DRUG ABUSE
THE BATTLE OVER HARM MINIMISATION
First Presented as the H.R.Francis Memorial Lecture; May, 2003
Revised November 26, 2004
By
Dr. J.N. SANTAMARIA
"The American Disease", was published in the United States in 1999. .The author, David Musto, is a Professor of Child Psychiatry and the History of Medicine.
“ The phrase ‘harm reduction’ is not easy to define…………To some, the phrase ‘harm reduction’ is merely a mask disguising the goal of legalising drugs, a policy too unpopular to advocate directly. Harm reduction could also include the provision of heroin, cocaine, and marihuana to users at low cost and assured purity. Advocates of this sort of policy commonly find nothing wrong or dangerous in most drug use, seeing it as a personal decision that should not be affected by the government……”
Musto then briefly describes the Dutch situation and concludes by commenting that …..” (the) philosophy is to support the user until he or she quits or enters therapy without coercion.”
In Australia, it is claimed that the policy of Harm Minimisation is a successful public health measure in the field of drug use. But the proponents of this policy often avoid the term "public health" and focus on the phrase "a health issue" which directs the attention to an individual and circumvents the concepts of community health, the principles of primary prevention and the Common Good. The measures adopted to contain the epidemic of Road Trauma is a good illustration of the application of public health philosophy (see later-a scenario).
The concept of Harm Minimisation (HM), as applied in the field of drug use, is basically flawed. It effectively marginalises the basic principle of Primary Prevention, a cardinal feature of a sound Public Health Policy when dealing with a problem of epidemic proportions.
The concept of HM commences with an assumption that ”recreational” drug use is a response to a universal demand to use chemical substances to alter the way our minds function - mind-altering substances. In the Occasional Paper No.1 of the Drugs and Crime Prevention Committee, it is claimed that such use is not significantly harmful :
“A goal of harm minimisation will recognise important differences that are overlooked by a goal of reducing use.
If the goal of drug policy and practice is simply to reduce the level of drug use - that is, to reduce the total number of people using drugs or the overall amount of drugs being used - then the issues about the type of drug that people use, or whether they use it in a high risk or a low lrisk way, or how heavily they use, will not be a central concern of public policy.” (see also section called “A Scenario”).
Then again :
“The other side of the coin is that there will be cases where harms can only be effectively reduced by avoiding efforts to reduce use, or by recognising that reduction of use or abstinence is unachievable in the circumstances......For example, attempting to minimise (as opposed to simply reduce to some degree) the harms connected with blood borne virus infection might prove so great a drain on the resources available to a drug strategy that it would stifle the reduction of other harms, which reduction might collectively have a greater impact on the overall net minimisation of harm across society.”
The document claims that our society should adopt the position of use tolerance.
The arguments are speculative, disjointed and not evidence based. They ignore the intrinsic dangers of mind-altering drugs and weigh as more harmful the “criminalisation” of the drug user. Moreover, even with the high level of such drug use in Australia (one of the highest in the world), fifty percent of the community have not used such substances. The primary aim of a national policy should be to expand this percentage of non users and never users. It does not in the first instance aim at reducing the prevalence rate to zero users but it targets possible new users (the incidence rate) and seeks measures to treat those who are current users.
A national drug policy is not ‘ simply’ about reducing drug use. Reducing demand and drug use is one part of the policy: the application of the first principle of public health. It is simplistic, to say the least, that the HM policy should focus on so-called high and low risk use, on how heavily or how often drugs are used. That has led to the nonsense of saying or implying that the mind-altering drugs are not intrinsically dangerous and that we should develop a drug education programme that is based on ‘responsible use.”
This has long been the policy of the Australian Drug Foundation which is heavily funded by Government sources. Its concept of Prevention is interesting. Its way of promoting “responsible use” is to redefine primary prevention as “minimizing” the harms that arise from legalized drug use. This was classically demonstrated recently by the proposed study of such drugs in Victoria and South Australia. The harm targeted was the possible use of ‘”contaminated” stimulants whilst giving the “green light” to the use of the stimulant drugs for rave and other parties. On the issue of mind-altering drugs, it is psychologically inept. From a public health point of view, it is a disaster. It was to the credit of government leaders and responsible news commentators that such a policy direction was repudiated. The Australian Medical Association, through its Victorian president, was reported as saying: “The concern is that no matter what the quantity or quality of the (mind-altering) pill…….it’s still dangerous no matter how pure or impure it is.”
