Speech to the Drug Advisory Council of Australia: Soft on Drugs Hard on Families

The Melbourne Age reported on September 30 that:

Almost 40,000 frontline workers will be trained in how to deal with ice-affected people, in an admission the drug epidemic is taking a toll on an unprecedented number of workers.

The report went on to state that the Victorian government had advertised for a service provider to train people working in the health, human services, justice and education sectors to cope with ice users.

A week later, my local papers noted the trends. The Heidelberg Leader reported that drug dealing and trafficking crimes had more than doubled in the municipality over the past year. Drug offences, burglaries, break-ins and thefts had all risen significantly. Similarly the Manningham Leader reported a significant increase in crime. The story is the same across Melbourne, indeed the State of Victoria.

According to state government figures, there was an 88 per cent increase in the number of times ambulances were called to deal with patients affected by methamphetamine between 2011-12 and 2012-13 in Melbourne. The number of calls in regional Victoria increased by nearly 200 per cent.

In NSW, Western Australia, South Australia and the ACT, amphetamines have overtaken cannabis as the second-most common ‘principal drug of concern’, the Australian Institute of Health and Welfare reported in June.

The Director of St Vincent Hospital’s Department of Addiction Medicine in Melbourne, Yvonne Bonomo, said Australia-wide, about 268,000 people used ice, and of those about 160,000 were dependent. “There’s no doubt that the prevalence is increasing,” she said.

Drug offences were up 4.1 per cent in Victoria in the year to June 2016, the latest figures from the Crime Statistics Agency show.

The Age earlier reported that:

The devastating impact of the drug ice has hit Victorian schools, with agencies fielding calls from desperate principals wanting help.

Students are turning up to class ravaged by ice, or crystal methamphetamine, with some teachers now working in pairs for safety.

Prevalence and Trends

Consider the latest (2013) data from the Australian Institute of Health and Welfare.

About 8 million people aged 14 and over in Australia (42 per cent) have ever used an illicit drug, and 2.9 million (15.0 per cent) had used an illicit drug in the 12 months before the survey, increasing from 2.7 million (14.7 per cent) in 2010.

In 2013, 1.2 per cent of the population (or about 230,000 people) had used synthetic cannabinoids in the last 12 months, and 0.4 per cent (or about 80,000 people) had used other emerging psychoactive substances such as mephedrone.

Cannabis and methamphetamine users were more likely to use these drugs on a regular basis with most people using them at least every few months (64 per cent and 52 per cent respectively) while ecstasy and cocaine use was more likely to be infrequent, with many users only using the drug once or twice a year (54 per cent and 71 per cent respectively).

While there was no rise in methamphetamine use in 2013, there was a change in the main form of methamphetamines used. Among methamphetamine users, use of powder fell from 51 per cent in 2010 to 29 per cent in 2013 while the use of ‘ice’ (also known as crystal) more than doubled, from 22 per cent to 50 per cent over the same period.

More frequent use of the drug was also reported among methamphetamine users in 2013 with an increase in daily or weekly use (from 9.3 per cent to 15.5 per cent). Among ‘ice’ users there was a doubling from 12.4 per cent to 25 per cent.

Particular drugs

Cannabis

In 2013, it was estimated that about 6.6 million (or 35 per cent) people aged 14 or older had used cannabis in their lifetime and about 1.9 million (or 10.2 per cent) had used cannabis in the previous 12 months.

Ectasy

The opportunity to use ecstasy was less common than cannabis with 7.2 per cent of Australians stating they had been offered or had the opportunity to use the drug in the last 12 months. Ecstasy was the second most commonly used illicit drug in a person’s lifetime, with 2.1 million (10.9 per cent) people aged 14 or older reporting having ever used the drug and 500,000 had done so in the past 12 months, representing 2.5 per cent of the population

Methamphetamines

In 2013, about 1.3 million (7.0 per cent) people had used methamphetamines in their lifetime and 400,000 (2.1 per cent) had done so in the last 12 months. Males were more likely than females to have used methamphetamines in their lifetime (8.6 per cent and 5.3 per cent, respectively) or in the last 12 months (2.7 per cent and 1.5 per cent respectively).

Cocaine

There was a significant increase in the proportion of people who were offered or had the opportunity to use cocaine in 2013 (from 4.4 per cent in 2010 to 5.2 per cent). However, there was no change in the proportion using cocaine in the previous 12 months (2.1 per cent). Recent users also used cocaine less often in 2013, with a lower proportion using it every few months (from 26 per cent to 18.0 per cent) and a higher proportion using it once or twice a year from 61 per cent to 71 per cent. Of people aged 14 or older, 8.1 per cent (or 1.5 million) had used cocaine in their lifetime, and 2.1 per cent (or about 400,000 people) had used it in the previous 12 months.

