#72 HepSA Community News by Hepatitis SA

#72 â&#x20AC;¢ January 2017

Community News

Cirrhosis: What Should I Do? Hep B: News & Community Events

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Hepatitis SA provides free information and education on viral hepatitis, and support to people living with viral hepatitis.

Cover: Image glitched by James Morrison Correspondence: Please send all correspondence to The Editor at PO Box 782, Kent Town, SA 5071, or email editor@hepatitissa.asn.au. Editor: James Morrison

Street Address: 3 Hackney Road, Hackney Postal Address:

PO Box 782 Kent Town SA 5071

Phone:

Fax:

(08) 8362 8443 1800 437 222 (08) 8362 8559

1 News

Online:

www.hepsa.asn.au admin@hepatitissa.asn.au

HEPATITIS SA BOARD Chair Arieta Papadelos Vice Chair Bill Gaston Secretary Lindsay Krassnitzer Treasurer Sam Raven Ordinary Members Catherine Ferguson Ratan Gazmere Kirsten Hicks Nicci Parkin Kerry Paterson (EO) Sharon Jennings Jeff Stewart

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Contents

‘Silent Disease’: The Government Responds

Hep B Community Education

Big Issue Celebration

Hep B in SA

Living with Cirrhosis

11 NSPs in Prisons 12 LiveRLife 14 In Our Library 16 What’s On

Disclaimer: Views expressed in this newsletter are not necessarily those of Hepatitis SA. Information contained in this newsletter is not intended to take the place of medical advice given by your doctor or specialist. We welcome contributions from Hepatitis SA members and the general public. SA Health has contributed funds towards this program.

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News

DAAs may reactivate hep B Research indicates there may be serious risks for some people who are co-infected with both hepatitis C and B, and who are being treated with certain direct-acting antiviral (DAA) medicines for their hepatitis C. Consumers and healthcare professionals are advised that these DAAs have been associated with the reactivation of the hepatitis B virus in patients with a current or previous HBV infection. A recent Therapeutic Goods Administration review of the available data, including data from international regulators and medical literature, found evidence of this association. Reactivation of HBV can cause serious liver problems, including hepatitis, liver failure and in rare cases death. The TGA is working with the manufacturers of DAA medicines to update their product information to contain warnings about HBV reactivation, including the need for HBV screening prior to DAA therapy, the monitoring of patients with positive HBV serology, and HBV treatment according to clinical guidelines. The DAA medicines available in Australia include Daklinza,

New HCV treatment

Sunvepra, Viekira Pak, Viekira Pak-RBV, Zepatier, Harvoni, Sovaldi, and Simeprevir (which has been discontinued, but will be available until February this year). If you or someone you provide care for has a history of HBV infection and is taking a DAA medicine for the treatment of chronic HCV infection then please contact your doctor. Your doctor may order a blood test to check whether you have ever had a HBV infection. If you are currently receiving treatment for HCV infection with a DAA medicine and you notice any new symptoms of liver disease (such as loss of appetite, tiredness, nausea, vomiting, stomach pain, yellowing of the skin or eyes or confusion), seek urgent medical advice. If you have any questions or concerns about this issue, talk to your doctor.

Liver cells under attack from HBV

2017 begins promisingly with news that more new medicines for hepatitis C will continue to become available in Australia, and they will be more effective across a range of hepatitis C genotypes. From 1 January a new medicine, Zepatier (grazoprevir + elbasvir, given as a once-daily tablet), became available on the Pharmaceutical Benefits Scheme (PBS). This extends treatment options for all people with genotype 1 and 4 infection, including those taking opioid substitution therapy and those with chronic kidney disease. Hepatitis C treatments are continuing to evolve and improve and it is anticipated that more new hepatitis C treatments will be made available on the PBS during 2017, assisting Australiaâ&#x20AC;&#x2122;s progress towards the elimination of hepatitis C as a public health concern.

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Quite Little, Very Late

he Federal Government’s response to the ‘Silent Disease’ inquiry into hepatitis C in Australia falls well short of what anyone living with hepatitis C could have hoped. Coming nearly 18 months after the report was submitted, the response fully accepted only three out of ten of the recommendations. The Silent Disease Report was a comprehensive study from the House of Representatives Standing Committee on Health, and can be read online at bit. ly/2jxOABX. It made 10 main recommendations about the way the Australian Government should respond to the ongoing epidemic. 1. The Department of Health should enhance reporting on the National Hepatitis C Strategy. 2. The Australian Government, in collaboration with the states and territories, should work to develop well-informed hepatitis C awareness campaigns targeted at the general community, populations at high-risk of hepatitis C infection, people living with hepatitis C who have not sought advice about treatment options since their initial diagnosis, and the wider community (to highlight the impact of stigma on the social and emotional wellbeing of people living with hepatitis C and their families).