(The Age, November 6, 2004)
Public Health
A comprehensive public health policy is based on the three Principles of Prevention - primary, secondary and tertiary. Primary prevention is concerned about numbers (prevalence and particularly incidence); secondary prevention deals with early intervention, restoration of health, the prevention of relapses and close monitoring for early signs of a relapse. Tertiary prevention is concerned with the management of the symptoms and complications of advanced disease, with attention paid to early diagnosis and intervention for serious avoidable complications, such as paraplegia in a person with malignant disease of the vertebrae.
In the context of the use of mind-altering drugs, reduction of use is the target of primary prevention, but it is equally important to have available the complementary measures for secondary prevention – management and recovery of the addicted persons, and a reduction of the “at risk” populations, particularly the risky behaviour of using the drugs for their mind-altering purposes.
In recent months, the famous English neuroscientist, Susan Greenfield, voiced similar concerns about the impact of psychoactive drugs on the brain and their serious effect on the “personalization” of brain circuits. In her book, "The Human Brain", Greenfield describes what is now called the plasticity of the human brain, the continued development of the neural structures after birth and their connectedness which play such an important part in the maturation of the human person and his/her intellectual and psychological development. The interference to the functioning of the brain circuits is what she describes as the serious effect on the personalisation of the individual.
The fact is that the promoters of the harm minimisation strategy are dismissive of the neuroscientific evidence which does not support the normalisation of use of such drugs. Even more so, it becomes critically important that we abort the taking of such drugs in young people for the reasons mentioned by Susan Greenfield. The promoters of HM have failed to understand (or refuse to acknowledge) the importance of drug dependence and cognitive impairment on the ability of drug addicts to recover from their state of bondage. They persist in refusing to recognize that the chronic use of such drugs and the drug addicted state are grave personal harms and they do not acknowledge that a high prevalence of drug use is a serious social harm that their so-called preventive measures have exacerbated.
The Occasional Paper No.1 misrepresents the concept of public health and runs up against the problem of weighting harms when it talks about a collective impact. Take the issue of blood borne infections and the needle and syringe exchange programmes. There is strong evidence to suggest that the programmes are counterproductive. (see Appendix 1) What is the equation of harms, judged on a comprehensive analysis of all the scientific data, the qualitative differences between harmful effects and the long delay in the emergence of serious outcomes such as chronic hepatitis, cirrhosis of the liver and liver cancer? (see Appendix 2)
A Scenario
Consider the problem of Drink-driving. Drink - driving per se is a risky form of behaviour. Not all drivers who exceed .05 are equally impaired and not all such drivers get into trouble or even attract the attention of the police. But we have learned that drinking and driving have created a major public health problem - in the number of deaths, the high morbidity, the costs of health care, the social devastation of families, etc. Mere information about the dangers had little impact.
What did have an impact was proscription of driving with that much alcohol in the blood, an amount discovered by scientific studies. We did not talk about the levels of risk, that it was less dangerous at .05 than at .15 because the message would have been wrongly interpreted . But that was not enough. It was realised that, if people behaved in such a way, there had to be a good chance of being caught in the act. So we introduced random roadside breath testing. To this we added the slogan: “If you drink and drive, you’re a bloody idiot.”
The object was to separate risky drinking behaviour from driving a motorised vehicle. Proscription of risky behaviour has been shown to work in many areas of social activity - on the roads with speed limits, in the workplace with safety procedures, in transport with the prohibition of drug use in airline pilots and so on. Not only does it reduce the incidence rate of risky behaviour but it normalises safe behaviour as has happened with seat belt legislation.
The drink driving slogan or the speeding laws are not designed to stigmatise certain types of drivers but to discourage risky behaviour and to encourage the development of skills to avoid such problems in modern everyday living. Disincentives are an integral part of public health and serve the purpose of encouraging behaviour to protect the common good of the community and the health of individuals and their families. The drug affected person is not an island in human society but this is the implicit assumption of the HM philosophy. It asserts or assumes that individuals have a right to use recreational drugs and society’s response should be to institute measures that “minimize” the harms as selected by so-called drug experts.
