recovery as ‘well-being, citizenship and freedom from dependence, and as
an ‘individual personal journey’.
Substance Dependence: Dr Adrian Reynolds (2011-2012 pg. 21), quotes the DSM IV-
TR 2000, definition of dependence ‘substance dependence occurs when an individual
continues using a substance despite it having a significantly negative effect on his or her
life, including functional impairment and emotional distress.

8. Executive Summary
Anecdotal evidence of rising dissatisfaction levels amongst pharmacotherapy clients in
southern Tasmania prompted this project. The ADS, which is contained within the DHHS
is a state government managed service that is comprised of various services. Our area of
interest lies within the delivery, co-ordination and management of the NSP,
pharmacotherapy and detoxification services and the interactions that take place in
Southern Tasmania. Discussions with stakeholders, held in October 2012, raised concerns
regarding punitive and judgemental service, lack of resources within the program,
prolonged waits and other difficulties including the unavailability of an advocacy service
within the sector. According to the AIVL, (2012), they discover that a main site of
discriminatory treatment and micro-aggressions, occurred at drug treatment sites.
People on pharmacotherapies elicited some sympathy for trying to ‘help themselves’ but were
also seen as simply seeking a cheap source of drugs rather than as making use of treatment or
harm reduction services (AIVL 2011, p. 2).
Evaluation of statistics showed that in and around 2008 there was only an average of 50%
occupancy of the St John’s Park detoxification unit due to staff shortages. Further
evaluation identified that there was under-utilisation of the public facility with only 11
clients being dosed from St John’s Park, (HMA 2008, pg 34 -36).
In the period 2008-09 Tasmania had 2081 treatment episodes and 15 government–funded
alcohol and other drug treatment agencies, which highlights a reduction of agencies by
one and 221 fewer treatment episodes, compared with the 2007-08 period (AIHW 2011).
Clients report being treated punitively and feel they cannot voice their concerns to ADS
due to the fear of repercussions. They also state their treatment is inconsistent and
decisions about their treatment were being made for them without consultation. From this
information the project evolved. The title for this project, Ground Zero is taken from
‘Voices on Choices: working towards consumer led alcohol and drug treatment’ as a
description of the lack of consumer led activity within this community sector in Tasmania
(Hinton 2010 pg 83). This project has set out to discover what the literature in this area
and stakeholders have to say about the pharmacotherapy services offered in southern
Tasmania. It has been coincidentally written at the implementation of new treatment
guidelines TOPP See Appendix 6.1.
Little has altered since the release of ‘Voices on Choices’ however, the ATI has been
funded from April 2010 to June 2013 by the DHHS via ADS to be the provider of
advocacy services in the ATOD sector. ATI have created a ‘Consumer and Carer
Participation Program’. This suggested model was approved by ADS. In ATI’s document
entitled ‘Response to Tasmanian Opioid Pharmacotherapy Policy and Clinical Standards

9. Draft 2011’ (TOPP) ATI state that they were ‘informed at an early stage that some
important issues (including take-away dosing) were not really “on the table” for
consideration’ (ATI 2011, pg 2).
‘Advocacy seeks to represent the interests of powerless clients to powerful individuals
and social structures’ (Payne 2005, pg 295). Reading the ATI’s service development plan
2011-2012, it could be argued that it is tokenistic and the delivery of this product has the
possibility to constrain the ATOD client group to that of passive consumers of ATI’s
product. Payne (2005, pg 301) looks at Croft and Beresford’s (1994) viewpoint that
‘a participative approach is valuable because people want and have a right
to be involved in decisions and actions taken in relation to them. Their
involvement reflects the democratic value base of social work; it increases
accountability, makes for more efficient services and helps to achieve social
work goals. It also helps to challenge institutionalised discrimination’.
In Dec 2008, the Tasmanian Minister for Health released a five year plan encompassing
2008-2013 for the ATOD sector. Its aim was to highlight opportunities for investment
and provide a quality, sustainable, supportive system for those in our society who have
substance abuse issues. The plan stated that 17.1 million would be spent over 4 years.
Outcomes of this investment would be improved services within the withdrawal
management unit and higher expenditure in the pharmacotherapy program.
The DHHS has benchmarked certain standards to be achieved by 2020 in their Annual
Report 2009-2010. The benchmarks include, reducing the levels of Tasmanians who used
illicit drugs from 14.8% in 2007 to 9 % by the year 2020. The report also states that under
standard 4.3 they will increase service delivery, meeting client need for those with
serious mental illness from 35 % in 2009 to a target of 90 % by 2020 (DHHS 2010).
The importance of working effectively with clients cannot be overstated as the
occurrence of mental illness will affect more than one in five Australians. Those
undergoing mental unwellness are precipitously placed to go on to develop co morbidities
involving alcohol, tobacco and other drugs (NSW Health 2007, pg 3). Many clients in the
ATOD sector have a dual diagnosis, which includes a mental illness. Whilst reviewing
current literature there has been a lack of documentation that provides a roadmap to
achieving these targets.
Trends further from home illustrate that stakeholders need to have a global awareness to
allow for appropriate future planning. The EMCDDA (2011, pg 13) states ‘Polydrug use,
including the combination of illicit drugs with alcohol, and sometimes, medicines and
non-controlled substances, has become the dominant pattern of drug use in Europe’.
Further to this the RCPSYCH and RCGP College report (2012, pg 6) makes the
distinction that,

