The Australian Family, September 1999, p. 17
Drug Treatment -The Way Forward
22 June 1999
It seems to me that there is a fundamental issue of difference as to the best way forward on the drug issue. On the one hand, there are those who believe in treatment leading to a drug-free status and, on the other hand, those who call for drug law reform and acceptance of the inevitability or even the normality of illicit drug use.
What exactly are we seeking to treat and what are the dimensions of the problem? Obviously a prime goal of the drug policy and treatment should be to reduce drug related deaths. It is important to remember that the big killers are tobacco and alcohol. I am sure I speak for the treatment community when I say that we are frustrated that we are least successful in the treatment of the biggest killer. Too often I have seen people overcome addiction to alcohol and other drugs but then die of smoking-related causes. For that reason alone - and there are many others - we should resist the pressure to decriminalise marijuana. Professor Wayne Hall and others have reminded us of the potential respiratory and carcinogenic consequences of widespread and heavy pot smoking.
There has been a dramatic change in admissions to treatment services from the middle aged alcoholic to the younger poly drug user. Heroin is but one of the drugs identified by the clients as their choice. Whilst heroin has gained a high and somewhat sensationalist profile and is undoubtedly a serious and increasing problem, let us be careful of the "doom and gloom, everything has failed" picture that is too easily and too often presented by the media. The slide shows the lifetime prevalence of heroin use in the last 12 months. It shows lifetime prevalence in 14 to 29-year-olds as the red line, lifetime prevalence for the general population as the yellow line, and "used in the last year" as the green line at the bottom.
Whilst there has undoubtedly been some increase in the last three years - the last figure here is 1995 - it is not likely that it has been more than 0.2 per cent in the " used in the last year" group. What it is telling us is that 98 per cent of the population is not using heroin. That is not exactly a failure of existing strategies.
I am sorry this is not in graphic form, but this list of figures points out that opioid-related deaths over 10 years in New South Wales have risen by 45 per cent and Australia wide by 72 per cent. That is a reason for great concern. Each death is a tragedy and represents a sad marker of pain, grief and unrealised hopes. But the Coroner's report in New South Wales shows that three-quarters - 76 per cent in fact - of those deaths were the result of a fatal cocktail of drugs, especially central nervous system depressants such as alcohol, benzodiazepams, codeine, et cetera used in conjunction with an opiate. The fatalities were predominantly amongst long-term users, the average age being 36.1 years. There were actually 19 deaths in the under-20-years category.
The challenge, therefore, is for treatment to not simply deal with any particular substance, but with addiction per se. It is worth remembering that the Titanic was not sunk by the part of the iceberg that could be seen but by the larger and dangerous dimensions of what lay beneath the surface. So it is with addictions. The actual substance abuse is largely symptomatic of what lies beneath. Focusing on a particular substance, providing it or the means to use it, substituting one substance for another, will not bring healing and wholeness or the quality of life that we saw demonstrated to us yesterday by those two very inspiring speakers who are in recovery. Whilst I recognise the legitimate and necessary place of methadone and other pharmacotherapies, because if they are accompanied by appropriate counselling and support services they remain as valuable harm reduction strategies, I do not see them as treatment.
The grand illusion of the alcoholic has always been, "I might some day drink socially as normal people do." Five million Alcoholics Anonymous [AAZ members around the world can attest to the unattainability of that dream; similarly, close to one million Narcotics Anonymous [NA] members understand the cliche that one is too many and a thousand is not enough. The Salvation Army's abstinence-based treatment services do not promote abstinence for purely moral reasons. We do in fact provide outpatient services, treatment programs and counselling that recognise some people are simply abusing alcohol rather than being alcoholic. But the truly addicted person cannot safely use the substance of his or her addiction in a controlled way.
The treatment of addictions should not be limited to a biomedical model. It is not only a medical problem; it is a health problem, in the holistic sense. Of course, there are certainly medical elements to the condition and required in the treatment, but the paradigm of treatment must be broad enough to recognise and encompass the gamut of factors involved: psychosocial, legal, economic and societal. Also, as you might expect from a Christian minister, I believe there is a significant spiritual dimension to addiction. Many treatment services, religious or not, recognise the search for meaning and purpose - what I call the God emptiness - in our clients. Perhaps this is a reflection of the same malaise afflicting our society. "God as I understand Him" is an important discovery and element in the recovery of millions of people worldwide.
The good news is that treatment works. It is both effective and cost-effective. As we heard this morning, and as the Rand Corporation research shows, $1 spent on treatment returns $7 to the community. These figures from the United States of America refer to the effectiveness of treatment one year after use. I will not read out the figures, but they can be quite dramatic. These are drug abuse treatment outcomes from the national treatment improvement evaluation study in the United States of America. They show that after five years the number of users of illicit drugs was reduced by 21 per cent, cocaine by 45 per cent, marijuana by 28 per cent, crack by 17 per cent, and heroin by 14 per cent. The graph shows also the numbers engaging in illegal activity. The sorts of factors and societal improvements that we are looking for are being achieved in well constructed and presented treatment services.
We do not have to cross the Pacific to demonstrate the effectiveness of comprehensive treatment. The Network of Alcohol and Drug Agencies [NADA] in New South Wales recently completed a two-year study across 10 agencies looking at outcomes 12 to 18 months after leaving treatment. These are the results. The graph shows many figures, which you can read at your leisure in the paper that has been made available. I point out that relating to opiates, 45.81 per cent of those presenting for pretreatment were having trouble with opiate addiction. Post-treatment the figure had reduced to under 20 per cent. On my calculations that is a 60 per cent improvement.
Recently Mr Keith Halliwell, the United Kingdom's drug policy co-ordinator, visited Australia. He remarked on the current debates in Australia, especially those about heroin trials and safe injecting rooms, neither of which are available in the United Kingdom. The United Kingdom, with a population of more than 50 million, has approximately half the number of overdose deaths that Australia has. He attributes this to the United Kingdom's comprehensive policy of preventive education, for both school and the community; community policing and diversionary policies; treatment services in prisons; and increased resourcing of treatment facilities in the community. The goals are directed towards a drug-free outcome for the people who come to notice. He remarked that the United Kingdom policy is similar to the Commonwealth national illicit drug strategy and to Premier Carr's seven-point plan presented at the Council of Australian Governments conference.
In Sweden the lifetime prevalence of 16- to 29-year-olds using illicit drugs is 9 per cent, in Australia it is 52 per cent; estimated dependent users per million of population; the yellow slice of the pie chart for Sweden is 500, and for Australia between 5000 and 16,000. If we are to apply models from overseas, let us look at those that have demonstrated effectiveness. I believe that we can and must do better.
Above all, it is my hope that we will not be distracted by populist and simplistic solutions or be diverted from the strategic policies that can bring positive and long-term outcomes. I believe that treatment works, if we are prepared to work the treatment.