The Australian Family, October 1999, p. 34
Drugs And Drug Policies
It seems that every few years a Drug Summit is called to review the serious problems associated with the use / abuse of mind-altering drugs. I recall vividly the last one held in Victoria in August, 1989, under the auspices of the now defunct Drug Rehabilitation and Research Fund. I had attended a similar meeting in Canberra on another occasion. It is a very exhilarating and exhausting experience and excitement and emotions can run high. Therefore it is important to reflect on such meetings in more sober moments.
The NSW Drug Summit was held in May 1999, having been convened by the Premier, Mr. Carr, in fulfilment of a pre-election promise. It was held in Parliament House before a full complement of members of both Houses of the Parliament and ran for five days. There were plenary sessions with invited guest speakers and contributions from other invited delegates. The agenda included a statement of Purpose and Future Directions. Apart from the formal papers, there were 11 concurrent workshops which generated their own reports and sets of recommendations, which were submitted late on the final night to a general session of the parliamentarians and delegates. It can all be found on the Internet. The papers are of variable quality and reveal the tensions of opposing camps - the harm reduction school and the restrictive policy school, both claiming to act in accordance with the principles of public health. I was struck by certain interesting comments such as: many of the clinicians who are committed to this field have worked out that the health of the patients ....is far more likely to be damaged by the effects of laws designed to deter drug use (Wodak); drug addiction is a chronic relapsing disease (Currie, van Beek); evidence based policy making (Baume) and find out what the truth is (Malouf); those who fail to understand history live out the same mistakes again and again (Penington).
As both sides appealed to the principles of public health, it is important to understand what those principles are.
The first principle is to identify what is the problem that we need to address. In this instance, it is the widespread use of mind-altering chemical substances known as drugs. Mind-altering means substances that act upon the brain to alter mood and cognition. What this means is that such individuals have difficulty in paying attention, in concentrating, in focussing their minds, in retaining information in the memory centres, of processing information and linking it with other information; of making judgments and decisions, partly because the information in the brain, if it is still there, is distorted and jumbled, so that normal "cognitive capacity" is diminished. All the mind-altering drugs have this capacity in varying degrees, quite apart from the problems of dependence and physical disease. Moreover the drugs alter behaviour and skilled performance which impact on the wider community, particularly on families. This happens long before the later physical complications.
The second principle is to determine the direct and indirect causes of the problem which in the case of drug abuse is complex and multifactorial.
The third principle is the size of the problem - the numbers using or who have ever used these substances (prevalence) and the numbers who start to use them (incidence). The greater the prevalence and incidence, the greater is the problem for the society. Primary prevention aims at reducing the incidence rate and subtracting numbers from the prevalence rate so that the size of the problem is reduced to manageable proportions. Here there was a divergence of opinions between the two camps and there were many speakers who failed to observe the dictum about history, including Professor Penington. The observations about the failure of Prohibition was a classical example. So too were the allusions to Heroin Trials, with no mention made to the comments of the World Health Organization. So too were the remarks about diversionary programmes for young users of marijuana which were first proposed to the Victorian Government by the Australian Family Association in May 1996, following the release of the Penington Report which recommended legalization of the personal use of cannabis.
The fourth principle is the early detection and intervention of cases with a drug taking problem. Here there was a certain level of agreement between the opposing camps. Nobody liked the idea of imprisoning persons who were addicted to drugs nor of persons who were experimenting for the first time nor even those who were regular users but not yet addicted. But opinions diverged about the legalisation of drug use, especially of cannabis use.
A new element crept into the debate when some speakers talked about the pharmacological effects of drugs on brain function. The Drug Law Reformers avoided this aspect of the debate and focussed on the moral stigmatisation of drug users when restrictive laws were in place. This was the central focus of this group and underlines their concept of Harm Reduction. In fact, this is a fundamental mistake made by many field workers in drug addiction. They fail to understand the significance of primary prevention of drug abuse, which targets the next generation of potential drug users to discourage them from using mind-altering drugs.
