A Drug Strategy

The Australian Family, March 2001, p. 12

A Drug Strategy

Joe Santamaria is Research Officer for the Drug Advisory Council of Australia.

Before we respond to the present situation, we need to be aware of certain facts. The first is that the drug problem is not simply about heroin deaths or intravenous drug use. It is about the widespread use of mind-altering chemical substances. The drugs used are many and they are roughly categorized into several groups, depending on whether they depress or excite the mind or distort its normal processes.

The second fact is that these drugs are dangerous to use for non-therapeutic purposes. First and foremost, they are dangerous because of their chemical actions, especially on the higher functions of the brain which affect the ability to learn and to understand. These functions come under the general heading of cognition. This then affects behaviour, performance and social relationships. Related to these harms is the phenomenon of the addictive state, a compulsion to use the drugs repetitively and in high doses.

The third fact is that nations become concerned about the use of these substances when they are used widely in the community. We are familiar with the use of opium in China and cannabis in the Middle East but there have been epidemics of amphetamine use in Japan after World War 2 and in Sweden in the 1960s. Cannabis (or marijuana) use spread rapidly in the United States in the 1960s and 70s. Recently in Australia we have developed a major problem with heroin and cannabis use. Previously there had been a drug abuse epidemic in the United States of America at the turn of the twentieth century.

The International Conventions arose because many nations became concerned about widespread use of these drugs within their own borders and fear of spread from adjacent nations. To control the movement or availability of such drugs required co-operation between nations and the conventions were drawn up under the auspices of the United Nations. The Conventions, once ratified by a nation, entail certain obligations to conform to its provisions. In Australia, that responsibility resides with the Federal Government.

The terms drug abuse or drug misuse are used interchangeably in the literature. Drug abuse is recognized as a serious social and personal problem in modern Western society.

People often do not know what harm results from the regular use of the mind-altering drugs. It is stated that heroin has no major toxic effects as are seen with alcohol and tobacco. It is claimed that marijuana is less dangerous than alcohol. We are informed that the health costs associated with the use of alcohol and tobacco are astronomical compared to the health costs of the use of marijuana. We are led to believe that there is nothing wrong with using the illicit drugs, provided that we do so responsibly, in accordance with safe guidelines which however are poorly enunciated.

What our drug educators fail to describe are the early manifestations of harm. The early manifestations are not due to physical disease which is a late manifestation, whether it be due to alcohol, tobacco, cannabis, heroin, cocaine or the designer drugs. What occurs early are the distortion of the normal processes of the brain, the effects on cognitive function. It is described as cognitive dysfunction.

The drink-driving laws in Australia are based on blood alcohol levels. Our level is set at .05 grams per 100 mils of blood. Very few people show features of intoxication at that level. Most would pass the old clinical tests for intoxication. But it has been shown that, at that level, most people show evidence of cognitive impairment, to a degree that interferes with their ability to handle a motor vehicle safely. This impairment of cognitive functions is usually manifested when skilled performance is required or by a change in behaviour.

The state of cognitive dysfunction must also take into account the syndrome of dependence. We do not know the mechanism of the dependent syndrome but we know that it has certain features - a tolerance for the drug used so that high doses of the substance are craved. There is a narrowing of focus or drive so that the person becomes preoccupied with the use of the drug to which he/she is addicted. This further distorts and constricts the capacity of the brain to cope with the exigencies of daily life. These effects are seen in the outcomes of chronic use of such substances, a phenomenon that we have long recognized in chronic alcoholics, long before they develop serious physical disease.

What we learnt with chronic alcoholics was that their dependent state, their dysfunctional brain processes, could be reversed by abstinence from alcohol, an observation clearly understood in the twelve steps of Alcoholics Anonymous. What scientific studies discovered was that the brain unscrambles itself only over a period of time - often over months - and that a person needs to restructure his life and correct painful habits, whilst severing himself from destructive associations that help to perpetuate heavy drinking. This often takes months and needs dedicated help and patient care. We also learnt that the dependent state can be re-established quite quickly, if drinking is resumed, so that continued abstinence from the drug is necessary if one wishes to reclaim one's life.