10. Heroin and cocaine use is stable or in decline, whereas new drugs such as ‘legal highs’ are
emerging. Increasing numbers of young people are using alcohol and stimulants, and long-term
drug and alcohol use by older people is becoming more significant.
This trend of ageing populations of drug users in treatment has also been reported on
previously by the EMCDDA.

11. Recommendations
The authors propose the following recommendations with the belief that their
implementation would pioneer a positive shift towards aligning the mental health,
ATOD and pharmacotherapy services toward best National Practice Standards
and create a new voice on policy agendas.
• That funding is made available for the development of an independent of
services consumer-led advocacy group with the mission of participation,
empowerment and involvement. This will place Tasmania on an equal
footing with other states and territories.
• A fully costed Tasmanian roadmap is constructed for the integration of
services in the mental health and ATOD sector that is underpinned by a
holistic philosophy. The roadmap to be in line with evidence that this will
meet service user and community expectations.
• That the social determinants of health as defined by the WHO are
recognised and incorporated into policy changes in the ATOD sector.
• Review international and national models of education and implement
workforce training that incorporates CALD policy and that said training be
available nationally for stakeholders ie; medical professions and allied
health care services, law enforcement agencies and students in the ATOD
sector. This is to be undertaken collaboratively with CSO’s, KE’s, NGO’s
and educational institutions to identify and prioritise skills shortages and
develop pathways and frameworks for referral and engagement that are
consistent nationally. An example of this type would be that used by
health funds when members transfer.
• DHHS to fund availability of the TOPP guidelines for ADS clients and
provide information sessions about these guidelines.
• Undertake cost analysis of new drug technologies for possible
implementation in Tasmania as part of a best practice and client centred
strategy

12. 1.0 Introduction
1.1 Background
‘we are people living with the outcome of over two centuries of highly
repressive and unjust social and legal responses to injecting drug use’
(AIVL 2011, pg vii)
From the onset of this project it was the intention to utilise Participatory Action Research
(PAR) to assess the needs of pharmacotherapy clients; however there have been barriers
to this that will be discussed under methodology. This project sought to take an
interpretive stance and advocate for change by bringing the need for an independently
funded ATOD consumer led advocacy group to the attention of those with power to
create change. PAR involves the stakeholders who will be mostly impacted by the
outcomes of the research. From a strengths perspective PAR can be liberating,
empowering and educative and create relations of mutual respect that can bring the
community involved into the policy debate therefore validating their knowledge (Elsevier
Science Ltd, 1995). In conventional research there is little stakeholder involvement, yet it
is these individuals who are mostly impacted by its outcomes. The table below illustrates
a comparison between the two processes:
Table 1 PAR vs CR
Participatory Research Conventional Research
What is the research for? Action Understanding with perhaps
action later
Who is the research for? Local people Institutional, personal and
professional interests
Whose knowledge counts? Local people Scientists
Topic choice influenced by? Local priorities Funding priorities,
institutional agendas,
professional interests
Methodology chosen for? Empowerment, mutual Disciplinary conventions,
learning ‘objectivity and ‘truth’
Who takes part in the stages of research process?
Problem identification Local people Researcher
Data collection Local people Researcher, enumerator

13. Interpretation Local concepts and Disciplinary concepts and
frameworks frameworks
Analysis Local people Researcher
Presentation of findings Locally accessible and useful By researcher to other
academics or funding body
Actions on findings Integral to the process Separate and may not
happen
Who takes action? Local people, with/without External agencies
external support
Who owns the results? Shared The researcher
What is emphasized? Process Outcomes
Elsevier Science Ltd, 1995
In 1997 the Tasmanian user’ Health and Support League (TUHSL) was established. Their
work consisted of peer support, community education work for injecting drug users and
the development of a drug user magazine TASTE. Due to the lack of funding, resourcing
the organisation became unsustainable and was eventually integrated with the work of
Tasmanian Council on AIDS, Hepatitis B & related diseases (TasCAHRD). Although
TasCAHRD continues to promote consumer participation activities they are not a
consumer-based organisation. Unlike other states, Tasmania no longer has a consumer
group who promote the interests of this community.
Through their relationship building, TasCAHRD engages consumers involving them in
program development and planning. This is done by: having consumer representatives
attending quarterly program advisory group meetings; participation in focus groups in the
development of information resources; appointing people who are injecting drug users as
Australian Injecting and Illicit Drug Users League (AIVL) delegates to participate in
national policy debate (Hinton 2010, p.82).
The National Pharmacotherapy Policy for people Dependent on Opioids (NPPPDO)
states,
"The provision for treatment services for people who are drug dependent reduces drug use and
prevents drug-related harm". These harms include health costs, not only to the individual but to
the community, spread of blood borne viruses, risk of overdose, family breakdown, economic
costs associated with morbidity, mortality and absenteeism related to illicit drug use and the cost
of law enforcement for drug related crime". The NPPPDO further states, "there is an expectation
in the community and among drug users and their families that treatment services will be

