inquiry into the supply and use of methamphetamines, | p a g e access for this substance. the...
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VICTORIAN ALCOHOL & DRUG ASSOCIATION
Inquiry into the supply and use of methamphetamines, particularly ‘ice’, in Victoria
November 2013
VAADA Vision
A Victorian community in
which the harms associated
with drug use are reduced and
general health and wellbeing is
promoted.
VAADA Objectives
To provide leadership,
representation, advocacy and
information to the alcohol and
other drug and related sectors.
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The Victorian Alcohol and Drug Association
The Victorian Alcohol and Drug Association (VAADA) is the peak body for alcohol and other drug (AOD) services in Victoria. We provide advocacy, leadership, information and representation on AOD issues both within and beyond the AOD sector. As a state-wide peak organisation, VAADA has a broad constituency. Our membership and stakeholders include ‘drug specific’ organisations, consumer advocacy organisations, hospitals, community health centres, primary health organisations, disability services, religious services, general youth services, local government and others, as well as interested individuals. VAADA’s Board is elected from the membership and comprises a range of expertise in the provision and management of alcohol and other drug services and related services. As a peak organisation, VAADA’s purpose is to ensure that the issues for both people experiencing the harms associated with alcohol and other drug use, and the organisations that support them, are well represented in policy, program development, and public discussion.
Introduction
VAADA welcomes the opportunity to provide evidence to this inquiry which we hope will enable the
development of evidence informed responses to the growing issue of methamphetamine use in the
community.
VAADA has recently undertaken two consultations with the alcohol and other drug (AOD) treatment
sector to canvass issues related to methamphetamine. The feedback from the AOD treatment sector
generally noted an increase in methamphetamine presentations to treatment agencies; it was
however highlighted that other drugs, including alcohol continue to consume a much higher portion
of resources. There were varying views on the efficacy of specific treatment types; however, there
was a general consensus that additional time, resourcing and training is necessary to respond to this
issue.
The various datasets generally indicate an increase in methamphetamine use, and more strongly an
increase in the harms associated with its use.
There are a number of elements which should be considered in addressing these challenges, with
evidence informed early intervention and prevention-based activities also key to reducing the
uptake and transition to intravenous use which carries greater risk.
VAADA will not be commenting on areas related to reducing the supply of methamphetamine with
the exception that there appears to be a general over-emphasis of supply reduction approaches in
dealing with these issues which are not necessarily supported by a strong evidence base for the
reduction of harms and cost effectiveness; although supply reduction strategies play a key role,
many of them are implemented after the demand for methamphetamine has been established and
the harms have already occurred.
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Key themes
A range of data sources indicate that there has been an increase in the prevalence of harms
associated with methamphetamine use;
It is probable that there has been an increase in the number of individuals using
methamphetamine; this may include AOD treatment and harm reduction naïve cohorts;
There has been a significant increase in the purity of methamphetamine which is likely to be
a significant contributor to the increase in harms;
Methamphetamine is often consumed in tandem with other substances, which may amplify
the harms;
AOD treatment is effective in addressing methamphetamine dependency, but the current
treatment modalities need to be adapted to meet contemporary treatment expectations;
Prevention, early intervention and harm reduction initiatives are necessary to reduce the
take up methamphetamine and the associated harms;
Existing successful programs such as the Drug Court of Victoria should be rolled out state-
wide to address this and other AOD related issues; and
St Vincent’s Hospital in NSW provides a useful example of addressing the challenges from
drug induced psychosis presentations at ED.
Examine the channels of supply of methamphetamine including direct importation and local
manufacture of final product and raw constituent chemical precursors and ingredients
This question is not within VAADA’s remit of expertise.
Examine the supply and distribution of methamphetamine and links to organised crime
organisations including outlaw motorcycle gangs
This question is not within VAADA’s remit of expertise.
Examine the nature, prevalence and culture of methamphetamine use in Victoria, particular
amongst young people, indigenous people and those who live in rural areas
Methamphetamine use has featured prominently in public discussion, including media, and although
it is a problematic substance, there exists an evidence base indicating that other drugs, both licit and
illicit, are also be similarly problematic. For instance, within the general population, alcohol is far
more prevalent in causing harm than any other drug.
