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IMPORTANCE: There are known risks of using opioids for extended periods. However, less is known about the long-term trajectories of opioid use following initiation. OBJECTIVE: To identify 5-year trajectories of prescription opioid use, and to examine the characteristics of each trajectory group. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study conducted in New South Wales, Australia, linked national pharmaceutical claims data to 10 national and state data sets to determine sociodemographic characteristics, clinical characteristics, drug use, and health services use. The cohort included adult residents (aged ≥18 years) of New South Wales who initiated a prescription opioid between July 1, 2003, and December 31, 2018. Statistical analyses were conducted from February to September 2022. EXPOSURE: Dispensing of a prescription opioid, with no evidence of opioid dispensing in the preceding 365 days, identified from pharmaceutical claims data. MAIN OUTCOMES AND MEASURES: The main outcome was the trajectories of monthly opioid use over 60 months from opioid initiation. Group-based trajectory modeling was used to classify these trajectories. Linked health care data sets were used to examine characteristics of individuals in different trajectory groups. RESULTS: Among 3 474 490 individuals who initiated a prescription opioid (1 831 230 females [52.7%]; mean [SD] age, 49.7 [19.3] years), 5 trajectories of long-term opioid use were identified: very low use (75.4%), low use (16.6%), moderate decreasing to low use (2.6%), low increasing to moderate use (2.6%), and sustained use (2.8%). Compared with individuals in the very low use trajectory group, those in the sustained use trajectory group were older (age ≥65 years: 22.0% vs 58.4%); had more comorbidities, including cancer (4.1% vs 22.2%); had increased health services contact, including hospital admissions (36.9% vs 51.6%); had higher use of psychotropic (16.4% vs 42.4%) and other analgesic drugs (22.9% vs

PURPOSE: The POPPY II cohort is an Australian state-based cohort linking data for a population of individuals prescribed opioid medicines, constructed to allow a robust examination of the long-term patterns and outcomes of prescription opioid use. PARTICIPANTS: The cohort includes 3 569 433 adult New South Wales residents who initiated a subsidised prescription opioid medicine between 2003 and 2018, identified through pharmacy dispensing data (Australian Pharmaceutical Benefits Scheme) and linked to 10 national and state datasets and registries including rich sociodemographic and medical services data. FINDINGS TO DATE: Of the 3.57 million individuals included in the cohort, 52.7% were female and 1 in 4 people were aged ≥65 years at the time of cohort entry. Approximately 6% had evidence of cancer in the year prior to cohort entry. In the 3 months prior to cohort entry, 26.9% used a non-opioid analgesic and 20.5% used a psychotropic medicine. Overall, 1 in 5 individuals were initiated on a strong opioid (20.9%). The most commonly initiated opioid was paracetamol/codeine (61.3%), followed by oxycodone (16.3%). FUTURE PLANS: The POPPY II cohort will be updated periodically, both extending the follow-up duration of the existing cohort, and including new individuals initiating opioids. The POPPY II cohort will allow a range of aspects of opioid utilisation to be studied, including long-term trajectories of opioid use, development of a data-informed method to assess time-varying opioid exposure, and a range of outcomes including mortality, transition to opioid dependence, suicide and falls. The duration of the study period will allow examination of population-level impacts of changes to opioid monitoring and access, while the size of the cohort will also allow examination of important subpopulations such as people with cancer, musculoskeletal conditions or opioid use disorder.

Family-based therapy is a common front-line strategy to prevent child maltreatment in high-risk families. This review aimed to systematically assess the evidence of the effect of family-based therapy programs on child maltreatment outcomes. CINAHL, Scopus and PsycINFO were systematically searched to March 25, 2023. Outcome data were extracted for child protection reports and out-of-home care (OOHC) placements from administrative data, and parent- or child-reported maltreatment risk. 12 RCTs and two observational studies of 8,410 screened were included. All 14 studies had high risk of bias. Sample sizes ranged from 43 in an RCT to 3875 families in an observational study. In seven studies with child protection report risk estimates, five studies (3 RCTs, 2 observational) showed results in favor of the intervention (risk differences (RD) of 2.0–41.1 percentage points) and two RCTs in favor of the comparison (RD, 2.0–8.6 percentage points). In the four studies with OOHC risk estimates, three studies (2 RCTs, 1 observational) showed results in favor of the intervention (RD, 0.9–17.4 percentage points) and one observational study showed results in favor of the comparison (RD, 1.5 percentage points). Most studies had ≤ 100 participants, did not estimate main causal effects, and had high risk of bias. Thus, although family-based therapy programs may reduce child maltreatment, the high risk of bias, typically small sample sizes (> 62% of studies had sample sizes < 100), and inconsistent results across studies means it is currently unclear whether family-based therapy interventions achieve better child maltreatment outcomes, compared with usual care services.