14. accessible regardless of age, race, gender, sexual preference and location" (Australian
Government Department of Health and Ageing for National Drug Strategy 2007, pg 2).
The general public therefore has certain expectations surrounding standards for treatment,
for those undertaking pharmacotherapy. The issues that led to this project and appear to
be ongoing within the ADS do not sit within socially accepted behaviour. AIVL confirms
this with their research that found 'members of the wider community were very disturbed
by the thought that the medical profession would discriminate against drug users: people
feel that medical professionals should be above such human flaws. Once vocations such
as the medical profession start treating one group differently, where might it end?' (AIVL
2011, pg 71). This is reflective of dominant societal values concerning health
professionals and the Hippocratic Oath.
Research suggests that clients in this sector are reluctant to lodge complaints an/or are
unsure of how this process works.
Under s26 of the Ombudsman Act 1978, the Ombudsman is precluded from disclosure of
relevant information. The Ombudsman report of 2010-2011 states that complaints against
DHHS were 27% of their total complaints received and that nearly all DHHS divisions,
were involved in complaints (Allston 2011).
Unfortunately there is no further breakdown of statistics for divisions within DHHS.
Requests made to the state health minister’s office for relevant data were not productive.
Furthermore, p34 of the Health Complaints Commissioner’s 2011 annual report (Allston
2011) documents a case which highlights the inequality, problematic and fractured nature
of issues that surround service delivery, policy, legislation and procedures surrounding
the ATOD sector. Ongoing, client centred service delivery and client based self-advocacy
is required. AIVL has further identified from their online survey that injecting drug users
are
‘a group of people who are acknowledged as being extremely reluctant to come forward to report
such treatment through formal complaint systems.’
(AIVL 2012, p.8)
Treatments in Europe consist of the main modalities of opioid substitution, detoxification
and psychosocial interventions (EMCDDA 2011, pg 29). Ranges of treatments exist in
Tasmania for those dependent on opioids or other drugs.

15. Graph 1
Reynolds, 2011
According to the National Opioid Pharmacotherapy Statistics Annual Data Collection:
2011 (NOPSADC) report there are a total of 645 clients accessing pharmacotherapy in
Tasmania. (refer to table 2) Of those participants 382 are male and 254 are Female with 9
recorded as ‘not stated’.
Table 2 Number of clients, by sex, pharmacotherapy type, state and territory
Sex NSW Vic Qld WA SA Tas ACT NT Australi Australi
a a (per
cent)
Methadone
Males 9,578 5,971 1,738 1,409 1,233 247 400 23 20,599 64.3
Females 5,081 2,974 1,254 860 726 168 259 8 11,330 35.4
Not — 88 1 — — 4 — — 93 0.3
stated
Total 14,659 9,033 2,993 2,269 1,959 419 659 31 32,022 100.0
Buprenorphine(a)
Males 2,872 433 509 61 220 26 34 9 4,164 66.0
Females 1,300 216 369 75 131 29 11 10 2,141 33.9
Not — 3 — — — 1 — — 4 0.1
stated
Total 4,172 652 878 136 351 56 45 19 6,309 100.0
Buprenorphine–naloxone(a)
Males n.a. 2,697 1,224 640 587 109 81 47 5,385 66.4
Females n.a. 1,343 605 337 286 57 40 26 2,694 33.2
Not n.a. 30 2 — — 4 — — 36 0.4
stated
Total n.a. 4,070 1,831 977 873 170 121 73 8,115 100.0
Total (all pharmacotherapy drugs)
Males 12,450 9,101 3,471 2,110 2,040 382 515 79 30,148 64.9
Females 6,381 4,533 2,228 1,272 1,143 254 310 44 16,165 34.8
Not — 121 3 — — 9 — — 133 0.3
stated
Total 18,831 13,755 5,702 3,382 3,183 645 825 123 46,446 100.0

16. AIHW 2012 p.10
Statistics, whilst informative give us only a partial insight into the lived experiences of
those with dependency issues. Qualitative research can provide us with a deeper
understanding. Hinton quotes;
One worker described a client on a reducing dose of methadone with significant pain
issues where they had tried to get the Alcohol and Drug Service to coordinate with the
pain management clinic but with little success (Hinton 2008, pg 52)
Figure 1 Accidental Addict
The Age, 2012