Lucy Sullivan has commented as follows :
“A godsend for the Harm Minimisation strategy of regulated flouting of the law in the name of public health was the arrival of AIDS. A great hypothetical case was made that HIV infection would flow into the heterosexual population via injecting drug users (IDUs), who would contract it through their habit of sharing injecting equipment. It was asserted that the general public could only be protected by supplying free needles and syringes to IDUs so that they would not be tempted to share their needles etc. Special dispensations were necessarily introduced to enfranchise injecting drug use in the vicinity of needle distribution outlets, and bins for used needles were placed in strategic places...
The odd thing was, however, that IDUs, despite their free needles and the expanding number of outlets, did not behave with the rigorous concern for avoiding infection typical of medical professionals in a clinic so that the blood borne infection of Hepatitis C spread among them like wildfire, appearing even to be linked to needle exchange participation. Puzzlingly, HIV infection remained at a low level in the same group. By a strange logic, the supporters of free needles and syringes find evidence in this for expanding needle distribution, despite the knowledge of the natural history of Hepatitis C.”
Hepatitis C
On the question of Hepatitis C, the problems to be considered are :
1. the natural history of the disease;
2. the mode of transmission, with the high rate of spread among injecting drug users (IDUs);
3. parenteral drug use among IDUs is frequent and repetitive.
The reality is that the intravenous and parenteral use of drugs is highly dangerous, particularly among the young drug users and multiple drug users. It has been obvious since the 1970s and 1980s that today’s population of injecting drug users differs greatly from the drug addicts of the 1920s and 1930s. The highest incidence rates of Hepatitis C are in the under 20s and they have the highest rates of equipment sharing, even when on the exchange programmes. Studies from various parts of the world - Canada, the USA, Sweden, Italy, and Australia - reveal that between 30 and 40 % of intravenous drug users share injecting equipment or materials.
In the Position Paper justifying the establishment of an Injecting Room by St. Vincent’s Hospital, Sydney, (July,1999) the chief executive officer for the Sisters of Charity in the Darlinghurst area noted that 95% of clients on the programmes in Frankfurt were positive for Hepatitis C. What was the prevalence rate of that infection in the same group as they entered the programmes? Somewhere along the line of their injecting history, these patients must have shared equipment. The centres themselves would have facilitated a network of associations between the clients and between clients and dealers, as well as consolidating this method of drug use. It is story of perpetual motion. (see Appendix 3)
It is foolhardy to believe that minimisation of harm in the context of blood borne Hepatitis C infections will be achieved by maintaining and extending this injecting population. The scientific literature points out otherwise. It is also a fallacy to believe that restrictive legislation constitutes a major source of harm rather than an opportunity to intervene in a more constructive way in the care of those afflicted by the addictive state. Moreover, I believe that we do the injecting drug users a great disservice by channelling them into such band-aid, dead end programmes when their best interests are served by achieving a drug free state.
The establishment of such Rooms does not constitute a trial of the effectiveness of such “safe injecting havens,” for the provision of supervised injecting is not the only service being provided, a comment also made by the WHO assessors of the Swiss heroin trials. For example, what is the heroin overdose death rate, the incidence of Hepatitis C and Human Immunodeficiency transmission in those who enter abstinence programmes? There is no mention of a controlled study, only an evaluation based on very selective criteria.
Research & Conclusion
By way of a conclusion to the thorny subject of Harm Minimisation, I wish to speak briefly on a relevant subject. Some months ago, I attended an International meeting on the Ethics of Medical Research. During the course of the meeting, reference was made to Evidence Based Medicine, the ideology of the researcher, the publication of results in peer reviewed journals and the use of statistical devices such as Meta-analysis and Ecological Studies. During the discussion period, it was commented that every reader of research papers should be aware of certain problems that have arisen over the last 25 years.