However, it is clear that there has been an increase in harm, and possibly the use, of
methamphetamine in recent times. It is also likely that there are a number of subpopulations which
are at higher risk. Contributions to a higher prevalence of harms include an increase in purity and
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access for this substance. The evidence supporting this increase in harms includes upward trends in
ambulance, AOD treatment, acute drug toxicity mortality and policing data involving
methamphetamine. To this end, it is unclear as to whether there is an increase in methamphetamine
use or related harms or both.
The ACC (2013) reports that the purity of methamphetamine has increased from 19.6% in 2010-11
to 60% in 2011-12; this increase in purity is likely to put upward pressure on health services, as the
risk of harm is increased.
On a global scale, Australia reports the equal third highest methamphetamine use globally (UNODC
2013)1, although this data contains limitations, the most prominent being the absence of a large
portion of jurisdictions.
It is probable that there are new cohorts of individuals using methamphetamine and that many of
these individuals, not being regular users of illicit drugs, are naïve to the harms associated with
methamphetamine and effective harm reduction strategies. These populations may be at significant
risk, as the AOD treatment sector reports that use of this substance can quite rapidly result in
dependence; however, this is evident with a range of both licit and illicit substances.
The following data provide an overview of methamphetamine use and is indicative of the associated
harms:
Slightly over 2% of Victorians aged 14 years and over had used methamphetamine in the
past 12 months (AIHW 2011);
The Illicit Drug Reporting System (Cogger, Dietze and Lloyd 2012) reports that in Victoria
during 2012, 67% of the surveyed injecting drug using population had used
methamphetamine over the past 12 months, with 64% administering intravenously;
Methamphetamine use has increased amongst drug using populations, from 32% to 59% of
those surveyed having used ice within the past six months (Cogger, Dietze and Lloyd 2012);
and
Cogger, Dietze and Lloyd (2012, p 37) note that 92% of surveyed injecting drug using
population indicated that methamphetamine was very easy to obtain.
AOD treatment – amphetamines in Victoria
The AIHW (2013) indicates that treatment presentations for amphetamines (including
amphetamines, dexamphetamine and methamphetamine) has increased in Victoria by over 80%
between 2009/10 to 2011/12 as per Figure 1 below.
1 This rating only accounts for those countries where drug consumption data is available.
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Figure 1: Amphetamine treatment episodes - Victoria2
Ambulance attendances provide another means of measuring methamphetamine related harms.
The most recent data regarding methamphetamine ambulance attendances is as follows:
Methamphetamine related attendances have increased in metropolitan Melbourne from
282 attendances in 2010/11 to 592 in 2011/12;
In regional Victoria 78 methamphetamine attendances were recorded in 2011/12 – the
Victorian total for 2011/12 is 670 (Lloyd 2013, p 41).
Figure 2: Methamphetamine Ambulances attendances 2002-03 to 2011-12
2 This graph has been developed through reference to table S7.10 from the additional material accompanying the AIHW
publication.
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
Amphetamines 2,918 2,680 2,949 3,422 3,399 2,970 2,666 3,429 4,876
-
1,000
2,000
3,000
4,000
5,000
6,000
tre
atm
en
t e
pis
od
es
Treatment episodes: Amphetamines - Victoria
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Figure 2 reveals a strong increase in methamphetamine related ambulance attendances over the
past decade. Although this increase is significant, ambulance data indicate that many other drugs are
creating a far heavier demand on ambulance services than methamphetamine, including alcohol (17
fold demand) and heroin (approximately four fold demand) (Turning Point cited in the Herald Sun
2013).
A number of factors have contributed to this increase in ambulance attendances which include:
o Reporting the use of methamphetamines when other amphetamines have been
used, therefore potentially inflating the data;
o The increase in the purity of methamphetamine;
o High levels of poly drug use; and
o Methamphetamine use in the community may have increased.
Largely, the consensus view of the Victorian AOD treatment sector is that there has been an increase
in methamphetamine treatment presentations and in a number of cases, these presentations
involve a range of complexities including:
o Challenging behaviour in the treatment setting;
o History of poly-substance use; and
o Issues with the current treatment response. For example, the duration of the funded
withdrawal period is inadequate to address methamphetamine dependence.