17. 1.2 Methodology
Severe limitations to this project require mention. The researchers found engagement
with this community particularly difficult. It was time constrained and undertaken from
1.10.12 to 20.11.12 therefore not allowing for adequate time to develop community
relationships and undertake a full community needs assessment of the community
targeted in this paper
With a wider timeframe, a comprehensive focus group plus a more detailed survey would
have been developed. It is hopeful that this will occur in due course. Arranging meetings
that would be ideal with the service users could not be accommodated. Many workers in
this sector are overworked, time poor and part-time. Also, attempts to meet with key
experts/stakeholders had challenges beyond workforce constraints. Those interviewed
have given information supporting the service user’s claims but stated that they wish their
name to remain off the record.
Some of the agencies and professional KE had a culture of suspicion and defensiveness.
Hinton, whose research suggests that, Tasmania arguably has a culture of denial
regarding the extent of drug related harm. Historic failure to commit resources in this
area, plus the actual geographical and population size of the Tasmanian community
creates barriers to participation due to privacy and confidentiality issues. Consumer
participation remains near to non-existent. Others in this sector have also experienced
low response rates, which appear to be the norm in this community.
Hinton also found that ‘this reflects the difficulties workers had in encouraging their
clients to participate and the stigma still attached to talking openly about these issues’
(Hinton 2008, pg 21). ATI also acknowledged difficulty in gaining access to this
particular client group in their report Response to Tasmanian Opioid Pharmacotherapy
Policy and Clinical Standards Draft 2011 (TOPP). The breakdown of state-wide
responses (18 in all) they received are as follows; 10 from private prescribers, 8 from
ADS and a total of 7 from Southern Tasmania. The HMA report 2008 Appendix b shows
a total of 8 responses from the NSP to a specialist ATOD survey undertaken by them.
Table 3 Organisations Referred to by Respondents

18. Our original methodology plan for consulting with this community included hosting a
focus group, unstructured interviews with stakeholders, online survey, and a mailed out
survey via the Man2Man magazine. An approach to the Bridgewater NSP to access their
client base for a focus group was declined. Due to an extremely short window of
opportunity the magazine mail out was missed. Flyers were distributed advertising the
brief anonymous and confidential survey to various locations accessed by the client base.
To date there has been two responses. Feedback will be taken on board and a new
strategy regarding surveying this group will be reflected upon. It has proved a valuable
learning experience that can be refined. Results will be posted as indicated on the survey
flyer (refer to Appendix II) by December 7. The original date was extended due to low
response rate. Follow up action with the stakeholders will hopefully boost the number of
responses.
Ethics, professionalism and personal values ensured that we did not seek out service users
at source even though this was suggested by a Polytechnic staff member that ‘at this
level, Diploma, I would expect that you would’. Societal norms would disapprove of
survey seekers outside of a breast screen clinic, Warfarin or Diabetes clinic. The
researchers feel human rights are for everybody, no exclusion clauses.
The responsibility for maintaining trust and ethical standards cannot
depend solely on rules or guidelines. Trustworthiness of both research
and researchers is a product of engagement between people. It involves
transparent and honest dealing with values and principles, the
elimination of ‘difference blindness’ and a subtlety of judgement required
to eliminate prejudice and maintain respect and human dignity.
(AVIL 2002, pg 6)
Very recent changes to the delivery of Hepatitis programs in southern Tasmania have
hindered the consultative process also. Earlier this year the Hepatitis Program was put out
to tender. TasCAHRD, the organization that was running the Hepatitis Program put in an
application to continue, but the tender was awarded elsewhere. The net result of the loss
to TasCAHRD has been almost 40% of their funding. This has had a great impact to the
organization. As a result the organization’s capacity to provide support is limited.
Stakeholders offered various insights to working with substance dependent clients which
helps inform our research. A pharmacist with past experience with Methadone patients
and no longer in this sector felt that;
All addicts will try to manipulate any situation to their advantage as it is the nature of their
illness, so you could never trust them if they told you there had been a dose change. You always
had to double check with the doctor. Some were very impatient and could be quite rude if they
weren’t dosed immediately. If the prescriptions had been delayed because of dose changes or
because we were busy with other patients they were often not very pleasant. Addicts will crush
and try to inject anything
Anonymous pharmacist