BACKGROUND: Clinicians' experiences of providing care constitute an important outcome for evaluating care from a value-based healthcare perspective. Yet no currently available instruments have been designed and validated for assessing clinicians' experiences. This research sought to address this important gap by developing and validating a novel instrument in a public health system in Australia. METHODS: A multi-method project was conducted using co-design with 12 clinician leaders from a range of NSW Health Local Health Districts to develop the Clinician Experience Measure (CEM). Validity and reliability analyses were conducted in two stages, first assessing face and content validity with a pool of 25 clinicians and then using psychometric analysis with data from 433 clinicians, including nurses, doctors and allied health and representing all districts within one jurisdiction in Australia. RESULTS: Data gathered from 25 clinicians via the face and content validity process indicated that the initial 31-items were relevant to the range of staff employed in the NSW state health system, with minor edits made to the survey layout and wording within two items. Psychometric analysis led to a rationalised 18-item final instrument, comprising four domains: psychological safety (4-items); quality of care (5-items); clinician engagement (4-items) and interprofessional collaboration (5-items). The 18-item four-factor model produced a good fit to the data and high levels of reliability, with factor loadings ranging from .62 to .94, with Cronbach's alpha (range: .83 to .96) and composite reliability (range: .85 to .97). CONCLUSIONS: The CEM is an instrument to capture clinicians' experiences of providing care across a health system. The CEM provides a useful tool for healthcare leaders and policy makers to benchmark and assess the impact of value-based care initiatives and direct change efforts.

Background and Aims: The configuration of alcohol and other drug treatment service systems has been influenced by the uptake of market mechanisms for treatment funding and purchasing. This study measured the impact of market mechanisms for funding and purchasing alcohol and drug treatment services on client outcomes. Design: An observational cross-sectional study, employing multi-level analysis: episodes of care data, nested within person-level data, nested within treatment site and nested within organization. Setting and participants: One hundred and seventy-eight alcohol and other drug treatment service sites in Australia. Measurements: Client outcome variables were length of stay and successful treatment completion. Predictor variables were competitive tendering, number of funding contracts, recurrent funding, the ratio of episodes to staff, type of professions, years of clinical experience, staff turnover and type of provider (government; non-government). Analyses controlled for drug type, type of treatment received and client characteristics. Findings: There were no significant associations between the procurement and contracting variables and length of stay [incidence rate ratios (IRRs) ranged between 1.01 and 1.07, all P > 0.05; Bayes factors (BF) < 0.03], and inconclusive results for treatment completion [odds ratios (ORs) ranged between 1.04 and 1.15, all P > 0.05, BF = 0.51–0.63]. Having an alcohol and other drug (AOD) work-force relative to an ‘other’ work-force (IRR = 0.79, P = 0.021) and lower case-loads (IRR = 0.99, P = 0.047) may be associated with longer stay in treatment. Receiving services from a government compared to non-government provider may also be associated with less treatment completion (OR = 0.34, P = 0.023, BF = 2.14). Conclusions: There appears to be no association between client outcomes and procurement and funding contract arrangements for alcohol and drug treatment services.