3. The Department of Health, in consultation with relevant stakeholders, must devise a specific target or targets for hepatitis C testing and report on progress towards reaching the target or targets annually. 4. The Department of Health should consider the ways in which rapid point of care testing (RPOCT) can assist in implementing the goals of the Fourth National Hepatitis C Strategy and the National Hepatitis C Testing Policy. 5. The Department of Health should work with the Royal Australian College of General Practitioners and liver clinics to examine appropriate information provision, treatment processes, and patient counselling for people diagnosed with hepatitis C. 6. The Department of Health must work with States and Territories to produce culturally and linguistically specific information for migrant groups with higher rates of hepatitis C infection to inform them about hepatitis C including: transmission methods, testing and treatment options. 7. The Department of Health should work with States and Territories to develop strategies to address the high prevalence rates of hepatitis C in the

Aboriginal and Torres Strait Islander population. 8. The Department of Health must work with State and Territory health and corrections agencies to develop a standard approach to data collection and reporting of prisoner health in custodial settings, and give consideration to the provision of support for safe tattooing, barbering and any other legal practices which may present a risk of hepatitis C transmission in custodial settings. 9. A national strategy for blood-borne viruses and sexually transmissible infections in prisons must be developed. 10. The Australian Government should raise the issue of hepatitis C in prisons, and the establishment of national standards in prison health delivery as part of the Council of Australian Governments (COAG) Health Council process. (Interestingly, the main way in which the Silent Disease report itself fell short, in failing to recommend easy access to new direct-acting antiviral (DAA) medication for hepatitis C, has been overtaken by events. In 2016 a number of DAAs were made available on the PBS, and are performing extremely well: more than 90% of people who complete treatment are now free of their hepatitis C.)

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Three out of Ten

In its long-awaited response, the Federal Government has fully agreed with only three of these ten recommendations (numbers 1, 6 and 7), though it claims that funding has been provided to support several more. Several recommendations are merely ‘noted’ in the governmental response.

government to take the lead on an important issue means that all state hepatitis organisations, like Hepatitis SA, must keep up the pressure on their State governments to bring the matter up for discussion.

The Australian Government’s statement is that “[We are] willing to work with states and territories on [hepatitis C in prisons] if they wish to raise it as part of the COAG Health Council process.” This characteristic unwillingness on the part of the Federal

You can read the Australian Government’s responses to the report at bit.ly/2j9TSqw. The views expressed in this article do not necessarily represent those of SA Health.

Image adapted from a photo CC by Laura La2008 [flickr.com/people/laurala2008]

Disappointingly, The Government has ruled out a national hepatitis C awareness campaign, saying “To change the wider community’s beliefs and attitudes around hepatitis C will only result from a longterm ongoing discussion within the community as a whole. Community leaders (including political and cultural leaders) will be pivotal in engaging with the wider community on these issues.” This may be true, but the Australian community has a vast number of issues to consider at any one time. Without an awareness campaign to provide information and prompt reflection, it is likely that serious discussion of hepatitis C will not be heard above the noise.

to recommendations for a National Strategy for bloodborne viruses in Australian prisons. They have instead stated that any action on hepatitis C in prisons is the responsibility of the various State Governments.

The Government has agreed, in principle, that standardised data collection in prisons is valuable, and it will engage with the Australian Institute of Health and Welfare for future versions of the ‘Health of Australia’s Prisoners’ report. However, the Government has not agreed

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Hep B Community Education

Working with community groups around SA

epatitis B community education projects are popping up around Adelaide. First off the rank is a project with the Filipino community which Hepatitis SA is running in partnership with the Filipino Settlement Coordinating Council of South Australia.

The project had a flying start with fun and games at the Filipino Fiesta in October, followed by an information and education session with the Filipino Aged Care group in December.

The Vietnamese community education project is supported by Hepatitis SAâ&#x20AC;&#x2122;s old friend and partner from the Vietnamese community: Community Access and Services SA.

There are also plans to run information sessions in rural centres.

For more information about the hepatitis B community education projects, visit bit.ly/2jcZ7BX.