From a public health point of view, there is another aspect of harm, which is not acknowledged by the harm minimisation philosophy. In fact it is deliberately avoided by the proponents of that policy, under the umbrella of use tolerance. That issue is the dimension of drug use. The current drug establishment claims that the demand for the mind-altering drugs is universal across cultures and down through history and we cannot eliminate that demand by criminalising drug use, without inflicting harm on the person who wishes to use such substances. This claim is a distortion of the historical facts.¹. As our knowledge about these drugs has developed, nations have become deeply concerned about the impoverishment of their societies and the economic costs of treating casualties, when such drugs are used widely. Consequently, the incidence and prevalence of such drug use becomes a major social harm. Experience has shown that a liberalised policy, such as prevails in the Netherlands, as it prevailed in Sweden and the United States in the 60s and 70s, always results in a blow out of the drug using population.

The first principle of public health is that widespread drug use should be discouraged. The national policy should be based on Demand Reduction and Harm Prevention.

We should abandon the present policy of Harm Minimisation for it is based on the false and dangerous proposition that we should tolerate drug use and concentrate on measures to "minimise" the dangers of drug use. Demand reduction is based on sound drug education and the retention of sanctions on the use of the mind-altering drugs. Sound drug education should eschew the concept of responsible use for it has been a singular failure, particularly since no-one has defined how such drugs can be safely used on a repetitive basis, especially when used intravenously.

Equally important in any drug strategy is the principle of early intervention. Whilst sanctions must apply, there should be provision to divert the drug user into programmes of rehabilitation. This requires adequate treatment services and a range of measures to meet the requirements of the apprehended population. Some will not be addicted but at risk of becoming regular and dependent users. Others will be more firmly addicted and socially marginalised and many will be in between. This will require quick induction into assessment and treatment and priority should be given to detoxification and long-term abstinence based programmes.

Early intervention should aim at discouraging continued drug use, especially by the young and immature. But a problem will arise when serious crimes have been committed by an apprehended addict. There is a strong argument for the establishment of a dedicated Drug Court, assisted by competent assessment advisers, and with power to adopt coercive measures against truly addicted persons who have committed serious crimes. In the United States, Sweden and other countries, this power of the Court has proved to be effective in inducting drug abusers into treatment pathways.

The proposal for injecting rooms should be abandoned. The scientific evidence about the dangers of injecting drugs is now overwhelmingly against perpetuating this mode of using drugs. Moreover there is no convincing evidence that it offers anything to saving the lives of heroin addicts, nothing that could not be achieved by other treatment services and the intense policing of the open drug markets. The transmission of Hepatitis C and its ominous prognosis has changed all that. Moreover there is now sufficient evidence to warrant an independent review of the needle and syringe distribution programmes for they are misfiring.

It is important to move the drug addict out of his current milieu (the drug subculture), which encourages the continued use of drugs and delays the entry into treatment programmes. This can be done by using the power of the courts to commit people to detoxification centres, followed by longer-term rehabilitation in drug free therapeutic communities. We should remember that the cognitive functions of the brain remain dysfunctional for some weeks, during which time efforts should be made to establish a rapport based on caring for the addict and winning his/her trust for what you have to offer. Here we can learn from a variety of programmes - Community Encounter, Teen Challenge, Odyssey House, Victory Outreach, the Benelong Programme and the facility known as San Patrignano in Italy. These can be adapted to the Australian culture but they already have a track record in several countries.

Harm Prevention takes in the principle of primary prevention. This is a complex field of issues which cover such problems as the "at risk groups", adverse social conditions, distressed individuals and families and the operations of the "markets." It covers such measures as the control of the availability of drugs and their movement around the world and across Australia. This requires a social policy that addresses a wide range of issues that currently lead to a stressed population, particularly among young people who are in a transitional phase of human development and who require strong family and community support to mature into responsible members of society.