The NSW Drug Summit highlighted the difference between two concepts for a national drug policy. The proponents of the Harm Reduction model claim that the greatest harm is the result of law enforcement of drug prohibition which they maintain has been an abject failure. It urges that we must focus on measures that will protect drug users from complications of drug use and that all the illicit drugs should be decriminalised.
The second group maintains that the use of mind-altering drugs is a serious health and social problem ; whilst treatment services must be provided for those already addicted to drugs, we must discourage the use of such substances by education and disincentives. Those who engage in other criminal behaviour to maintain their state of addiction or to exercise their desire to use such drugs should be subject to the legal provisions of a Restrictive Drug Law.
The Harm Reduction model was postulated by Dr. Alex Wodak who is the national president of the Australian Drug Law Reform Foundation which is linked to similar bodies overseas.This policy is supported by many of the senior advisers to governments. It is well articulated in a feature article by Ernest Drucker: Harm Reduction Theory ....(holds) that many of the most destructive consequences and refractory problems of illicit drug use are not the results of the drugs per se, but rather of drug policies, i.e. the prohibition of drug use and the criminalisation of the drug user...But because of the continued availability and use of increasingly potent drugs, the harm reduction approach addresses the drug problem by altering drug control policies, not the drugs themselves - and certainly not human nature. ..... the harm reduction approach holds that, over time, controlled use of all drugs is an achievable goal - even for those people who have become chemically dependent.
As one reads on, the harm reduction policy advocates the removal of legal restrictions on the use of mind-altering substances, education to establish practices for the safe or responsible use of such drugs, the use of drug maintenance programmes for the addicted patients ( methadone and heroin maintenance) so that they can function normally, and the free distribution of needles and syringes to contain the spread of AIDS and Hepatitis C. There are references to the success of such programmes in the USA and the UK during the 1920s and 1930s which were sabotaged by the militant temperance movement in the USA and the moral rhetoricians.
It is worth noting that the same type of language appears commonly throughout the Penington Report released in April 1996.
It is not surprising therefore that in 1998, the Australian Drug Law Reform Foundation (ADLRF) adopted the following 10 point plan which was drawn up at a weekend meeting of the ADLRF in 1998. It reads as follows:
A Restrictive Drug Policy (under the banner in Australia of Zero Tolerance) is the preferred option of the Howard (national) Government . It is the one adopted by the governments of the United States and Sweden and is the one advocated by the United Nations International Narcotics Control Board. In Australia, Harm Reduction ( or Harm Minimisation ) was approved by NCADA - National Campaign Against Drug Abuse - as the basis of the national policy in the mid 1980s. But the truth is that our national policy has been a mixture of both concepts and this has produced programmes which are self defeating, especially in the fields of prevention and treatment.
It has been complicated by overseas experiments, particularly in the Netherlands and Switzerland. The Netherlands coined the terms Normalisation and Responsible use of drugs, which have become an integral part of the Harm Minimisation policy. The United States has been severely criticised for its law enforcement policy but this is a consequence of a lax policy in the 1960s and 70s which resulted in a rapid expansion in the number of drug users and a most significant change in the population of drug users. It was this change which torpedoed the opiate maintenance programmes, not the moral rhetoricians.The same applies to Sweden which tried a relaxed policy in the mid 60s which was abandoned when the numbers got out of hand and the promised benefits did not eventuate. The same has now happened in the Netherlands as reported in a devastating critique in the Journal of Foreign Affairs, which was reproduced in a recent issue of the Financial Times in Australia.
That is not to say that the Harm Reductionists have a malicious agenda or lack true compassion or that they have no valid arguments. It is not to say that the term Harm Reduction is not a good concept. But it does mean that their approach is narrowly focussed and some of their evidence is now suspect.
The term Prohibition is used in a variety of ways. Many people refer to the period of alcohol Prohibition in the United States of America (1919-33). In 1986, a professor of criminal justice at Harvard had this to say: People who invoke the lessons of Prohibition to argue the legalisation of drugs are misreading history. What everyone (claims to know) about Prohibition is that it was a failure. (They claim) it did not eliminate drinking; it created a black market, which spawned criminal syndicates and random violence. Corruption and widespread disrespect for law were inculcated, and Prohibition was repealed only 14 years after it was enshrined in the Constitution. The lesson drawn by commentators is that it is fruitless to allow moralists to use criminal law to control intoxicating substances. Many now say that it is equally unwise to rely on the law to solve the drug problem.