Much research occurs in fields of medicine that have become politicized, such as embryonic stem cells, artificial reproductive technology and the promotion of a drug policy. Evidence based medicine can serve an ideological purpose, when the evidence is selectively chosen and other evidence is suppressed or summarily dismissed. Some research is not research at all but hypotheses or declarations that are proposed to win public or political support. Other claims are published in popular magazines or through the media, often with the use of clever expressions formulated by public relations experts hired by medical or research centres. This is particularly evident in the field of reproductive technology. Other research reveals deep conflicts of interest as some research scientists stand to make fortunes from certain new but ethically dubious experimental procedures.
Ideological positions, often based on personal autonomy or distorted liberalism, are strongly to the fore in the field of drug use, especially when dogmatic claims are made about the harms associated with a restrictive drug policy. Uncomfortable evidence is often deliberately ignored and slogans are presented as if certain claims are incontestable. Meta-analysis and Ecological studies are widely used to assert the success of harm minimisation measures and economic estimates of positive gains rest on doubtful premises and inferences
An outstanding example of such complex issues is revealed in the devastating critique by Gary Christian of the evaluation Report of the King’s Cross Injecting facility (The Sydney Medically Supervised Injection Centre). The critique is based on the data presented in the Report. It reveals virtually all facets described above and the manner in which the media and the protagonists of the Injecting Centre have drawn highly misleading inferences that are not borne out by the actual data.
In a recent download from a commentary by Dr. A. Lanfranchi on a study reported in the Lancet, I came upon this statement that I found to be very pertinent:
Studies that take data from many previous studies and reanalyse them (or put them into a meta-analysis) need to have sound scientific reasons for excluding some published studies. Without valid exclusion and inclusion criteria, the results can be skewed and inaccurate because they allow an author’s personal bias to consciously or subconsciously enter the selection process, thus corrupting the conclusion (and the inferences that flow from that conclusion.) Undoubtedly this sort of bias is what has led some observers to call (much modern) epidemiology a pseudoscience.
Once again, there is a difference between identifying drug use as a health problem as against dealing with it as a public health problem. Public health strategies are based on carefully formulated principles concerned with the Common Good of communities. The care of individual patients falls within the framework of a national policy on drug use but the policy should be based on the principles of preventiom and the unbiased interpretation of properly conducted research.
APPENDIX 1
Prevalence of Drug Use
The 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. In the 2001 report which used larger samples the figures suggest that a downward trend may be emerging.
The increases occurredunder 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 %. 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 %.
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, 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. This is reinforced by early intervention with programmes that aim at abstinence from drug use. The way to achieve this is to impose sanctions on drug use, 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. At the present time, the flawed Harm Minimisation model has absorbed a disparate amount of available funds and has compromised the establishment of abstinence programmes.
The prevalence of drug use across Australia 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.
If we are to arrest large increases in drug use, there is an urgent need to place harm prevention as the lead drug policy in Australia, This is the situation in the USA which has recently released reports on the outcome of their Drug Policy.
The Situation in the USA.
Recently information has been received from the United States of America, setting out information about the use of illicit drugs in that country.
According to University of Michigan Monitoring the Future study:
Use of any illicit drug in the past year decreased by a statistically significant amount from 2001 to 2002 among 8th and 10th graders. Use at least once in the student’s lifetime declined among 8th graders, and use in the past month declined among tenth graders. The percentages of 8th and 10th graders using any illicit drug were at their lowest level since 1993 and 1995, respectively.
Among 10th graders, marijuana use in the past year and past month decreased from 2001 to 2002, and daily use in the past month was down as well. The past-year marijuana use rate of 14.6 percent among 8th graders is the lowest level seen since 1994.
Ecstasy use in the past year and past month decreased significantly among 10th graders from 2001 to 2002. Ecstasy use was down in all three grades. Past-year use rates were below those for year 2000 in each grade. This is a major turning point.
Lifetime and past-year LSD use decreased significantly among 8th, 10th and 12th graders. Past-year and past-month LSD use by 12th graders reached the lowest point in the 28-year history of the survey.
Lifetime use of inhalants decreased in 8th and 10th graders, and past year use declined for 8th graders.