Further it does not accord with contemporary treatment requirements. This is
evident not only with treatment needs for methamphetamine but also for a number
of other drugs.
Regarding at risk cohorts, the Women’s Alcohol and Drug Service (which provides support for
pregnant women with AOD dependency issues) has highlighted the health implications and risks of
methamphetamine use and pregnancy as follows:
o Methamphetamine use can be harmful for pregnant women with regard to harms
associated with intoxication, withdrawal creating foetal distress and the
downstream impact methamphetamine use on self-care, which includes attending
appointments;
o Methamphetamine use can contribute to intrauterine growth restriction (IUGR) and
a preterm birth;
o Methamphetamine is similar in many ways to other substances with regard to the
risk of harms to the developing foetus; and
o The social and behavioural impacts of methamphetamine use are a significant
challenge and can impact upon the overall health of the child.
Youth services are generally citing an increase in methamphetamine presentations and ‘contacts’:
o Many of these contacts are related to misuse and do not necessarily trigger
treatment as dependency / crisis may not be evident; and
o Families are often contacting VAADA members regarding young people and
methamphetamine use.
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Examine the links between methamphetamine use and crime, in particular crimes against
the person
Illicit drugs are explicitly linked with crime, by virtue of their illegality. Regarding crimes against the
person, it is difficult for AOD treatment agencies to provide a succinct and precise assessment of this
issue. Specific agencies may be able to provide an overview on a number of behavioural issues,
especially those agencies providing forensic AOD treatment services. It should be noted, however,
that other substances demonstrate a greater prevalence in violent behaviour than
methamphetamine. For instance, Table 1 reveals a much higher prevalence of alcohol rather than
illicit drugs involved in family violence cases.
Table 1: Family violence related police callouts 2011-12 (Victoria Police 2013, pp 131-132)
definitely involving alcohol definitely involving drugs total FV episodes
12626 3598 50386
Alcohol is definitely involved in approximately one quarter of callouts; illicit drugs (including but not
limited to methamphetamine) are involved in approximately seven per cent of call outs.
Pollard et al (2011) provide longitudinal data on AOD forensic treatment presentations and highlight
the significant growth in alcohol and amphetamine related presentations between 2000 and 2010.
Alcohol related presentations have increased from approximately 1500 to 4600, and amphetamines
from approximately 200 to 1200 over that timeframe. The significant increases highlights both
substances as problematic, especially as the same report indicates an increase in AOD forensic
presentations involving violence from approximately 1600 to just under 5000 over the same time
frame.
It is difficult to pin point a causal link between methamphetamine and violence in part due to the
prevalence of polydrug use and the overwhelming acute harms associated with alcohol
consumption. Research indicates that chronic methamphetamine use can create a sense of paranoia
with users responding adopting a different response to heightened situations than they otherwise
would have had they not been using. However, there is no ‘career path’ to violence through
methamphetamine use, with ‘drug affects and outcomes mediated by the users norms, values,
practices and circumstances’ (Sommers and Baskin 2006, p 93).
VAADA’s (2012) position paper entitled Connections: family violence and AOD provides a useful
discussion on the nexus between AOD and family violence.
Examine the short and long term consequences of methamphetamine use
Methamphetamines Dependence and Treatment detail the range of long and short term physical and
psychological impacts of methamphetamine use (Lee et al 2008, p 2 – 3). These impacts may have a
deleterious effect on an individual’s social circumstances (a risk evident with problematic substance
use and dependence), including family breakdown, issues with employment and in more extreme
cases interface with the justice system (Lee et al 2008, p 7 – 8). There are mixed views regarding
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cognitive impairment related to methamphetamine use, with (Hart et al 2012) highlighting a number
of studies which demonstrated minimal variance in cognitive capacity between methamphetamine
users and control groups.
Individuals experiencing methamphetamine dependence may be reluctant to attend AOD treatment
(Kenny, Harney, Lee and Pennay 2011) which can exacerbate existing adverse circumstances.
Additionally, the Victorian AOD treatment sector has expressed concern that new cohorts of
methamphetamine using populations are emerging, with minimal ‘drug use’ experience, and
therefore naïve to both the elements of treatment as well as specific harm reduction strategies.
Evidence informed prevention and early intervention programs should be developed to address the
needs of this new cohort.