Work with the Chinese and Vietnamese communities are not far behind with project officers appointed from the respective communities. With the support of liver nurses from the Queen Elizabeth Hospital, there have been two very successful fibroscan days for members of two Chinese associations. More are being planned. The Chinese community education project partners include the Chinese Association of South Australia, the Overseas Chinese Association of SA, the Chinese Welfare Services of SA and the CASA Chinese Ethnic School. TOP LEFT: Celebrating at the Filipino Fiesta BOTTOM LEFT: Cynthia Caird (at left), chair of FSCCSA, and Leticia De La Cerne TOP RIGHT: Hepatitis SA worker Bin explains hep B BOTTOM RIGHT: Our cutest visitor on fibrosan day

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PBS to cover prisoners’ hepatitis C treatments

Hepatitis B and Mothers-to-be There are limited information resources and support for those who are new to English, and even with interpreters, it is questionable how much information they can absorb there and then at the time of diagnosis. There is concern that women may be going home with insufficient understanding of what they need to do to protect their babies and household members. With the support of staff from the WCH’s Microbiology and Infectious Diseases team, Hepatitis SA is working in partnership with the Chinese Welfare Services to explore possible ways to meet the needs of these women.

majority of the pregnant women who present with hepatitis B diagnoses at the Women’s and Children’s Hospital (WCH) are from nonEnglish speaking cultural backgrounds. According to doctors at the hospital, some of these women are already aware of their hepatitis B but for others, the diagnosis is new and raises many questions and worries.

To date, a pamphlet providing information on pregnancy and hepatitis B has been produced in English, Chinese and Vietnamese. Work is also underway to make an audio version which the women can access at home in their own time and perhaps share with their partners. This project is one of five hepatitis B community education projects being rolled out in South Australia. In Australia, and worldwide, most people living with chronic hepatitis B got it from their mothers during birth.

Unlike people who contract the virus in adulthood, nine out of ten newborns who get hepatitis B at birth or as infants will go on to develop chronic hepatitis B. Because hepatitis B will often have no symptoms until decades after initial infection, about half of those who have it don’t know it. Left unmanaged, hepatitis B can lead to liver failure or liver cancer. Fortunately, there are effective ways to prevent infants from becoming infected. To ensure that babies are protected, all mothers-to-be in Australia are tested to see if they have chronic hepatitis B so that appropriate steps can be taken to protect their baby should the need arise. Babies born to mothers with hepatitis B are given a Hepatitis B Immunoglobulin (HBIG) injection and a dose of hepatitis B vaccine in the first 12 hours after birth. This should be followed by three more doses at two, four and 6 months respectively. For copies of the pamphlet Hepatitis B and Mothers-tobe, contact Cecilia@hepsa. asn.au or read it online at issuu.com/hepccsa/docs/ momsandhbv_eng_stanford (also available in Chinese and Vietnamese).

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Celebrating with Big Issue

taff from Hepatitis SA were delighted to celebrate alongside Big Issue vendors, Street Soccer players, as well as staff and volunteers from various organisations at the Big Issue end-of-year party in mid-December. The Community Street Soccer Program is an initiative of The Big Issue, which changes the lives of many marginalised people, supporting and empowering them to make positive changes in their lives through sport and social inclusion. (See the article in our last issue for more.) There were almost 100 people who joined together on what was a warm sunny day in the South Parklands, at the Adelaide City Juniors

Football Club. This is where the Big Issue Street Soccer players meet each week throughout the year to take on other teams. The occasion was made even more joyous with entertainment from the Hutt St Band, who played a number of popular tunes with passion and tenacity. Their performance was enjoyed by all. After a tremendous barbeque feast of delicious vegetables, with something to suit everybody (all generously donated) including wonderful desserts, soccer matches were played in a giant inflatable soccer pitch and fun was had by all. A huge thank-you to The Big Issue for inviting us along.

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Hep B in SA

Improving treatment uptake will save lives and money

he uptake of hepatitis B treatment in South Australia is low, and the cost-effectiveness of increasing treatment rates has not been assessed, a new study has found. Infection with hepatitis B or C is the most significant risk factor for hepatocellular carcinoma (HCC), the most common form of liver cancer. Despite increasing rates of vaccination for hepatitis B in Australia, it’s estimated that more than 1% of the population is living with chronic HBV, with almost half of these cases undiagnosed. The annual costs for managing and treating HBV infection in Australia are likely to be more than $300 million this year.