19. This pharmacist indicated that they always tried to be nice to all of their patients but at
times this could be quite a challenge.
Our lack of real action to end the war on drugs has not only given the ‘green light’ to
poor attitudes towards people who inject drugs: it has actively fuelled the epidemic of
discrimination and human rights violations we live with today (AIVL 2011, pg 36).
During an interview with a former NSP worker they indicated that because of the
anonymity surrounding clients it was possible for clients to shop around the NSP’s so that
items could then be sold on to the ‘big wigs’. There was a feeling that this program could
be exploited. There was a common thread amongst the clients of wanting to get onto
programs yet some had no financial means to do so (co-payment) and could not meet the
criteria. There was a lot of negativity about ‘jumping through hoops’. This worker
indicated instances throughout the interview where they had been witness to preferential,
punitive and judgemental work practices by DHHS employees.
Another interview with an ATOD worker, who wish to remain anonymous due to fear of
personal ramifications stated:
“They feel like they have no voice. I have heard clients say if they try to talk to someone
about any issues that they have they would be susceptible to punitive actions.”
The wait time and lack of consultation in treatment were other issues clients complained
about. The worker stated, when people come to access services they need our support to
make a change. With the long waiting time to get into the program and the lack of other
services “we are losing people” who are ready to make the change that will give them a
healthier lifestyle and improve their quality of life.
Discrimination and labelling were impediments that researchers came across throughout
this project. The stigma that is prevalent in this sector is another barrier that limits access
to quality healthcare. In a discussion with another ATOD worker, the researchers asked
about talking with some of their clients. The statement below illustrates clearly that
stigma and discrimination is endemic.
“Why would you want talk to them? They are liars and thieves. They will lie to you.”
This statement shocked the researchers.
Feedback from an AIVL focus group about discrimination experienced by them, within
the broader community showed that medical professionals and pharmacists were the top
two offenders (AIVL 2011, pg 62)
The authors commenced this project as part of their studies towards their Diploma of
Community Services; however they have choosen to use this report as a springboard for a
final draft for advocacy by engaging with a Federal Politician. During a meeting with
Andrew Wilkie, (Federal Independent Member for Denison), on 5/11/12, the issue of
treatment towards ADS clients and lack of an independent of services community lead
advocacy group was discussed. The outcome of the meeting was a promise to reconvene

20. in June 2013 with a final strategic report and business plan for a consumer lead advocacy
group.

21. 2.0 Literature Review
The literature review incorporated mainly web based data, statistics and reports as these
proved to be the most up to date and inclusive of current social discourse. Library
bookshelves had a plethora of books regarding health matters but an extremely poor
choice if you wished to research drug addiction or pharmacotherapy. This again
reinforced to the authors the strong social stigma surrounding this group. If your drug of
choice is food the choice of reading material is never ending. Celebrity is the cloak of
tolerance towards drug use. Think Paris Hilton, Michael Jackson, various AFL Football
Players, Heath Ledger, Whitney Houston. Without this status you are the person
attending a visit with your private prescriber who receives discriminatory service and
micro aggression from other patients in the room, the doctor’s receptionist, and/or the
doctor. These judgemental attitudes of the general public and health professionals, speaks
of the stigma of criminal activities surrounding their drug use. One could raise the
question that has not been covered in this review that the decriminalization of certain
drugs would be cost effective and enable substance dependent people to be disassociated
with the criminal system making dependency a health issue where evidence is
increasingly showing it should sit.
A core issue for the ATOD and mental health sector is the disconnect between services
and lack of holistic intervention across organisations. This can be explained from the
viewpoint of funding structures that are currently in play and there is sometimes a sense
of client ‘ownership’ that comes with this, thus underscoring a reluctance to seek out
services from other CSO’s for a client that is case managed by a particular organisation.
A further explanation is outlined.
Due to the different methodologies used by the alcohol and other drugs and
mental health sectors there are often difficulties in engaging with clients with
both issues and developing an effective treatment approach. There often tends to
be a lack of collaboration between the sectors and thus they traditionally have
worked in isolation from each other
(NSW Health 2007, pg 21).
Further exacerbation of this compartmentalising of clients is underscored by geographic
location of services, differing workplace methodologies and philosophies and differing
administrative practices. One of the issues identified by HMA relating to the ADS was
that common client assessments weren’t being used and resulted in duplication region to
region (HMA 2008, pg 43). Pharmacotherapy clients are highly impacted by the
challenge of managing their symptoms and dealing with the medication management by
ADS. One stop shopping is not a preferred option due to lack of skills in the sector, rather
an inter-agency collaborative approach is required to provide best outcomes to clients.
Australia’s drug strategy approach differs somewhat from that of the EU and other
countries as it has the broadest scope of substances, with harm minimisation being the
overarching strategy (EMCDDA 2011, pg 20-21). Everyday across the globe,
governments and organisations endeavour to have effective policy and to respond to
emerging trends. This has occurred since 1912 when the first International Opium
Conference was held (AIVL 2011, pg 18).