But the conventional view of Prohibition is not supported by the facts. He then sets out the positive gains of prohibition in America. The elimination of the saloons, the fall in per capita consumption, the fall in the physical complications of alcohol abuse, the fall in alcohol related crime and accidents and several other parameters on which the anti-prohibitionists remain silent. That same message is repeated in a more recent article by Dr. I Tyrrell which appeared in the journal Addictions in 1997.
The term "Prohibition has failed" is also used in relation to the failure of restrictive laws to control the vast movement of illicit drugs around the world, their ready availability in Australia, the high demand for their use and the alarming level of criminal activity and corruption associated with their supply and use. But again we find the same blinkered analysis by the harm reductionists. There are many reasons why these problems have arisen and history reveals that demand is closely related to the lax laws and confused responses in the 1960s and 1970s, particularly in the United States and Sweden. It is now happening in the Netherlands and it happened in the Lenten Park experiment in Switzerland. It happened in Japan in the immediate postwar period. Japan and Sweden clawed back their situations by restrictive laws and sound treatment policies. The United States developed a high prevalence rate of drug use over the period 1960 - 1975 and has struggled to find the right mix of restrictive laws with treatment services.
Prohibition has become an emotive word but restrictive laws apply to many aspects of our daily lives. It particularly applies in the field of primary prevention.
When health education is a major component of prevention, we must realize that knowledge alone rarely alters human behaviour or a desire to act autonomously. The concept of the Common Good and the protection of the vulnerable often requires deterrent legislation such as we have with:
It is at this point that the harm reductionists have a valid argument - often the punishment does not seem to fit the crime. There is a tension between a penalty that acts as a deterrent and a punishment that seems to be disproportionate to the offence.
For years, magistrates around the country have used their discretion to handle young people who have been charged with the possession and use of cannabis. Today, in Victoria, the Police Department, with the approval of the Government, has developed diversionary programmes for such offenders and the early results are promising. In addition, drug addicts are now increasingly being referred to treatment centres rather than being convicted by the courts but the problem that we now face is that there are too few treatment centres and there are long delays in getting into treatment. This has prompted the clamour for Injection rooms for there are people dying from heroin overdoses.
But the harm reductionists now face a dilemma that they wish to camouflage. There are several important facts that need to be thrown into the debate. The first is that the Swiss heroin trials have been severely criticized by the World Health Organization and the International Narcotics Control Board as well as in an editorial in the British Medical Journal. Their trials did not prove that injectable heroin and heroin maintenance were the crucial factors in the reported results of their trials. Moreover their methodology, especially the recruitment of subjects and their reliance on self-reporting, was severely criticized. Moreover the question of injecting rooms cannot be divorced, either pragmatically or ethically, from heroin maintenance programmes which require several intravenous injections a day at a high per capita cost. At this point, three other facts need to be considered.
Nearly all the deaths put down to heroin overdose occur in multiple drug users who have other drugs in the body at the time of death–alcohol, benzodiazepines, cannabis, codeine, amphetamines. This finding has been known for over 10 years and has been a consistent observation but rarely declared publicly.This behaviour was not altered by the Swiss trials.
But even more important is what is happening in the injecting population. The needle and syringe exchange programmes were introduced to control the spread of AIDS and Hepatitis C. While it seems that AIDS has not spread, there has been a dramatic increase in the spread of Hepatitis C. There has now accumulated enough evidence to warrant a review of the needle and syringe exchange programmes in Australia as there is a prima facie case that they have become counterproductive. But such a review should be done by an independent body, independent of the establishment, as was found necessary in the Swiss trials.
