Heavy cannabis use in three remote Aboriginal communities in Arnhem Land, Northern Territory, Australia: patterns of use, natural history, depressive symptoms and the potential for community-driven interventions

For Aboriginal and Torres Strait Islander (Indigenous) Australians, tobacco, alcohol and\ud petrol misuse have received much attention. Cannabis, by contrast, has not been\ud viewed as a major problem. However, since the 1990s it has become apparent that\ud cannabis use is very common in some remote Indigenous communities in northern\ud Australia. Significant associated health and social burdens are now being recognised.\ud \ud Indigenous Australians, whether living in urban or rural settings, are more likely than\ud other Australians to report cannabis use. This appears similar to recent reports of\ud cannabis use in Indigenous populations in New Zealand, Canada and North America.\ud Limited data are available to describe patterns of use among Indigenous Australians.\ud \ud This thesis describes patterns and natural history of cannabis use in a five year followup\ud study, and their cross-sectional association with depressive symptoms, in a\ud community sample of adolescents and adults (aged 13–36 at baseline in 2001) in\ud remote Indigenous communities in Arnhem Land, Northern Territory (NT, Australia). It\ud also considers the potential of three community-driven initiatives established to address\ud cannabis and other substance use.\ud \ud Data for this thesis are drawn from two research projects. A combination of quantitative\ud and qualitative methods were adapted to suit the study setting, to meet the needs of\ud research conducted in small and highly mobile groups, and across considerable\ud language and cultural barriers.\ud \ud Primary data collection methods include a structured survey, semi-structured\ud interviews, review of data routinely collected by health and other agencies, and\ud estimations of cannabis use in the communities by local Aboriginal Health Workers and\ud key community informants (proxy respondents). Interviews were conducted wherever\ud possible using a combination of plain English and the local Indigenous language.\ud Interviews were typically conducted in a private location comfortable for participants.\ud Local Indigenous research staff assisted in interviews for the longitudinal study of\ud cannabis use.\ud \ud Persistent cannabis use and dependence symptoms were found to be commonplace in\ud this Indigenous cohort, raising concerns for the physical, social and psychiatric burden\ud on these vulnerable communities. High prevalence of cannabis use appears to have\ud persisted from baseline to five year follow-up (63%–60%; use in the previous 12\ud months). After five years, the majority reported continuing cannabis use, with\ud continuing users aged thirty years (median). Past petrol sniffing among baseline\ud cannabis users is also a key predictor of heavy cannabis use (≥ 6 cones, daily) at\ud follow-up. Regular heavy cannabis use was found in almost 90% of users, and around\ud 90% of the Indigenous users report symptoms of cannabis dependence (DSM-IVR).\ud \ud Regular and heavy patterns of cannabis use that are predominant in these study\ud communities also occur alongside poor mental health and severe disadvantage. In a\ud cross-sectional study, heavy cannabis users were found to be four times more likely\ud than the remainder of the sample to report moderate–severe depressive symptoms (on\ud a modified Patient Health Questionnaire-9) after adjusting for age, sex and other\ud substance use.\ud \ud What might be done to address the substantial health and social burdens related to\ud cannabis misuse in these remote Indigenous communities? Broad community-wide\ud preventive measures and programs that provide youth diversion from court and prison\ud offer enhanced youth resilience and connectedness in remote Aboriginal communities,\ud and alternatives to substance use.\ud \ud Treatment programs for chronic cannabis users are urgently needed, along with locally developed\ud preventive programs to raise community awareness of the harms\ud associated with cannabis and other substance use. Such programs would need to\ud incorporate local Indigenous language and cultural concepts, build capacity of local\ud Indigenous professionals, be guided by Indigenous residents, and be founded on\ud strong partnerships between a range of Indigenous and non-Indigenous stakeholders.\ud \ud A holistic approach is needed to address substance misuse instead of tackling each\ud substance separately, and to address mental illness and the social determinants of\ud poor health. Potential programs need to draw on community ideas and understanding\ud of the problems being faced. Solutions imposed without reference to local context have\ud little chance of success or longevity. The one-size-fits-all approach assumes\ud homogeneity, but what works for one community is unlikely to be suitable for mass\ud rollout. Ultimately tackling cannabis and other forms of substance misuse in remote\ud settings will depend on working with communities to create opportunities for social\ud development, and continuing education, training and employment in adolescents and\ud young adults