Table 2 demonstrates an increase in portion of acute drug toxicity deaths involving
methamphetamine, from one in 25 deaths in 2010, increasing to 1 in 11 deaths in 2012 (Coroners
Court 2013). Although this increase in concerning, it should be noted that the overall acute drug
toxicity death rate has increased annually since 2010, and many of these deaths would involve more
than one drug. Further, there are a number of other substances which have made significantly larger
contributions to acute drug toxicity mortality.
Table 2: Methamphetamine contributions to Victorian acute drug toxicity deaths
Year Methamphetamine contribution: total Victorian acute drug deaths
2010 14:349 one methamphetamine contribution in 25 acute drug deaths
2011 29:366 one methamphetamine contribution in 12.5 acute drug deaths
2012 34:367 one methamphetamine contribution in 10.8 acute drug deaths
The Victorian Coroners Court (2013b) provides methamphetamine related mortality over a more
extended timeframe, between 1 January 2000 and 30 June 2013; key features are as follows:
230 individuals died between 2000 and June 2013 where methamphetamine had been a
causal or contributory factor; and
214 of those deaths involved at least one additional substance.
Table 3: Methamphetamine mortality involving more than one drug
Frequent co-contributing drug groups Frequent co-contributing individual drugs
Drug Group deaths Individual drug Deaths
benzodiazepines 157 Heroin 129
Pharmaceutical opioids 141 Diazepam 126
Illegal drugs (excl amph) 139 Codeine 70
antidepressants 65 Methadone 57
Antipsychotics 35 Alprazolam 42
Alcohol 31
Oxazepam 22
Temazepam 19
Oxycodone 18
MDMA 17
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Table 3 reveals that benzodiazepines (particularly diazepam) and heroin are common co-occurring
substances in acute drug toxicity deaths with methamphetamine as a contributor. From the available
data, it is apparent that the annual death rate for methamphetamine has increased, from
approximately 14 per year from 2000 to 20010, increasing the 29 in 2011 and 34 in 2012; 2013 is
tracking on par with 2012 data, with 15 deaths recorded by June 30.
There may be a number of populations which incur elevated risk; these include populations which
interface with the justice system, with some agencies reporting an increase in methamphetamine
related forensic presentations is also quite high. Table 4 details methamphetamine contributions to
post release prisoner mortality within 2 months of release or while on a corrections order post
release.
Table 4: methamphetamine contributions to post release mortality
Methamphetamine contribution: total acute drug deaths 2 months post release
2000-2010 14:120 one methamphetamine contribution in 11.7 acute drug deaths
This data, which covers the period between 2000 – 2010 (inclusive) highlights the high prevalence of
methamphetamine contributions to these deaths. The confluence of the increasing
methamphetamine related ambulance call outs, increased amphetamine treatment episodes and
increased purity evident in recent years are likely to put upward pressure on methamphetamine
related harms in vulnerable populations, including prisoners.
The Coroners Court (2013c) provided specific information on the nexus between methamphetamine
and heroin in acute drug toxicity deaths (see Table 5). The overlap is significant with heroin evident
in approximately half of all methamphetamine deaths since 2011. This information contributes to
the knowledge base on drug trends, and should inform harm reduction and treatment activities.
Table 5: Nexus between methamphetamine and heroin in acute drug toxicity mortality – 2010 -
(June) 2013
Year heroin mortality methamphetamine mortality overlap
2010 139 14 5
2011 129 29 14
2012 109 34 18
2013 (June) 67 15 9
Examine the relationship of methamphetamine use to other forms of illicit and licit
substances
The Victorian AOD treatment sector relayed to VAADA that poly drug use is common theme with
methamphetamine dependent populations. The treatment sector has indicated that a range of
substances are often used in tandem with methamphetamines. This includes alcohol, with the harms
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exacerbated by methamphetamine use allowing for the consumption of a quantity of alcohol
beyond an individual’s standard tolerance levels.