Dr Mohamed Asif Chinnaratha

The state of HBV treatment is especially important in SA, because only 2.9% of HBV patients receive treatment here, compared to the national rate of 5.3%. The SA Hepatitis B action plan aims to increase this treatment uptake rate to 10%, while the national treatment uptake target is 15%. But which of these targets will provide the best cost-effective outcomes? To answer this a study was conducted by Mohamed Asif Chinnaratha and a team of researchers at Flinders Medical Centre and Flinders University. The study, to be published in the Journal of Gastroenterology and Hepatology, models the projected outcomes over a 10year period for the following three scenarios in SA.

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Scenario 1: The current treatment uptake level of 2.9%

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Scenario 2: The SA state target of 10%

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Scenario 3: The Australian national target of 15%

The third scenario, with the highest target, was the obvious winner in the study. It led to the lowest average costs per patient, and the biggest overall quality of life gains (which includes lower HCC, liver transplant and mortality rates). Indeed, the model predicts that the 15% treatment uptake rate would result in a 50% reduction in HBV-related HCC and a 30% reduction in HBV-related deaths compared to the current scenario of 2.9% treatment uptake over a 10-year period. This research underlines the need for higher treatment uptake for people living with hepatitis B. Though new treatments for hepatitis C over the last year have dominated the news in relation to hepatitis, there must be an equal emphasis on making use of new and effective hepatitis B treatments. Read about new hepatitis B treatment being considered for the PBS: bit.ly/vemlidy.

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Living with Cirrhosis What can I do about liver cancer?

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CHECKING FOR LIVER CANCER: There are no symptoms in early liver cancer. It can only be detected with a liver ultrasound. If you have cirrhosis, make sure you have a liver ultrasound every 6 months. It may save your life. APPOINTMENTS: Don’t rely on reminders from your doctor or the hospital—they might not get to you for many reasons. Top tip: make sure your GP has your current address and phone number. TIME FLIES!: Make a note of when your ultrasound is due. See your GP for a request form and book your appointment at your nearest or usual medical imaging centre. Top tip: Put an alert on your phone and set it to recur every 6 months. RESULTS: See your doctor to discuss your results soon after your ultrasound. That way you can be sure that your results have been checked and you’ll also know if anything further is needed.

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You’ve just found out you have cirrhosis: what should you do next? The best thing you can do once you have been diagnosed with cirrhosis is to get some information as to what this means and what you need to do to monitor your condition and stay well. Make an appointment to spend some time with a healthcare professional who can answer your questions and help explain your diagnosis, lifestyle changes you may need to make, monitoring, and so on. This is an ongoing process. Understanding your condition is the first step in looking after yourself. Joanne Morgan Clinical Practice Consultant Clinical Research Coordinator Hepatology Royal Adelaide Hospital

All

Cirrhosis is a chronic disease and needs to be managed life-long. Defining what the cause of the cirrhosis is and addressing this is very important so that you can try to stop the progression of the disease. A referral to a hepatologist (liver specialist) is recommended, and this can be done by your GP. The hepatologist will monitor your cirrhosis and ask you to do the following: • Have 6-monthly ultrasounds and blood tests to screen for liver cancer. Anyone with cirrhosis is at a slightly higher risk than the general population to develop a liver cancer—regular screening is essential! • Have a screening endoscopy (depending on the severity of your liver disease) and any follow-up ‘scopes depending on the results. • Have a bone density scan to check the condition of your bones. It’s recommended to do this every 2 years. Your hepatologist and GP will work together to maximise your liver health. Rosemary McCormick Clinical Practice Consultant Chronic Liver Disease & HCC Nurse Coordinator Flinders Medical Centre

Visit issuu.com/hepccsa/docs/cirrhosis_-_hepsa to read Hepatitis SA’s Cirrhosis booklet, or contact us on 1800 437 222 to have a copy sent to you. January 2017 • HEPATITIS SA COMMUNITY NEWS 72

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HEP C & HEP B WORKFORCE TRAINING! Do you know where to refer clients living with viral hepatitis? Do you know if there is a cure? Do you worry about blood exposure and needle-stick injury? Sessions cover a range of topics, including: • Basics about hepatitis A, B and C • Transmission risks/myths • Best practice around blood and blood exposure • Discrimination • Lived experience from the perspective of a Positive Speaker • Any other topics relevant to your workplace! Cost: Free Time:

1-2 hours

Where: In-service: we will come to you! Contact the Education Team on 8362 8443 or email education@hepsa.asn.au