Objective: Both public (government-run), and not-for-profit (nongovernment) service providers provide alcohol and other drug (AOD) treatment services. Research has rarely studied the structural features of these providers, such as workforce characteristics, procurement arrangements, and funding security. The study reported here sought to document and analyze the differences between these two AOD treatment provider types in Australia. Methods: The study administered an online survey instrument targeted at managers of AOD treatment sites. The survey comprised three sections: (1) the service (e.g., treatment types); (2) workforce (e.g., total number of staff); and (3) funding and procurement arrangements (e.g., contract length). The study completed a total of 207 site surveys. The studied compared government and nongovernment services on structural features that may create a more or less sustainable or vulnerable service (funding arrangements, payment mechanisms, and contract length). Results: Government providers were more likely to provide medically oriented treatment types such as withdrawal management and pharmacotherapy, whereas nongovernment organization (NGO) providers were more likely to offer rehabilitation. Consistent with this, government services were more likely to employ medical professionals and nurses, indicative of a more medically oriented workforce, while NGO services were more likely to employ AOD workers, youth workers, peer workers, and counselors. Our data illustrate that NGO services were more likely to be subject to competitive tendering and to have shorter contract lengths, compared with government services, and overall to be more structurally vulnerable. Conclusion: Despite the reliance on NGOs to provide the majority of specialist care (71% of all treatment episodes in Australia), these services are more vulnerable than their government counterparts. To ensure that a comprehensive suite of treatment services is available, procurement arrange

A new Motional Stark Effect (MSE) analysis routine has been developed for improved spatial resolution in the core of the Large Helical Device (LHD). The routine was developed to reduce the dependency of the analysis on the Pfirsch–Schlüter (PS) current in the core. The technique used the change in the polarization angle as a function of flux in order to find the value of diota/dflux at each measurement location. By integrating inwards from the edge, the iota profile can be recovered from this method. This reduces the results’ dependency on the PS current because the effect of the PS current on the MSE measurement is almost constant as a function of flux in the core; therefore, the uncertainty in the PS current has a minimal effect on the calculation of the iota profile. In addition, the VMEC database was remapped from flux into r/a space by interpolating in mode space in order to improve the database core resolution. These changes resulted in a much smoother iota profile, conforming more to the physics expectations of standard discharge scenarios in the core of the LHD., source:Review of Scientific Instruments 88, 093518 (2017); https://doi.org/10.1063/1.4995808, source:https://doi.org/10.1063/1.4995808

Background Cancer of unknown primary (CUP) is a late-stage malignancy with poor prognosis, but we know little about what diagnostic tests and procedures people with CUP receive prior to diagnosis. The purpose of this study was to determine how health service utilisation prior to diagnosis for people with cancer-registry notified CUP differs from those notified with metastatic cancer of known primary. Methods We identified people with a cancer registry notification of CUP (n = 327) from the 45 and Up Study, a prospective cohort of 266,724 people 45 years in New South Wales, Australia, matched with up to three controls with a diagnosis of metastatic cancer of known primary (n = 977). Baseline questionnaire data were linked to population health data to identify all health service use, diagnostic tests, and procedures in the month of diagnosis and 3 months prior. We used conditional logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results After adjusting for age and educational attainment, people with a cancer-registry notified CUP diagnosis were more likely to be an aged care resident (OR = 2.78, 95%CI 1.37-5.63), have an emergency department visit (OR = 1.65, 95%CI 1.23-2.21), serum tumor marker tests (OR = 1.51, 95%CI 1.12-2.04), or a cytology test without immunohistochemistry (OR = 2.01, 95%CI 1.47-2.76), and less likely to have a histopathology test without immunohistochemistry (OR = 0.43, 95%CI 0.31-0.59). Neither general practitioner, specialist, allied health practitioner or nurse consultations, hospitalisations, nor imaging procedures were associated with a CUP diagnosis. Conclusions The health service and diagnostic pathway to diagnosis differs markedly for people notified with CUP compared to those with metastatic cancer of known primary. While these differences may indicate missed opportunities for earlier detection and appropriate management, for some patients they may be clinically appropriate.