National treatment data (AIHW 2013) reveals treatment episodes of secondary drugs where
amphetamines (including amphetamines, dexamphetamine and methamphetamine) is the principle
drug:
Cannabis – present in 30% of amphetamine related treatment episodes
Alcohol – present in 23% of amphetamine related treatment episodes
Benzodiazepines – present in 6% of amphetamine related treatment episodes
Heroin – present in 5% of amphetamine related treatment episodes
Review the adequacy of past and existing state and federal strategies for dealing with
methamphetamine use
The Victorian amphetamine-type stimulant (ATS) and related drugs strategy 2009-2012 has expired
and therefore Victorian policy in this area is not guided by a current strategy. The actions associated
with this strategy have not been reviewed and so it is unclear whether this strategy was successful.
The increase in harms associated with methamphetamine outlined in this submission is suggestive of
some shortcomings in the implementation of this strategy.
The National Amphetamine-type stimulant strategy 2008-2011 provided some resources in response
to amphetamine related issues, however, the efficacy of this strategy in guiding practice at a state
level is limited, as a number of the major stakeholders are primarily state government funded
services.
Consider best practice strategies to address methamphetamine use and associated crime,
including regulatory, law enforcement, education and treatment responses (particularly for
groups outlined above).
There are a number of strategies which should be employed to reduce the harms and prevalence of
methamphetamine use. These strategies involve a range of actions which include the development
and/or expansion of existing programmatic activity. There are specific actions which can occur at
various points of intervention, such as treatment agencies, hospital emergency departments and
Courts. Key actions are as follows:
The AOD treatment sector should receive additional funding to address the increase in
methamphetamine presentations through workforce training and capacity building as well
as increased treatment capacity;
Identify any new cohorts of methamphetamine users and target these populations with
prevention, early intervention and harm reduction initiatives;
Prohibition of the sale of methamphetamine pipes may result in individuals changing their
route of administration from smoking to intravenous use, which is more harmful and carries
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risks associated with injecting drug use. Revoking this prohibition may result in a reduction
of harms associated with intravenous drug use;
It is likely that new AOD naïve cohorts are commencing methamphetamine use. These
populations may be experiencing significant harms, in part due to a lack of knowledge on
harm reduction strategies and accessing AOD treatment. Further support for and expansion
of initiatives such as Dancewize and the NSW-based ACON Rovers to deliver harm reduction
information to these cohorts should be provided;
Mediation and treatment (if necessary) should be provided to school students in possession
or using methamphetamine within a school environment; expulsion should be used only as
an option of last resort and support needs to be provided to ensure that these children are
not ostracised from the system; and
The Drug Court model should applied to all Magistrate’s Court jurisdictions in Victoria,
commencing with those regions which are experiencing of the highest rate AOD harms and
dependence.
Methamphetamine related presentations at Emergency Departments
St Vincents Hospital in Sydney has a highly evolved process in responding to individuals who may be
experiencing drug induced psychosis. Major hospitals in Victoria should consider replicating relevant
elements of the NSW model to address problematic AOD related presentations in emergency
departments.
At St Vincent’s, NSW, individuals presenting at ED experiencing drug related psychosis are viewed as
patients requiring treatment rather than just ‘a problem to be managed’. Detailed records are
maintained for frequent flyers (patients regularly presenting with drug induced psychosis) with a
view to developing specific strategies to best address their individual health needs. This may include
retaining the details of friends and family, recording the most effective medications for treatment
and noting the likely substances which are regularly used.
Appropriate medications are administered to individuals experiencing drug induced psychosis to
‘take them down’ and a quiet space is provided to assist this process and minimise disruption to
other patients in the hospital. These patients may also be assessed and transferred to an inpatient
psych unit attached to the ED which can provide withdrawal services for up to seven days. Further
assessments can be carried out during the seven day withdrawal period to ascertain any other
health requirements.
This model could be replicated in Melbourne and to that end, it is recommended that this inquiry
establish contact with St Vincent’s in NSW to explore this program further.
AOD Treatment
The adult non-residential AOD treatment system is currently being recommissioned. This provides an
ideal opportunity to implement a number of initiatives within the treatment system which can
reduce the harms associated with methamphetamine dependence and elicit improved treatment
outcomes. This includes:
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Workforce development – the AOD treatment workforce must be provided with the capacity
to work with methamphetamine dependent individuals;
This could involve the provision of online training models for AOD workers
which can be undertaken through self-directed learning;
Enhance linkages and partnerships with mental health and community health services to
provide integrated health care to individuals experiencing methamphetamine related harm;
Flexible funding arrangements to allow for specific treatment modalities to adapt to the
treatment needs arising from methamphetamine dependency; and
Capacity for the delivery of education, health promotion and harm reduction activities
should be enabled within treatment agencies where appropriate.