22. The Rogerian method proposes empathy, acceptance, genuiness, congruence and
unconditional positive regard whilst placing the person at the centre of the care model
and is derived from the humanist perspective. Dr Carl Rogers (1902- 1987) was an
American born, influential psychologist who pioneered Client Centred therapy and
Person Centred care (Parrish 2010, pg 135). ‘Rogers’ inherently optimistic regard for
people is congruent with the strengths perspective associated with social work practice’
(Parrish 2010, pg 134). An acceptance of the client being the expert in their own life is a
supporting pillar to client centred care. Pharmacotherapy clients in Southern Tasmania
have no choice currently but to persevere regardless of service levels. Saleebey makes the
point that;
Empowerment-based practice also assumes social justice, recognising that empowerment and
self-determination are dependent not only on people’s making choices but also on their having
available choices to make (Saleebey 1997, pg 61).
A review of the TOPP clinical and practice standards reveals a document that appears to
exclude pharmacotherapy clients from social inclusion, choice and opportunity. The
document is over 200 pages long and looks to replace the 12 year old Tasmanian
Methadone Policy. It was published in May 2012 with a review date set for 2014. Its
stated aim is to provide a framework for delivering a safe, effective pharmacotherapy
program for those with an opioid dependence. It contains among other things background
information of opioid use in Tasmania, and the provision of pharmacotherapy within
Tasmania. Models of Practice referred to are those of the Gateway Model and the Shared
Care Model. It outlines the role of the ADS as that of facilitator and motivator of the
implementation of these models.
The document highlights structural barriers for TOPP to overcome such as the limited
availability of daily dosing pharmacies and also that those in existence have limited hours
of operation. It identifies workforce skills shortages as an area that constrains outcomes
for pharmacotherapy clients however it does not address how they will build workforce
capacity to meet outcomes. Workforce development appears crucial to being able to meet
the practice standards as written in this document.
Language usage throughout as exampled by ‘clients are made aware’ shows a lack of
client centred values and a non consultative functionalist approach. This type of focus,
which is conservative, emphasises clinical management, clinical risk and an
acknowledgement only of ‘expert’ specialist/medicalised knowledge. It provides
consistent practice standards and policy for safe treatment. It does not provide the right of
autonomy thus disallowing client self determination. One could argue that this is
repressive. Pharmacotherapy clients, have as consumers of this service, a right to make an
informed choice. Informed choice raises two important issues; firstly that of dignity of
risk as it exists in the disability sector is highly relevant here. It is the right of the
consumer to make an informed choice, to avail themselves of opportunities, to be
educated and become competent and independent, thereby enabling a calculated risk to
be taken. Secondly if consumers of this service are not advised or do not have treatment
explained then how can they give informed consent? The document points to the
reduction of clinical risk and speaks of public safety yet as clinicians surely their first

23. duty is to the patient and if ADS refer to the premise of ‘primum non nocere’ (do no
harm), this document elevates the possibility of restrictive practice occurring.
The TOPP policy document has awareness of age, gender and CALD specific
management issues. It names ATI as an independent body for advocacy services for AOD
service users, however as ATI is funded by DHHS it is therefore not independent from
the services provided by ADS.
A notice dated 22.10.12, was circulated to pharmacotherapy service users advising that
all clinical staff were now following the TOPP treatment guidelines. See Appendix I
(notice). Upon contacting the Pharmacotherapy team in mid November 2012, advice was
received that due to resource shortages, copies of TOPP were not being distributed to
clients; however a copy was available online. Some in the community and service user
group may not have access to the World Wide Web, nor the ability to fully comprehend a
large medicalised document. An attempt to purchase the TOPP report from Print Applied
Technology on Collins Street Hobart, met with a blank response, as a staff member had
no knowledge of this document. Yet this document applies to all as the ADS are
ultimately, the higher authority overseeing the pharmacotherapy program.
Graph_2
Reynolds, 2011

24. Graph 3
Reynolds, 2011
Tasmania has unique statistics that obviously the TOPP report is responding
to and there is no doubt a requirement for caution and concern around the
pattern of misuse of pharmaceutical drugs in this state, the question however
is how do we proceed forward as currently pharmacotherapy clients are
voicing that they are passengers only in this journey and there is no allowance
for them to be part of the solution.

25. Figure 2 Dope is top drug worry
The Mercury, 2012

26. 3.0 Community Profile
HMA (2008, pg 18) explains the DHHS (1995) drug policy as ‘The Tasmanian state wide
Methadone Maintenance Program commenced as a pilot program in December 1992 in
Hobart’. Initially there was a rehabilitation unit and detoxification, also an outpatient
clinic all of which were government funded. This was subsequently followed by the start
of community-based pharmacotherapy so that more access would service client need that
existed outside of the immediate Hobart area. This was undertaken by DHHS (HMA
2008, pg 18).
Current information informs us that the risk of overdose deaths decreases for those that
undertake substitution treatment.
According to a study published in BMJ Injury Prevention, supply to Victoria has increased from
7.5 mg per capita in 2000 to 6735mg per capita in 2009. Deaths reported to the Coroner had
increased 21-fold, from 0.08/100 000 population in 2000 to 1.78/100 000 in 2009. They conclude
that the increase in the number of deaths involving oxycodone is significantly associated with the
increase in supply. They further state that most of the drug toxicity deaths, which involved
oxycodone, were unintentional. This trend identified in Victoria helps support concerns that
globally a pattern of increasing deaths involving oxycodone is emerging (BMJ, 2012).
Graph 4
Reynolds, 2012