Drug related issues

The AIHW describes drug use as ‘a serious and complex problem, which contributes to thousands of deaths, substantial illness, disease and injury, social and family disruption, workplace concerns, violence, crime and community safety issues’.

The use and misuse of illicit drugs is a risk factor for a range of health problems, including infection with blood borne viruses, low birthweight, malnutrition, poisoning, mental illness, suicide, self-inflicted injury and overdose.

A number of researchers have attempted to quantify the social and economic costs of drug use in Australia. Perhaps the most frequently cited estimates are those produced by health economists, Professors David Collins and Helen Lapsley.

Collins and Lapsley have estimated the economic costs associated with illicit drugs in 2004–05 to be $8.2 billion. This figure includes crime costs ($3.8 billion), health costs (net)($200 million), lost workplace productivity ($1.6 billion), lost home productivity ($495 million) and road accidents ($527 million). A decade later, the cost is much higher.

Policy responses

So what has been the response to this human tragedy? Australia’s approach to the challenge of illicit drug use has broadly fallen into three – possibly four – phases, approximately a decade in length, beginning in 1985. According to the ‘National Drug Strategy’, the philosophy of harm minimisation has underpinned Australia’s approach. However, the idea of ‘harm minimization’ has been subject to differing interpretations and policy responses over the past three decades. The approach taken by the Howard government differed substantially from that taken by Labor, both before and afterwards.

Phase 1

The first phase was a response to the outbreak of HIV/AIDS. In an endeavour to reduce injury while not stigmatizing the infected, a policy of harm reduction was adopted. Deliberately or otherwise, the previous approach was changed. Drug use was seen as a legitimate lifestyle choice. The emphasis was on preventing the spread of HIV/AIDS rather than drug use. The focus was on people injecting drugs and the response to their use.

Hence Dr Alex Wodak, one of the leading proponents of the new approach, asserted in 1989 that:

Attempts to discourage intravenous use of drugs should have the highest priority. Substitution from injecting to other forms of administration is preferable to continued injecting with the inevitable consequence of HIV infection.

As the National Drug Strategy stated: ‘the primary goal is reducing harm rather than drug use per se.’ Accordingly, the harm reduction approach accepted that drug use would continue to be part of society; the eradication of drugs is impossible; and continued attempts at eradication may well result in increasing harm to society.

Professor Margaret Hamilton, another leading advocate of the new approach, stated that ‘the continuation of attempts to eradicate (drugs) may result in maximising net harms for society.’

The House of Representatives Family and Community Services Committee noted in 2007 that the original intent of the policy was to reduce and control available drugs, discourage their use; and to help to reduce harm to continuing users.

By then, there had been a significant change of direction as the original focus on prevention of drug use and the amelioration of harm was abandoned in favour of the latter policy pillar only.

The (since disbanded) Australian National Council on Drugs, of which Professor Hamilton was the deputy chair, gradually moved its approach from prevention and treatment to reduce drug use and harm, to a policy of reducing harm regardless of levels of drug use.

Phase 2

The policy drift away from prevention was reversed by the Howard Government in 1998. Implementing a ‘Tough on Drugs’ program, the national government placed greater emphasis on the reduction of illicit drug supply, and prevention through education, diversion and treatment programs.

The implementation of a balanced model more akin to the Swedish approach drew local critics who regarded addicts as victims.

Phase 3

Since the Howard era, drug policy and practice returned to the earlier harm reduction model. While prevention is given lip service, the emphasis remains on decreasing the injury to individuals rather than tackling the supply and use of illicit drugs as such.

Phase 4

A fourth phase has hopefully replaced the third, following the widespread community concern about the ‘ice’ epidemic. The National Ice Taskforce, established by the Abbott government in 2015, found that more than 200,000 Australians were using the crystalline form of methamphetamine (commonly known as ‘ice’) in 2013, compared to fewer than 100,000 in 2007. It found that the distress ‘ice’ causes to individuals, families, communities and frontline workers is disproportionate to that caused by other drugs. It proposed both primary prevention and effective treatment. The Council of Australian Governments endorsed the approach in December 2015, setting out the objectives of a new National Ice Action Strategy, which focusses on preventing people from using the drug and treatment. What is important now is that the Strategy is rolled out in a practical manner, involving community organisations, and the $300 million allocated is not consumed by bureaucratic and administrative costs.