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References
ACC 2013, Illicit drug data report 2011/2012, Australian Crime Commission, viewed 10 October,
http://www.crimecommission.gov.au/publications/illicit-drug-data-report/illicit-drug-data-report-
2011-12
AIHW 2013, Alcohol and drug treatment services in Australia 2011-12, Australian Institute of Health
and Welfare, viewed 11 October 2013, http://www.aihw.gov.au/publication-
detail/?id=60129544486&tab=3
Coroners Court of Victoria 2013, Drug overdose deaths in Inner North West Melbourne, viewed 17
October 2013, http://www.coronerscourt.vic.gov.au/find/publications/coroners+prevention+unit+-
+overdose+deaths+inner+north+west+melbourne+-+yarra+drug+and+health+forum+sep+2013
Coroners Court of Victoria 2013a, Parolee overdoses 2000 – 2010, viewed 17 October 2013
http://www.coronerscourt.vic.gov.au/find/publications/coroners+prevention+unit+-
+parolee+overdoses+-+7+october+2013
Coroners Court 2013b, CPU data on overdose deaths involving methamphetamine, Coroners
Prevention Unit, Victoria.
Coroners Court 2013c, Intersection between heroin and methamphetamine contribution to over dose
deaths 2010-2013, Coroners Prevention Unit, Victoria.
Department of Health 2008, Victorian amphetamine-type stimulant (ATS) and related drugs strategy
2009-2012¸ viewed 17 October 2013,
http://docs.health.vic.gov.au/docs/doc/82A4EEFAAE4188B4CA2578A000833B4E/$FILE/ats_final.pdf
Hart, CL, Marvin, CB, Silver, R and Smith EE 2012, ‘Is cognitive functioning impaired in
methamphetamine users? A critical review’, Neuropsychopharmacology, vol 37, pp 586 – 608.
Herald Sun 2013, Alcohol ties up ambulance service, 10 October ,
http://www.heraldsun.com.au/news/victoria/alcohol-ties-up-ambulance-service/story-fni0fit3-
1226736991836
Kenny, P, Harney, A, Lee, NK and Pennay, A 2011, ‘Treatment utilization and barriers to treatment:
results of a survey of dependent methamphetamine users’, Substance abuse treatment, prevention,
and policy, vol. 6, no. 3.
Lee, N, Johns, L, Jenkinson, R, Johnston, J, Connolly, K, Hall, K and Cash, R 2007 Clinical Treatment Guidelines for Alcohol and Drug Clinicians, No 14: Methamphetamine dependence and treatment. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre Inc. Lloyd, B 2013, Trends in alcohol and drug related ambulance attendances in Victoria: 2011/12,
Fitzroy, Victoria: Turning Point Alcohol and Drug Centre.
National Drug Strategy 2008, National amphetamine-type stimulant strategy 2008-2011, viewed 7 November 2013, http://www.health.gov.au/internet/drugstrategy/Publishing.nsf/content/ATS-strategy-08
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Pollard, J, Berry, M, Ross, S and Kiehne, M 2011, Forensic AOD treatment in Victoria, Department of Health, Victoria. Sommers, I and Baskin, D 2006, ‘methamphetamine use and violence’, Journal of Drug Issues, vol 36, no 77, pp 77 – 96. UNODC 2013, Drug use statistics, United Nations Office on Drugs and Crime, viewed 10 October 2013, http://www.unodc.org/documents/data-and-analysis/WDR2011/StatAnnex-consumption.pdf VAADA 2012, Connections: family violence and AOD, Victorian Alcohol and Drug Association, Collingwood. Victoria Police 2013, Victoria Police Crime Statistics 2011/12, viewed 10 October 2013, http://docs.health.vic.gov.au/docs/doc/B7DEE775D281BE85CA25789A0081D70F/$FILE/methdeptreat.pdf
The Victorian Alcohol and Drug Association Inc. acknowledges the support of the Victorian Government.