Alcohol use and related injuries are a leading risk factor for deaths and disabilities in Australia, particularly for Aboriginal and Torres Strait Islander people. An improved understanding of individual and geographical community characteristics that are significantly associated with higher rates of alcohol-related injuries for specific populations can contribute to more effective efforts aimed at reducing alcohol-related injuries. For Aboriginal and non-Aboriginal Australians in New South Wales, this study used emergency department (ED) data to investigate rates of alcohol-related injuries, whether differences in rates vary between communities, and individual and community characteristics significantly associated with alcohol-related injuries. Differences in rates of alcohol-related injuries between Aboriginal and non-Aboriginal people varied significantly between communities. Being younger than 38 years old was significantly associated with increased risk of alcohol-related injuries, independent of Aboriginal status and gender. Increased disadvantage of the geographical community inhabited was associated with increased alcohol-related injuries for males. For Aboriginal males, living in a regional community was significantly associated with increased alcohol-related injuries, compared to living in major cities. Conversely, for non-Aboriginal people, living in regional communities was significantly associated with fewer alcohol-related injuries. It is therefore likely that an explanation for betweencommunity differences can be found in regional communities.

BACKGROUND AND AIMS: Recent research suggests that parental supply of alcohol is associated with more risky drinking and alcohol-related harm among adolescents. However, the overall effect of parental supply throughout adolescence remains unclear, because parental supply of alcohol varies during adolescence. Due to the complexity of longitudinal data, standard analytical methods can be biased. This study examined the effect of parental supply of alcohol on alcohol-related outcomes in early adulthood using robust methods to minimize risk of bias. DESIGN: Prospective longitudinal cohort study. SETTING: Australia PARTICIPANTS: A cohort of school students (n = 1906) recruited in the first year of secondary school (average age 12.9 years) from Australian schools in 2010-11, interviewed annually for 7 years. MEASUREMENTS: The exposure variable was self-reported parental supply of alcohol (including sips/whole drinks) during 5 years of adolescence (waves 1-5). Outcome variables were self-reported binge drinking, alcohol-related harm and symptoms of alcohol use disorder, measured in the two waves after the exposure period (waves 6-7). To reduce risk of bias, we used targeted maximum likelihood estimation to assess the (counterfactual) effect of parental supply of alcohol in all five waves versus no supply on alcohol-related outcomes. FINDINGS: Parental supply of alcohol throughout adolescence saw greater risk of binge drinking [risk ratios (RR) = 1.53; 95% confidence interval (CI) = 1.27-1.84] and alcohol-related harms (RR = 1.44; 95% CI = 1.22-1.69) in the year following the exposure period compared with no supply in adolescence. Earlier initiation of parental supply also increased risk of binge drinking (RR = 1.10; 95% CI = 1.05-1.14), and any alcohol-related harm (RR = 1.09; 95% CI = 1.05-1.13) for each year earlier parental supply began compared with later (or no) initiation. CONCLUSIONS: Adolescents whose parents supply them with alcohol appear to have an increased ris

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Background: The relationship between comorbid disease and health service use and risk of cancer of unknown primary site (CUP)is uncertain. Methods: A prospective cohort of 266,724 people aged 45 years and over in New South Wales, Australia. Baseline questionnaire data were linked to cancer registration, health service records 4–27 months prior to diagnosis, and mortality data. We compared individuals with incident registry-notified CUP (n = 327; 90% C80)to two sets of randomly selected controls (3:1): (i)incident metastatic cancer of known primary site (n = 977)and (ii)general cohort population (n = 981). We used conditional logistic regression to estimate adjusted odds ratios (ORs)and 95% confidence intervals (CIs). Results: In fully adjusted models incorporating sociodemographic and lifestyle factors, people with cancer registry-notified CUP were more likely to have fair compared with excellent self-rated overall health (OR 1.78, 95% CI 1.01–3.14)and less likely to self-report anxiety (OR 0.48, 95% CI 0.24−0.97)than those registered with metastatic cancer of known primary. Compared to general cohort population controls, people registered with CUP were more likely to have poor rather than excellent self-rated overall health (OR 6.22, 95% CI 1.35–28.6), less likely to self-report anxiety (OR 0.28, 95% CI 0.12−0.63), and more likely to have a history of diabetes (OR 1.89, 95% CI 1.15–3.10)or cancer (OR 1.62, 95% CI 1.03–2.57). Neither tertiary nor community-based health service use independently predicted CUP risk. Conclusion: Low self-rated health may be a flag for undiagnosed cancer, and an investigation of its clinical utility in primary care appears warranted.