27. Research has also established evidence of higher accident rates for those using opioids.
The review found that opioid prescribing in Tasmania is around 45% above the national
average and that many GP’s have limited understanding of the impact of excessive use of
pain management medication (HMA 2008, pg ix).
Tasmania has also followed this disturbing trend. From the graph below we can see that,
like in the other states methadone prescribing has not only increased but is the highest.

28. Graph 5
Reynolds, 2012

29. Figure 3
ABC News, 2012
While we are on different continents the overall picture of illicit drug use is similar as the
EMCDDA report 2011 pg 14, suggests that there is growing concern, in North America
and internationally surrounding the issue of prescription opioids particularly painkillers
being misused and their availability and that the use of illicit synthetic opioids via the
diversion of substitution drugs from drug treatment is a current trend.

30. Graph 6
Reynolds, 2011
From graph 6 we can see overall opioid prescribing is escalating at alarming rates in
Tasmania. These figures are cause for great concern.
Figure 4
The Mercury, 2012

31. Graph 7
Reynolds, 2012
Table 4 shows the chosen top 3 out of 18 choices, response results of survey respondents
within the ATOD community when asked where they believed there was significant
unmet need for services in this sector in Tasmania. The top five are case management,
outpatient detoxification, medicated detoxification, residential rehabilitation that is less
than 35 days and pharmacotherapies.
Table 4 Perceived need for Specialist Alcohol, Tobacco, and Other Drugs in Tasmania
HMA 2008, pg 67

32. This is further confirmed by Hinton, whose research outlines that:
What workers wanted to see was a case management system which was able
to join all the services up together – mental health, alcohol and drug
services, accommodation and family support (Hinton 2008, pg 53).
Figure 5 Our State of Dependence
The Mercury, 2012

33. 4.0 Outcomes
Saleebey highlights the importance of working from a strengths based perspective, which
has true relevance with ATOD clientele.
Strengths are all we have to work with. The recognition and embellishment of strengths is fundamental to
the values and mission of the profession. A strengths perspective provides for a levelling of the power
relationship between social workers and clients. Clients almost always enter the social work setting in a
vulnerable position and with comparatively little power. Their lack of power is revealed by the very fact
that they are seeking help and entering the social structure of service (Saleebey 1997, pg 63).
Figure 6 How to reduce opioid overdose deaths in Australia
The Conversation, 2012
An independently funded consumer led advocacy group would assist in ameliorating the
deficits in the current ATI model and whilst this type of service is commencing from
ground zero in this state it would aid in the recovery process and in time offer a co-
ordinated approach for consumer involvement, participation and empowerment.

34. Tasmania is the only state of Australia without a consumer led organisation. Stigma and
discrimination are barriers to consumer participation. ‘Stigma is experienced as social,
vocational, and recreational barriers in the community due to widespread ignorance and
misunderstanding that reinforces shame and isolation’ (NSW Dept of Health 2007, pg 5).
Figure 7 Oprah Quote
Positive Motivation, 2012
Different studies on drug trials show promising results in relation to naltrexone implants,
buprenorphine implants and suboxone in an electronic device and futuristically these
could assist with compliance, cravings, relapse and treatment diversion. (EMCDDA
2011, pg 79). Tasmania could be well placed to avail itself of these newer drugs to
ameliorate these issues in the community here. However, new technology usually attracts
optimal pricing and treatments would need to be cost effective. Due to Tasmania having
large rural areas, which are under serviced in this sector, as a state we need to have our
own solution not a ‘one size fits all’.
The fact that engagement with this community was so difficult re-enforces the need for
an independently funded consumer lead advocacy group as they have no voice currently
and how can we provide positive outcomes without hearing their voice.