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AMA: NSPs vs BBVs

NSPs needed in prisons to prevent spread of HBV and HCV

he Australian Medical Association (AMA) has called for needle and syringe programs (NSPs) to be introduced in prisons and other custodial settings, to reduce the spread of blood-borne viruses (BBVs), including hepatitis B and C, as well as HIV. AMA President Dr Michael Gannon said that the prevalence of BBVs is significantly higher in prisons than in the general community, and yet custodial facilities also provide a unique opportunity to protect the health of inmates. Launching the AMA Position Statement on Blood Borne Viruses 2017, Dr Gannon said that with new BBV treatments, including the hepatitis C direct-acting antivirals that became available on the subsidised Pharmaceutical Benefits Scheme in 2016, now is the time to identify people with undiagnosed BBVs. “BBVs are a major health problem in our prisons, which is no surprise given that many people are in custody for drug-related offences in the first place,” Dr Gannon said. “BBVs may be transmitted through infected blood, exposure to contaminated drug products, unsterile injecting practices, sexual

contact, failures in infection control in health care, mother to child transmission, and unsterile tattooing or body piercing practices. “All the evidence shows that harm minimisation measures, such as access to condoms and lubricant, regulated needle and syringe programs, and access to disinfectants such as bleach, protects not just those in custody, but prison staff too. “It also reduces the likelihood of someone being discharged from prison with an untreated BBV, and it spreading in the outside community. “The AMA supports NSPs as a frontline approach to preventing BBVs. Prison-based NSP trials have been shown to reduce the risk of needle-stick injuries to staff, and increase the number of detainees accessing drug treatment, while showing no adverse effect on illicit drug use or overall prison security.” The AMA Position Statement also calls for greater emphasis on prevention, reliable and affordable screening, immunisation, and treatment, with stronger referral pathways, and greater investment in specialist services. It also warns against making transmission of a BBV a

crime, arguing that BBVs are first and foremost a health issue, not a legal one. “Criminal sanctions should be used only as a last resort for people who intentionally put others at risk of BBV infection,” Dr Gannon said. “There is no evidence that laws that criminalise BBV transmission would either prevent or deter transmission. “Indeed, such laws can be a barrier to the prevention and management of BBVs by discouraging sex workers and injecting drug users from being tested and treated, or from disclosing their diagnosis. “Doctors are at the front line of BBV diagnosis and treatment, and should therefore be well informed about legal issues, particularly their own legal obligations, to provide the best advice and support to individual patients.” The AMA Position Statement also calls for specific resourcing and management of HLTV-1, a relatively unknown BBV that affects Aboriginal people in central Australia. You can read the full AMA Position Statement on Blood Borne Viruses 2017 at bit.ly/2ie90Pc.

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n early December 2016 the Outreach Hepatitis C Peer Education & Support Project and Clean Needle Program Peer Educators from Hepatitis SA assisted researchers from The Kirby Institute, University of NSW, with their LiveRLife Project. LiveRLife is a Viral Hepatitis Clinical Research Program, supported by Merck Sharpe & Dohme, Australia. The project, which commenced in 2012, is designed for drug and alcohol settings for people with a history of injecting drug use, and aims to assess subjectsâ&#x20AC;&#x2122; knowledge of liver disease, their willingness to receive assessment

for liver disease, as well as any barriers to receiving it. The project then aims to evaluate the impact of the LiverLife Campaign on liver disease knowledge, liver disease assessment, and uptake of interventions. From this they will develop guidelines for liver disease and FibroScan assessment in drug and alcohol settings. To date, the project has been rolled out across seven sites in NSW, two sites in Cairns and three sites in Brisbane. The project is ongoing, with plans for Orange, NSW and then possibly Thailand. The Kirby Institute collaborated with Drug and Alcohol Services South Australia (DASSA) who hosted the LiveRLife Liver Health Campaign here in SA and provided the clinical nurse assessments for liver disease screening of participants, as well as assessments of liver fibrosis by FibroScan. If required, referrals for hepatitis C treatment were then made. To assist this phase of the project in SA, our peer educators attended DASSA Central Services over a 4-day period to provide peersupport-based discussions to promote the project and enrol willing participants. The peer educators supported the participants to complete a self-administered survey on a tablet device to collect deidentified demographic information, injecting history, liver disease and HCV history, and knowledge of liver disease, HCV and treatment.

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Following completion of the survey, a non-invasive liver scan (FibroScan) was performed and the clinic nurse assessed the participant’s medical history and known or likely liver disease related conditions. A dried blood spot sample was then collected for future hepatitis research analysis and the participant was then assisted to completed a post-FibroScan and resource evaluation survey. Participants received a $20 gift voucher for their time that day, and another upon returning to complete a brief final survey and follow-up appointment. Over the four days our Peer Educators enrolled 33 participants into the project, and 20 of these people have been initiated onto treatment at DASSA as a result. This well and truly achieves the ultimate objective of this project—to demonstrate how targeted education and liver disease screening can increase the uptake of effective interventions for the prevention of liver disease.