The third fact is found in the proposal for the Canberra Heroin Trials. I shall say no more than to ask you to look at the budget for that trial and the cost of running a heroin maintenance operation which will expand to a degree that is unsustainable. The proposed ACT trial consists of two stages. Stage one covers 40 participants and stage 2 will have 250 subjects. Stage 1 will cost $800,000 a year and stage 2 is estimated at $1.5 million. A third stage involving three cities and 1000 subjects is not costed. In a newspaper report recently it was stated that the cost of treating one addict would be $30 a day or $11,000 a year. Nowhere in the project papers is the goal of abstinence mentioned. What is mentioned is the acceptability of this option to the addict and his/her retention in the programme. What the government wants to know is what the size of the population on this treatment will be in 3-5 years time and what proportion will become drug free?
Then there is the perennial debate about cannabis use and the evidence that has emerged about the current strength of cannabis preparations (especially in the Netherlands but in most countries) and the cognitive and behavioural effects associated with regular use. Cannabis is a mind-altering substance and may well be the trigger for psychotic disturbances. Mind-altering means substances that act upon the brain to alter mood and cognition.
In a recent outstanding monograph on cannabis, Solowij has this to say:
This supports the notion that effects related to the frequency of cannabis use are probably due to the accumulation of cannabinoids, possibly reflecting a state of chronic intoxication. When sufficient time is allowed for such accumulated cannabinoids to (be) eliminated from the body, the effects dissipate. On the other hand, the ERP results demonstrated that the primary effects on attention were associated with the duration of cannabis use and not frequency. That these effects were consistently replicated, were progressive with the number of years of cannabis use, and were still apparent, albeit to a lesser degree, in ex-cannabis users, suggests an enduring alteration of brain function that is slow to recover. It is important to recognize that frequency and duration of cannabis use may indeed have differential effects on cognitive function.
(The) findings are entirely consistent with Leavitt's conclusions that
Solowij is concerned that in long term cannabis users the cerebral dysfunction may be enduring and not simply a reflection of the time required for the total elimination of the cannabinoids. Moreover in a series of questions and answers, she gives plausible responses to possible confounding variables and concludes that the case against cannabis is very strong.
In the light of that evidence, which explains the consistent observations of parents over many years, the harm reductionists' advocacy of legalising the personal use of cannabis is to condemn succeeding generations of young people to a very bleak future in a competitive world where skills and application are in high demand.
The Harm Reduction model for a drug policy is not tenable in the light of current events and close analysis of its implications. Nor are some of its most pressing demands for injection rooms, heroin maintenance programmes and the legalisation of cannabis use. Some of its apparently successful programmes, such as needle and syringe exchange programmes and methadone maintenance services should be critically reviewed.
But there is a great need for adequate treatment services for the truly addicted, for good primary prevention programmes, for early intervention and appropriate restrictive laws with good diversionary programmes (deter and treat). Control of supply and control of demand are critically important and rescue from the drug subculture is a sine qua non of a successful intervention. As many others have pointed out, we need to address the contributing factors that create an at risk population and a population that needs to rediscover the true meaning of living in a human society.
Personally I believe that we do drug addicts a great disservice by labelling them as hard core and assigning them to programmes of long term drug addiction and regular drug taking. The drug maintenance programmes are essentially pharmacologically unsound as they continue to disrupt the cognitive functions of the brain and sustain a preoccupation with drug taking which is the cardinal feature of the addicted state. The preferred option of the drug addicts is a drug free state and a repossession of their higher mental faculties and their general sense of physical well-being.
The main argument for opiate maintenance programmes is that the hard core patients are unable to handle a target of abstinence or are prone to early and frequent relapses and are exposed to death by overdose. An opiate maintenance regime allows them to regain control of their lives, remain in contact with treatment facilities and improve physically and socially. There is evidence that the methadone maintenance programmes have had some positive results in these regards but such programmes should be reviewed and therapeutic communities should be revisited.
I believe that drug addiction is similar to that of any chronic relapsing disease and the management of such cases follows a clear cut protocol.
Such a form of management must be integrated within the total strategic plan based on the principles of public health (see above). But the basic objective must be prevention, and proper rehabilitation.