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HEALTH professionals should carefully consider “why they would even entertain” working inside the Northern Territory’s mandatory residential alcohol rehabilitation system, according to a GP who has worked for Aboriginal health services for more than 25 years.
Dr John Boffa, who is also an associate professor with the National Drug Research Institute and spokesperson for the People’s Alcohol Action Coalition, said there was no evidence that the system was effective.
Dr Boffa told MJA InSight the Alcohol Mandatory Treatment Act had been in place for 2 years with “no transparent attempt to evaluate its effectiveness”. Evidence was required to prove it was not simply “a cynical exercise to get people off the street”.
“Any system that denies people their liberty on the basis of a medical condition, for the purpose of treatment, has to be able to assess its effectiveness in terms of outcomes. If it can’t do that, it becomes unethical, and all health professionals should consider why they would even entertain working inside such a system”, Dr Boffa said.
“I would suggest all health professionals should, as a condition of employment, say they will only work in this mandatory treatment system if there is a guarantee that there is going to be a serious attempt to see whether it is working.”
Dr Boffa was responding to an MJA “Ethics and law” article, which said there was little evidence of the scheme’s efficacy, and that the NT Government “could adopt more cost-effective alternatives that would not involve the dubious application of a medical intervention to reduce public intoxication, with its concomitant legal and ethical issues”. (1)
The authors wrote that the “potentially discriminatory program” cost $27 million in the 12 months to June 2014, which represented $64 000 expenditure on each of the 418 people referred to the program.
Dr Boffa told MJA InSight that without evidence the program worked, that money would be better invested in an evidence-based primary health care treatment system which provided three streams of care — medical care, psychological care, and social and cultural support — with intensive case management for people most addicted.
“There are successful models in place you could build on”, he said, suggesting the Safe and Sober Support Service in Alice Springs, which was based on a successful 12-month trial that he had helped evaluate. (2)
Dr Boffa said supply reduction measures, such as where police prevent takeaway alcohol being sold to people living on alcohol-prohibited land, combined with a minimum unit price on alcohol, would make large-scale public drunkenness a thing of the past.
Professor Ann Roche, director of the National Centre for Education and Training on Addiction at Flinders University, described the mandatory treatment system as a discriminatory social-control mechanism that might be motivated by wanting to remove intoxicated Aboriginal people from streets and parks.
Professor Roche said that while this was not a good motivation for mandatory treatment, there was evidence that in some instances it might be helpful, such as programs used within the legal system to divert offenders into treatment.
“Whether that applies in this particular instance, where we are dealing almost exclusively with Aboriginal people who are profoundly disadvantaged and socially marginalised already, needs to be independently evaluated, in a very cautious way. It’s unwise to do something that there is no evidence base for and that is potentially high risk”, she told MJA InSight.
“We have invested for decades in a raft of services we know can achieve positive results. Why not build on that before stepping into an area that is much higher risk and represents a huge investment for an unknown outcome?”
Professor Roche cautioned against directing resources entirely towards “ambulance at the bottom of the cliff” responses, saying it was important not to lose sight of primary prevention measures such as providing education and employment opportunities for Aboriginal people.
Dr Robert Parker, president of the NT AMA, said the government would not tolerate the “political carnage” of any long-term approach as it did not offer an instant fix in reducing rates of public intoxication.
“There is no doubt you could have a more effective program with primary care involvement, but the issue is the time factor. It would take years to work. The government can’t have parks filled with people with alcohol issues and related behaviour. Unfortunately, the government hasn’t got the political capital.”
Dr Parker, a psychiatrist, said the NT’s Banned Drinks register, which required people to provide ID when purchasing alcohol, had been “working very well in controlling very difficult behaviour”, but it was abolished by the Country Liberal party in 2012.
Last month, the House of Representatives Standing Committee on Indigenous Affairs tabled a report on its inquiry into the harmful use of alcohol in Aboriginal and Torres Strait Islander communities. (3)
The report said: “Although there is some evidence that mandatory treatment can help some individuals the committee is concerned about mandatory treatment when there is no community follow-up. The committee was also concerned about the recriminalisation of drunkenness. The committee believes priority should be given to voluntary rehabilitation.”
(Photo: Africa Studio / shutterstock)
It doesn’t matter whether we are talking about alcohol related issues in the NT, drug issues elsewhere or chronic disease management where neither drugs nor alcohol are an issue, the basis pronciple that “no public money should be spent on a service without evaluation of its effectiveness, or lack thereof” should be endorsed. From a medical viewpoint we need to be constructively looking for whatever gives the best healthcare gains – not just for each individual, but also for the society as a whole. Individual rights to make poor health choices (excess alcohol, smoking, obesity, poor medication adherence, lack of exercise) should not “trump” community health, nor should they drive poor value interventions. Politicians cannot and will not say these things and continue to promise “all things to all people” telling us that each side will do a better job on health without having the tough public discussions about when it is in the community interests to have either some compulsion in engaging in remedial/preventative healthcare, or an acknowledgement that certain further services may not be provided to some individuals when predictable complications/readmissions occur.
If Clinicians and the community do not have this discussion, we are destined to contiue to throw money at issues for no gain. It would be great to perhaps see some AMA/MJA leadership in this difficult area away from elected politicians whose focus is on being popualr and getting elected.