More project information is available at kirby. unsw.edu.au/projects/liverlife-liver-healthcampaign. DASSA Central Services is located at 91 Magill Road, Stepney. If alcohol or other drug information or support is required, call ADIS on 1300 131 340 from 08:30am–10pm any day.

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Emotional wellbeing and its importance in maintaining physical health

It’s well known that poor mental health can have a negative impact on physical health and chronic health issues….and vice-versa. “Research shows that more than 40% of Australians living with mental health issues also have a chronic physical illness. Also people who are living with a chronic physical illness are more likely to develop depression than physically healthy people.” — MindHealthConnect, HealthDirect Australia. Here are some resources that provide the evidence base and the practicalities of maintaining good emotional well-being. Beyond the fragments: preventing the costs and consequences of chronic physical and mental diseases Maria Duggan, Australian Health Policy Collaboration, Melbourne, 2015. bit.ly/beyondthefragments “This paper has a specific focus on the needs of people with chronic and complex conditions which often involve concurrent

physical and mental health problems. Evidence tells us that integrated responses to complex interactions produce better outcomes; achieving this will mean moving beyond the fragmentation that characterises our current approach. This paper suggests that we need to start thinking about integrated care as a broader shift away from fragmentation and towards improved population health.” The four keys to well-being Richard Davidson, Greater Good Science Centre, University of Berkeley, 2016 bit.ly/fourkeys_wellbeing This article is adapted from a talk by Richard Davidson (neuroscientist and founder of the Center for Healthy Minds at the University of Wisconsin). Research has found that “well-being has four constituents that have each received serious scientific attention. Each of these four is rooted in neural circuits and each of these neural circuits exhibits plasticity—so we know that if we exercise these circuits, they will strengthen. Practicing these four skills can provide the substrate for enduring change, which can help to promote higher levels of well-being in our lives”. This article contains links to further research and information.

Health Check: seven nutrients important for mental health – and where to find them Jerome Sarris, Melbourne, 2015 bit.ly/nutrients_mentalhealth “An increasingly robust body of research points to the detrimental effect of unhealthy diets and nutrient deficiencies, and to the protective value of healthy diets – along with select nutritional supplements as required – for maintaining and promoting mental health.” This article, by a senior research fellow from the University of Melbourne, outlines the “seven key nutrients that may positively influence brain health, and the foods they appear in” along with links to supporting research. The Happiness Trap (free resources) Russ Harris, Melbourne. thehappinesstrap.com/ free_resources A former GP, Russ Harris’s interest in the psychological aspects of health led to a focus on human psychology. His work is now based on ACT (Acceptance and Commitment Therapy) which “gets its name from one of its core messages: to accept what is out of your personal control, while committing to action that will improve

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your quality of life. The aim of ACT is to help people create a rich full and meaningful life, while effectively handling the pain and stress that life inevitably brings.” This website provides access to YouTube videos, podcasts, worksheets, guides, mindfulness recordings and free chapters from some of Harris’s books. Clearing the Cloud National Drug and Alcohol Research Centre, Sydney. clearingthecloud.org.au Clearing the Cloud contains the following online programs and information: Prevention Programs Climate Schools: provides education courses which aim to empower students (aged 13-16) to gain knowledge about their health and wellbeing along with novel and effective ways of preventing substance use and related harms. Treatment Programs The DEAL Project is a 4-week psychological treatment delivered via the internet. The DEAL Project provides effective treatments for substance use and mental

health via Cognitive Behavioural Therapy and motivational strategies. Information Comorbidity Booklets: written for people who use alcohol, tobacco or other drugs and who have experienced depression, anxiety, psychosis or trauma. Our Healing Ways Manual: Putting Wisdom into Practice Victorian Dual Diagnosis Initiative. Melbourne. 2012 bit.ly/healingways “A manual of practice wisdom shared by skilled and experienced Aboriginal workers in Victoria. The manual is a guide for working with people with mental health and drug and alcohol issues which are often interrelated with other health, social and spiritual wellbeing issues. These issues if not looked after early on, can become severe, long lasting and complex issues. The manual is not intended to tell people what to do rather to guide people’s practice and support good decisionmaking processes.”