Evidence from Sweden, the United Kingdom and the United States of America reveals the importance of collaboration between treatment centres, law enforcement officers, penal authorities and probation officers, governments and international bodies. A Task Force of representatives from all these agencies working to a plan based on Harm Prevention, early intervention, sanctions on drug use, supply reduction and demand reduction, should act in a concerted endeavour to treat the addicted persons and deter the use of mind-altering drugs.

The strategy must have a long-term objective, running over 10 or more years, to reduce demand and to subtract long term addicts from the population, which uses mind-altering drugs. Because this proposal would bridge several parliamentary elections, the strategy should be above politics and the political parties should adopt a common purpose, as has happened in Sweden and is now happening in the United Kingdom.

The latest National Household Survey (1998) shows fairly dramatic increases in drug use in Australia since 1995. Of particular concern are the increases in young people's drug use. For example, the proportion of teenagers recently using heroin increased from 0.6% in 1995 to 1% in 1998 (see also Appendix 2); the proportion of teenagers recently using marijuana increased from 20% in 1995 to 35 % in 1998; the proportion of teenagers ever using marijuana increased from 36% in 1995 to 45% in 1998. ²

These increases have occurred under a Harm Minimisation framework. Other countries that have adopted a Harm Prevention framework have decreased their drug using rates, namely Sweden and the United States. In the United States, where prevention has been the lead drug policy, and community coalitions have been extremely active and funded, we see a marked decrease in illicit drug use. In 1979, 25 million, or approximately 10 % of Americans, used an illicit drug. In 1998, the figure was 13.6 million or less than 5 %. ³ This compares to the Australian figure in 1998 of 22% of the population who have used an illicit drug. The figure in 1995 was 17 %. ⁴

In Australia we see a growing pool (prevalence) of drug use. The increase in prevalence of use means an increase in the proportion of users who become chronic users and addicted. As the pool of prevalence increases, as it has been doing, other associated problems also increase. Some of these include increases in crime, breakdown in families, associated public health costs, and generally all the problems associated with drug addiction. The most successful strategy is to reduce the incidence of drug use, particularly with young people. The way to achieve this is to increase the information on the health risk of drugs, to increase parent education on drug issues and to create a climate in which drug taking is seen as harmful and damaging to the development of the young person and society and by funding and initiating community coalitions.

The alarming increase in drug use across the Australian population needs urgent action of a preventive nature. Drugs cause dysfunction of the brain and other organs in the individual but this dysfunction is also transmitted into the wider community, as the increase in drug use manifests itself as social dysfunction. There is an urgent need to place harm prevention as the lead drug policy in Australia, if we are to arrest the large increases in drug use.

Dr. Shane Darke of the National Drug and Alcohol Research Centre is reported to have told the APSAD Conference in November 2000 that the number of heroin addicts in Australia had doubled in the past 10 years. This increase in numbers was largely due to the recruitment of young people, especially young women, into the population of heroin users.

The average age of first heroin use has dropped from 20 to 16 years in recent years, and teenage girls, not `typical' users in the past, were increasingly becoming addicted to heroin. Their numbers were now matching those of their male counterparts.

Dr. Darke explained that young people were attracted to heroin because of a drop in its price, increased availability, increased purity and the fact that it could be smoked as well as injected.

However the following question should be considered: Could this result be the outcome of the free distribution of needles and syringes, which have facilitated the use of drugs intravenously and the expansion of the drug markets which have been tolerated under the umbrella of Harm Minimisation?

The timing of the two observations _ the beginning of the needle distribution programmes and the expansion of the population of heroin addicts _ reveals a startling correlation.

Year 1998 - no comparable figures available. But the average monthly death rate for the year was 22 (total 260)

² 1998 National Household Drug Strategy Survey, Australian Institute of Health and Welfare, August 1999.