35. 5.0 Summary
Funding is a key component to achieving positive results in the ATOD community on
behalf of and with clients. Each dollar is important and in the interests of good public
policy and accountability the most effective methods should be applied to overcoming
existing and on-going problems faced by this community. As a society, we need to ask
ourselves the question of ‘is it enough to just get by?’ or should we, together, strive
toward the attainment of best practice goals that encompass holistic solutions and real
outcomes for clients in the ATOD sector. The strengths perspective requires trust,
positivity and a strong emphasis on personal engagement. The health issues related to the
ATOD and mental health sector may question the validity of using the strengths
perspective in this community however Saleebey again shows us the importance of this
approach in relation to abilities;
A strengths orientation implies increased potential for liberating people from
stigmatising, diagnostic classifications that promote “sickness” and “weakness”
in individuals, families and communities. A strengths perspective of assessment
provides structure and content for an examination of realizable alternatives, for
the mobilization of competencies that can make things different, and for the
building of self –confidence that stimulates hope
(Saleebey 2007, pg 63)
Consumer led involvement draws on this perspective. Governments, CSO’s, stakeholders
and policymakers can be informed and guided by evidence that working alongside clients
is proven to have better, cost efficient outcomes. A considerable amount of interlocutors
within Australia are requesting prioritisation of evidence-based policy that is cost and
intervention effective. Having reviewed some of the available reports and literature, the
suggestion is that there is stigma and discrimination, fear of engagement, from this client
base and a strong medicalised/pathologising of the ‘weak’ or ‘sick’. Our suggestion
therefore is to include those marginalized in this process in solution-focused strategies. A
consumer led independent of services advocacy group is part of that solution.
An academic and sector worker with local and international experience, who also teaches,
commented that alcohol, tobacco and other drugs work really, really well for client’s so
that as a worker, one must ensure that the work undertaken and the interventions
employed are far superior to the effects of the substances used by clients. If one accepts
that clients are the experts in their own lives especially when well, then the move toward
client involvement and inclusiveness will be a fruitful, justifiable one.
The removal of stigma and discriminatory behaviour and policies along with further
education in all spheres is the way forward. The ATOD sector needs effective tools,
effective workers, and effective systems to bring about change, empowerment, service
user involvement and participation. Clients have rights that need to be upheld. The
Tasmanian community are deserving of interventions that make a positive cost effective
impact. An independent from services funded consumer led advocacy group in Tasmania
would spearhead this change for better, effective services, for all interested stakeholders.

36. 6.0 APPENDIX
6.1 APPENDIX
Notice From the Department of Health and Human Services

37. 6.2 APPENDIX
Flyer

38. 6.3 APPENDIX
Survey
Service User Survey
The purpose of this survey is to measure the quality of service provided by St. Johns Park.
Please check 1
Age: ____ Sex: ___Male ___Female ___Intersex
Postcode:____________
Are you a current service user of St. John’s Park? (Circle one)
Yes No
How long have you been a service user of St. John’s Park?
_____________
How would you rate their service? (On a scale of 1‐5, 1 being very poor and 5 being excellent)
1‐ very poor 2 – poor 3 – good 4 – very good 5 – excellent
How would you rate staff at St. John’s Park?
1‐ very poor 2 – poor 3 – good 4 – very good 5 – excellent

39. Do you believe this is a non‐judgemental service? (Circle one)
Yes No Unsure
Do you feel that the Department of Health and Human Services impose their own values on you
as a consumer of their services? (Circle one)
Yes No Unsure
If you had a preference, how would you like to receive your services?
(Please circle one)
Clinic (i.e. St.Johns Park) Local Pharmacy Private GP Other____________
For additional comments please use the space provided below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________
This survey ends 30/11/12. Thank you for taking our survey. If you would like to see the results
of this survey results will be published at www. Dec. 7, 2012, at http://stjpsurvey.wordpress.com/
This survey is also available online at: http://stjpsurvey.wordpress.com/

40. Survey Disclaimer – Confidentiality and Privacy
This research project guarantees respondent confidentiality. We conform to all aspects of the
Ethics Code of the Australian Community Workers Association's Code of ethics.
Most importantly, we guarantee that we will honor the Confidentiality clause of the Ethics Code,
namely "The welfare and community worker shall regard all information concerning clients
disclosed in the course of practice as confidential, except where:
With the client’s permission referrals are to be made and other professional consultation is
sought;
Failure to disclose information would breach the terms of the welfare worker’s employment
(such exception must be notified to the clients)."
All data will be used in a form that will make it impossible to determine the identity of the
individual responses. That is, the survey responses will not be integrated, analyzed, or reported in
any way in which the confidentiality of the survey responses is not absolutely guaranteed.
All survey responses will be transferred to a secure, password-restricted server. Access to raw data
will be tightly restricted to only those individuals directly involved in data analysis. The Polytechnic
Student Advocacy Class members (PSAC) of the Clarence Polytechnic and TasCAHRD will retain
the sole ownership of all raw data.
The survey report will be made available to the interested public at http://stjpsurvey.wordpress.com/.
Hard copies of the report will be available by contacting the Polytechnic Student Advocacy Class
members.
Once data analysis is completed, a digital file of the raw data will reside with the PSAC. If further
data analysis becomes necessary, the PSAC will review the proposed data analysis to ensure it
complies with the confidentiality policies listed above.
If you have any questions about these policies, please email the project staff at
survey.stjp@gmail.com. Alternatively you can contact TasCAHRD at 62341242.

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