Background: Little is known about the risk factors for cancer of unknown primary site (CUP). We examined the demographic, social and lifestyle risk factors for CUP in a prospective cohort of 266,724 people aged 45 years and over in New South Wales, Australia. Methods: Baseline questionnaire data were linked to cancer registration, hospitalisation, emergency department admission, and mortality data. We compared individuals with incident cancer registry-notified CUP (n = 327) to two sets of controls randomly selected (3:1) using incidence density sampling with replacement: (i) incident cancer registry-notified metastatic cancer of known primary site (n = 977) and (ii) general cohort population (n = 981). We used conditional logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results: In a fully adjusted model incorporating self-rated overall health and comorbidity, people diagnosed with CUP were more likely to be older (OR 1.05, 95% CI 1.04–1.07 per year) and more likely to have low educational attainment (OR 1.77, 95% CI 1.24–2.53) than those diagnosed with metastatic cancer of known primary. Similarly, compared to general cohort population controls, people diagnosed with CUP were older (OR 1.10, 95% CI 1.08–1.12 per year), of low educational attainment (OR 1.69, 95% CI 1.08–2.64), and current (OR 3.42, 95% CI 1.81–6.47) or former (OR 1.95, 95% CI 1.33–2.86) smokers. Conclusion: The consistent association with educational attainment suggests low health literacy may play a role in CUP diagnosis. These findings highlight the need to develop strategies to achieve earlier identification of diagnostically challenging malignancies in people with low health literacy.

Background: Evidence on the effectiveness of opioid agonist treatment (OAT) in reducing crime is mixed. We aimed to assess the effect of OAT on crime in terms of delaying time to first charge and reducing overall charge rates, as well as the relationship between OAT retention and overall charge rates. Methods: We did a retrospective cohort study of opioid-dependent people who entered OAT for the first time between Jan 1, 2004, and Dec 30, 2010, in New South Wales (NSW), Australia. We used three linked NSW and national administrative datasets. Data on OAT were obtained from the Pharmaceutical Drugs of Addiction System, data on charges were obtained from the Reoffending Database, and data on mortality were obtained from the National Death Index. The cohort was followed up until Dec 31, 2011. Time-dependent OAT exposure was modelled using Cox proportional hazards models (time to first charge) and Andersen-Gill intensity models (total charge-days). Retention in OAT was modelled using two features of treatment engagement, number of OAT episodes and proportion of follow-up time in OAT (presented in quartile groupings: lowest, low-mid, low-high, highest) using zero-inflated negative binomial regression (total charges). All models were adjusted for sociodemographic, criminographic, and treatment-related variables. Findings: 10 744 new OAT entrants were included in the study. 5751 (53·5%) people were charged with an offence. In adjusted analyses, OAT was associated with an initial benefit in delaying the time to first charge (hazard ratio 0·43, 95% CI 0·33–0·55) and reducing total charge-days (0·39, 95% CI 0·30–0·52); however, these protective effects reduced over time. Total charge rates were higher as the number of OAT episodes increased (incident rate ratio [IRR] 1·13, 95% CI 1·11–1·15), and when relatively lower proportions of time were spent in OAT (IRR among the lowest three quartiles ranged from 1·11 [95% CI 1·02–1·21] to 1·22 [95% CI 1·12–1·33]). Interpretation: OAT