According to the National Household Survey on Drug Abuse:
Adolescent drug use was prevalent in less than 1 percent of twelve-to seventeen-year-olds in 1962. By 1979, that number peaked at 34 percent. By then, 65 percent of high-school seniors had tried an illicit drug, 39 percent were using drugs monthly, and 1 in 9 smoked marijuana daily. Young peoples' alcohol use paralleled their drug use, and while the death rate for all other age groups declined, adolescents' death rate rose by 8 percent, an increase fueled by the unprecedented upsurge in drug use.
Political leadership, an increased stigma attached to drug use, parent groups, and other community organizations drove down drug use between 1979 and 1992. This effort cut
regular drug use in half among all Americans (from 25 million to 11 million), by two thirds among adolescents and young adults, and cut daily marijuana use among seniors by 500 percent (from 11 percent to 2 percent).
Though rising again in the mid-nineties, drug use has fallen again.
Drug courts, court supervised programs where arrestees receive treatment in lieu of incarceration, are expanding rapidly. As of August 2004, there are nearly 1,500 drug courts in existence or being planned around the country.
American University’s Drug Court Clearinghouse reports that over 400,000 drug-using offenders have participated in drug court programs since their inception in 1989. In 1997, the Government Accounting Office (GAO) reported that 71% of all offenders entering drug courts since 1989 have either successfully completed their drug court program or are currently actively participating in their program.
Recidivism among all drug court participants has ranged from 5 to 28% and less than 4% for drug court graduates.
The Federal government has sponsored the Cannabis Youth Treatment Study (CYT), which has developed innovative and effective treatment methodologies.
Using these treatment approaches, the percentage of youth reporting abstinence from intake went from 4% to 13% (3 months) to 34% (6 months) & those with no past month symptoms of substance-abuse related problems went from 19% to 39% (3 months) to 61% (6 months).
When fully implemented, the President’s Access to Recovery Initiative will reach 300,000 people otherwise unable to receive individualized drug treatment from a variety of community sources.
APPENDIX 2
Heroin Addiction
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.
This information was posted on the website of the ADCA library –
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.
Appendix 3
Hepatitis C
Sources of Information
1. Herald-Sun May 17, 2001
Quoted Source : Dr. Greg Dore
National Centre of HIV Epidemiology and Clinical Research
2. Annual Report 2000
National Centre HIV Epidemiology and Clinical Research
Note Slide 19
This is a chart headed: HCV IN NEEDLE & SYRINGE PROGRAMS 1999
It shows 3 sets of bars (male and female) and on the vertical dimension is the prevalence rate of HCV infection (%). On the horizontal dimension, there are 3 variables (a) IV drug users of less than 3 years duration (b) IV users 3-5 years. (c) IV users 6+ years
Variable 1 20% males
(< 3 yrs) 28% females
Variable 2 28% males
( 3-5 yrs) 32% females
Variable 3 65% males
( 6+ yrs) 67% females
Deduction - The longer one uses drugs intravenously, even in needle distribution centres, the more likely that all IV drug users will become infected with Hepatitis C.
Moreover the prevalence rate in any study will depend on the mix of IV drug users in that study.
Conclusion - We should discourage IV drug use, not maintain or facilitate it.
3. Drugs Dilemma Chapter on Hepatitis C pp 53-56
“Recreational drug use” is a coined expression to describe the non-medical use of drugs which are mind-altering and mood-affecting (psychotropic). It particularly applies to the specific intention to use them for those effects. It is frequently associated with the demand to use them legally.
Occasional Paper No.1. Harm Minimisation. Victorian Government’s Drug Reform Strategy. p.7
Santamaria , J.N. Drugs and the Family Paper presented at International Conference on Drugs July 1998.
Wodak, A. Proceedings of the NSW Drug Summit. May 1999.
By Incidence we mean the number of new cases (of a disease) that appear in a population under study over a given period of time - such as 20 new cases in a population of 100 in the study group = an incidence rate of 20%.
Sullivan,L. Paper submitted for publication in a periodical journal.
Drugs Dilemma Ed. J.N. Santamaria
Clifton, Tina Position Paper for the Provision of Health Services to People Engaged in Illegal Drug Use.
May 1999
See Thomas More Centre Bulletin Winter 1999. Section on Research.
Christian, G. Analysis of the Kings Cross Injection Report. 2003. Personal Communication. This study should be compulsory reading by all politicians.