The impact of the approaches

While there are passionate advocates of different policy approaches, good social policy should rest on verifiable outcomes. What does the evidence reveal?

First, illicit drug use increased from 39.3 per cent of people aged 14 years and older in 1995, to 46 per cent in 1998. In 2001, it had fallen back to 37.7 per cent, rising to 38.1 per cent in 2004. Since 2007, it has climbed again to 41.8 per cent.

Secondly, the death rates from opiate overdose for persons aged 15 – 54 increased from 36.6 deaths per million in the 1988 to 101.9 in 1991. From 1999 to 2004, they fell back to 31.3 deaths per million. In 2004, there were 320 overdose deaths. By 2011, the number had risen to 715.

Thirdly, Hepatitis C infections also increased significantly to a peak of 14,000 new cases in 1999, before falling in the following years.

Fourthly, the use of methamphetamines has escalated to alarming levels over the past decade. For some people, ‘ice’ can trigger psychological disturbances or violent or aggressive behaviour. Long term use may damage the brain and cause impaired attention, memory and motor skills.

These trends largely replicate the phases of drug policy. During the first harm reduction phase, drug use, deaths and infection rose. During the ‘Tough on Drugs’ phase, they fell, only to rise again when that strategy was abandoned.

Explanations, such as a short supply of opiates do not accord with the evidence, especially of drug use falling in other jurisdictions reliant upon the same supply.

We need to ask why an unsuccessful policy was pursued, and a successful one abandoned?

It would appear not to be as a result of public opinion. National household surveys since 2007 indicate that the overwhelming majority of Australians disapprove the use of drugs, including cannabis, and do not want them legalised. Indeed, most Australians want tougher penalties for drug dealers. On few social issues are the views of the public so clear.

The shift in emphasis by the policy makers has not reflected community attitudes. This is not the first time that the cultural elite have been at odds with the general populace.

Since these surveys were taken, we have witnessed the surge in ‘ice’ use throughout Australia.

The Impact on Families

Proponents of liberalised drug laws have presented their case as a private choice that only relates to the individual concerned. Conversely, the use of other substances, such as cigarettes and alcohol, is not treated as simply a choice relating only to the individual.

Jack Martin, the Emeritus Professor of Medicine at Melbourne University, wrote two years ago:

The Press every day leaves us with little doubt that drug use is a proximal cause of destructive behaviour that is often tragic, and that has increased in Western societies to an extraordinary extent in the last two decades. It is a major cause of crime, it destroys lives and families.

His conclusion is correct. More than 40,000 children aged 12 years and under reside in a household where an adult uses cannabis daily; and 14,000 children aged under 12 live in a house with an adult using methamphetamines at least monthly and in their presence. A 2007 study found that increased levels of substance use are also linked to other risk factors, such as exposure to violence, mental health issues and criminal behaviour. This has been compounded by the increasing use of methamphetamines.

Consider the impact in relation to child abuse and neglect, the use of protective services and out-of-home care. It is estimated that one-third of parents involved in substantiated cases of child abuse or neglect are affected by illicit substance use. This flows onto the use of protective services for at-risk children. One study found that substance abuse disorders were the most common factor associated with physical abuse and neglect of children by drug using parents. Other studies have revealed that up to 80 per cent of child notifications involve concerns about parental substance abuse, and that parental drug use was linked to 70 per cent of cases where children were admitted to alternative care.

Children living in households where parents misuse illicit substances are at greater risk for poor health and behavioural outcomes, including educational and employment prospects. The Parliamentary Committee observed that:

31.1 per cent of recent users of methamphetamines and 64.9 per cent of heroin users reported high or very high levels of psychological distress, as against 9.9 per cent of the general population.

These consequences have an intergenerational impact. One-third of abused or neglected children later maltreat children in some way when they become adults.

The consequences also flow onto the criminal justice system. Up to six in ten prisoners have a history of injecting illicit drugs.

There can be little doubt that a policy that is soft on drugs is hard on many families and disastrous for countless children as the House of Representatives Committee on Family and Human Services outlined in detail in 2007, and the National Ice Taskforce reiterated in 2015.

Before turning to alternatives, let me examine briefly the health consequences of the policy choices.

Health outcomes

The drug reformers established two pillars of their harm reduction policy: a safe needle and syringe program, and an opiate substitution program.

A number of conclusions can be drawn from the experience. First, there is no conclusive evidence that HIV transmission rates have decreased as a direct result of these policies. In fact, the incidence of HIV infection has risen in recent years, leading experts to suggest new prevention strategies and earlier access to testing and therapy.