Background: People with a family history of major depressive disorder (MDD) or bipolar disorder (BD) report specific psychoeducational needs that are unmet by existing online interventions. This trial aimed to test whether an interactive website for people at familial risk for depression (intervention) would improve intention to adopt, or actual adoption of, depression prevention strategies (primary outcome) and a range of secondary outcome measures. Methods: In this cluster randomised trial, primary care practises were randomised to either provide the link to the intervention or the control website. Primary health care attendees were invited by letter to opt into this study if they had at least one first-degree relative with MDD or BD and were asked to complete online questionnaires at baseline and 2-week follow-up. Results: Twenty general practices were a randomized, and 202 eligible patients completed both questionnaires. Thirty-nine (19.3%) of participants were male and 163 (80.7%) female. At follow-up, compared to controls, the intervention group: (i) were more likely to intend to undergo, or to have actually undergone, psychological therapies (OR = 5.83, 95% CI: 1.58-21.47, p =.008); (ii) had better knowledge of depression risk factors and prevention strategies (mean difference = 0.47, 95% CI: 0.05-0.88, p =.029); and (iii) were more likely to accurately estimate their lifetime risk of developing BD (mean difference = 11.2, 95% CI: -16.52- -5.73, p <.001). There were no statistically significant between-group differences in change from baseline to follow up for any of the remaining outcome measures (Patient Health Questionnaire, Perceived Devaluation-Discrimination Questionnaire and Perceived Risk of Developing MDD). Conclusion: The opt-in nature of the study may have led to participation bias, e.g. underrepresentation of males, and hence may limit generalisability to the broader population at familial risk for depression. This is the first website internation

BACKGROUND: People with a family history of major depressive disorder (MDD) or bipolar disorder (BD) report specific psychoeducational needs that are unmet by existing online interventions. This trial aimed to test whether an interactive website for people at familial risk for depression (intervention) would improve intention to adopt, or actual adoption of, depression prevention strategies (primary outcome) and a range of secondary outcome measures. METHODS: In this cluster randomised trial, primary care practises were randomised to either provide the link to the intervention or the control website. Primary health care attendees were invited by letter to opt into this study if they had at least one first-degree relative with MDD or BD and were asked to complete online questionnaires at baseline and 2-week follow-up. RESULTS: Twenty general practices were a randomized, and 202 eligible patients completed both questionnaires. Thirty-nine (19.3%) of participants were male and 163 (80.7%) female. At follow-up, compared to controls, the intervention group: (i) were more likely to intend to undergo, or to have actually undergone, psychological therapies (OR = 5.83, 95% CI: 1.58-21.47, p = .008); (ii) had better knowledge of depression risk factors and prevention strategies (mean difference = 0.47, 95% CI: 0.05-0.88, p = .029); and (iii) were more likely to accurately estimate their lifetime risk of developing BD (mean difference = 11.2, 95% CI: -16.52- -5.73, p < .001). There were no statistically significant between-group differences in change from baseline to follow up for any of the remaining outcome measures (Patient Health Questionnaire, Perceived Devaluation-Discrimination Questionnaire and Perceived Risk of Developing MDD). CONCLUSION: The opt-in nature of the study may have led to participation bias, e.g. underrepresentation of males, and hence may limit generalisability to the broader population at familial risk for depression. This is the first website internat

Introduction Smoking remains the leading risk factor for disease burden and mortality worldwide. Heavy Smoking is often associated with poor Nutrition, Alcohol abuse and Physical inactivity (known as 'SNAP'). Australia's first prison smoking ban was introduced in the Northern Territory in July 2013. However, relapse to smoking after release from prison is normative. Holistic and cost-effective interventions are needed to maintain post-release abstinence to realise the potential public health impact of smoke-free prison policies. Rigorous, large-scale trials of innovative and scalable interventions are crucial to inform tobacco control policies in correctional settings. Methods and analysis This multicentre, investigator-blinded, randomised parallel superiority trial will evaluate the effectiveness of a brief intervention on SNAP versus usual care in preventing smoking relapse among people released from smoke-free prisons in the Northern Territory, Australia. A maximum of 824 participants will be enrolled and randomly assigned to either SNAP intervention or usual care at a 1:1 ratio at baseline. The primary endpoint is self-reported continuous smoking abstinence three months after release from prison, verified by breath carbon monoxide test. Secondary endpoints include seven-day point prevalence abstinence, time to first cigarette, number of cigarettes smoked post release, Health Eating Index for Australian Adults, Alcohol Use Disorder Identification Test-Consumption and International Physical Activity Questionnaire scores. The primary endpoint will be analysed on an intention-to-treat basis using a simple log binomial regression model with multiple imputation for missing outcome data. A cost-effectiveness analysis of the brief intervention will be conducted subsequently. Ethics and dissemination This study was approved by the University of New South Wales Human Research Ethics Committee (HREC), Menzies HREC and Central Australia HREC. Primary results of the trial an