Secondly, overdose deaths increased in the late 1990s and more recently, along with the escalation of needle distribution. Thirdly, Hepatitis C infections increased significantly, leading Dr Wodak to state in 1994 that ‘we must virtually eradicate drug injecting from Australia if we are to gain control of the hepatitis C epidemic.’

Fourthly, the objective of the methadone program of stabilising users and then removing their addiction has failed. While methadone may reduce heroin use and improve health outcomes in the short term, it is no panacea. It is more addictive than heroin, and has negative long-term health consequences, particularly for liver and kidney function, and for chronic disease. Many people on the program continue to use heroin and other drugs. The number of people accessing the program has doubled in a decade.

Finally, the new methamphetamine epidemic has resulted in unprecedented levels of self-harm and family and community violence.

The evidence from the different policy approaches in Australia suggests a return to a program squarely based on prevention and rehabilitation has the best outcomes. But there is also supporting evidence from Sweden, which adopted the preventive approach.

Sweden

Sweden took a very liberal approach to drugs in the 1960s, effectively enabling doctors to prescribe drugs for non-medical use. Beginning in 1980, Sweden changed its lenient approach by first reversing a policy to waive prosecution for the possession of small amounts of drugs, and secondly, by allowing the police to undertake drug tests to obtain evidence of drug use. A new approach involving education and law enforcement was adopted. Drug testing was used to refer users to rehabilitation.

Per Johansson, the Secretary-General of the Swedish National Association for a Drug Free Society, observed:

One of the common stereotypes in global drug policy debates is that successful welfare states adopt permissive drug policies as part of their commitment to compassion and tolerance of diversity. Sweden, a country noted for its liberal views, stands out as an exception to this stereotype and offers a model for a more restrictive drug policy, not because it is repressive politically but because it promotes the public health and lowers both drug use and the harms caused by drug use.

The comparison with Australia is stark. With a population of 9.8 million, Sweden has 30,000 problem drug users, compared to Australia’s 270,000 injecting drug users. The National Ice Taskforce noted that over 200,000 people reported using ‘ice’.

Lifetime prevalence of drug use for 16-29 year olds in Sweden is 9 per cent, compared to 52 per cent for 14 – 25 year olds in Australia. Overall life time prevalence of drug use is 39.8 per cent in Australia, but just 17 per cent in Sweden. Annual Cannabis usage in Australia (10.6 per cent) is three times higher than in Sweden (3.4 per cent). Australia has 940 methadone patients per million of the population, compared to 50 per million in Sweden. Drug-related deaths per million of the population is 23 – half of the level of 46 in Australia. Australia has 250,000 Hepatitis C sufferers, Sweden has 43,000. The use of amphetamines in Australia is more than 3 times the level in Sweden. On every measure, drug use is significantly higher in Australia than in Sweden.

Conclusion

The evidence reveals that Australia’s recent approach is far from world’s best practice, and is failing many individuals and families. A return to a policy of education, prevention and early treatment and rehabilitation is warranted. The recommendations of the National Ice Taskforce need to be implemented in detail. The 2007 Parliamentary Report proposals should also be re-examined in light of the experience of the past decade.

In 2007, John Howard said:

There is no issue that bothers Australian parents more than the threat of illicit drug use. It represents one of the continuing social challenges to the wellbeing of young Australians, and anything that governments can do to help parents deal with this terrible problem they ought to do. I am very proud of the fact that since 1997 this government has spent more than $1.4 billion under its Tough on Drugs strategy across education, treatment and law enforcement measures. I am very pleased that over that 10-year period there has been a major change in community attitudes to the use of what used to be called soft drugs, like marijuana. Eight or nine years ago, attempts were made at a state parliamentary level on both sides of politics—both Labor and coalition—to decriminalise marijuana in the mistaken belief that marijuana was harmless. It is now realised by a growing number of Australians, particularly the parents of young people who have taken their lives in deep depression or because of a severe mental illness occasioned by marijuana abuse, that marijuana and other so-called soft drugs represent an enduring menace to the health of many thousands of young Australians. We are making progress in the war against drugs, but we have a long way to go. I say to those cynics who over the years have said it was all a waste of time, and the answer was to legalise it all and the problem would go away, that they could not have been more mistaken. The problem will only get worse if you legalise it all because you are saying to the drug traffickers and you are saying to the parents of children desperately trying to break the habit that it is all too hard and you might as well give up. This government will never give up in the fight against drugs. We will never adopt a harm minimisation strategy; we will always maintain a zero tolerance approach.

That was said before the ice epidemic that inflicts Australia. His words are as true today as they were a decade ago. We ignore them at our peril.

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