THE INTERNATIONAL JOURNAL OF DRUG POLICY 1993 4 2
THE REDUCTION OF HARM RESULTING FROM USE OF ILLICIT DRUGS
Given the health, social and economic costs of the present policy of demand reduction, Alex Wodak examines the success of prohibition and concludes that the main focus should shift from concern about the use of illicit drugs to the need to find ways of reducing the harms associated with it.
Over the last quarter century, the use of illicit drugs has become widespread in many industrialised countries. Illicit drug use has also become common in a number of developing countries during the last decade. The epidemic of HIV infection has brought about a re-evaluation of the potentially far-reaching consequences to
society of (injectable) illicit drugs. Nevertheless, in most countries, policy on illicit drugs remains dominated by a concern about drug use rather than about drug-related problems. This paper reviews current national and international success in reducing the harms that result from the use of illicit drugs.
TRENDS IN DRUG-RELATED HARM IN AUSTRALIA
During the last decade, heroin-related deaths per capita have increased two-and-a-half times in Australia whereas barbituraterelated deaths have declined to a similar degree. Overall, there has been a slight net increase in the population-adjusted deaths attributed to illicit drugs in this period. These trends are illustrated in Table 1.
TABLE 1: Death rate due to drugs, persons aged 15-34 years, 1981-1987 (rate per 100 000 population)
Collins and Lapsley (1991).
The limited impact of careful scientific assessment ofadverse consequences of mood- alter ing drugs onpolicy is well demonstrated by cannabis. A recent expert report on drug-related morbidity and mortality in Australia concluded that 'a search of the literature did not find any reports of death from acute toxicity from cannabis' (Holman et al., 1988). The authors also concluded that it would appear that apart from dependence, abuse and withdrawal, no other adverse effects of cannabis are sufficiently substantiated or quantified toenable an analysis of resultant morbidity or mortality (Holman et al., 1988). Although the consumption of cannabis is not associated with measurable adverse health consequences, considerable social costs accrue to consumers who are apprehended and substantial law enforcement costs accrue to non-consumers. A reduction in the harmful consequences of cannabis requires adoption of policies which more closely reflect the relative lack of toxicity of the drug. Sizeable law enforcement expenditure on cannabis, for which there is little evidence of benefit, must sooner or later come under scrutiny in an era of increasingly parsimonious public spending.
There are no trend data in Australia on morbidity, social or economic costs of illicit drug use. Table 2 presents some recent and conservative estimates of the economic costs of licit and illicit drugs in Australia.
THE NATURE OF DRUG-RELATED HARM IN AUSTRALIA
Before considering the prevention of drug-related problems, it is useful to review the harmful consequences of illicit drug use. The natural history of illicit drug use has been changed dramatically and irrevocably by the advent of HIV infection. In a recent comprehensive review of the mortality of injecting drug users (IDUs) (Holman et al., 1988), the pooled mortality rate was estimated as 9.6 deaths per 1000 years. Estimates of relative risk from five studies were 3.7-28.2 with a pooled estimate of 17. 1. Injecting drug use has changed in the era of AIDS from a somewhat hazardous pastime with predominantly adverse social sequelae to a profoundly dangerous high-risk behaviour. Recent studies of mortality among IDUs already reflect the increasing mortality of IDUs in the AIDS era.
Heroin overdose in the era of HIV is still an important cause of death among IDUs. Most overdoses are considered to be accidental rather than deliberate attempts at suicide. Accidental overdose from heroinresults from an unsuccessful attempt to estimate the dose required to achieve a desired state of intoxication. These errors occur because the concentration of street drugs is unknown as the degree of adulteration of illicit drugs varies.
TABLE 2: Estimated costs of drug abuse Australia (1988)
|Total as percentage of GDP
Commonwealth Department of and Health Community Services(1990).
The contamination of street drugs with bacteria, viruses, fungi or parasites results either from the unhygienic conditions of distribution of illicit drugs or as a consequence of the sharing of injecting equipment which forms a (now decreasing) part of the subculture of drug use. The variable and unknown concentration of street drugs, their adulteration with microbiological or chemical contaminants, and the non-sterile injecting practices associated with consumption of street drugs are all direct consequences of classifying certain drugs as illegal. Unless major progress can be made in the hitherto largely unsuccessful attempts to reduce the supply and/or the demand for drugs, a major and sustained reduction in the adverse health consequences associated with illicit drug use will require that drugs consumed are of known concentration, meet minimal standards of purity, and that the mode of administration is less hazardous than injection with used and often shared equipment. Much of the present harm associated with injection of heroin would be avoided by the widespread adoption of smoking, snorting or swallowing of heroin although there would still be some complications if heroin were consumed by non-parenteral routes.
HOW EFFECTIVE ARE PRESENT ATTEMPTS TO REDUCE DRUG-RELATED HARM?
Attempts in most countries to reduce the harmful consequences of illicit drugs have relied during recent decades on efforts to restrict the supply of drugs, decrease the demand for illicit drugs and provide treatment for drug-dependent persons. Successful treatment interferes with the illicit drug supply network thereby reducing the availability of drugs, and also reduces the number of drug consumers which also decreases the demand for drugs.
Since the HIV pandemic, increasing efforts have been directed towards approaches referred to as 'harm reduction'. These approaches are characterised by a recognition that for some individuals (or communities), elimination or reduction of drug consumption may not be an achievable objective and that diminishing the hazardous nature of drug consumption without requiring prior reduction or elimination of drug consumption is more likely to reduce drug-related harm. In many countries, law enforcement efforts directed towards restricting the supply of drugs attract the major part of funds allocated in response to illicit drugs. Despite this expenditure, mortality resulting from illicit drugs in Australia increased by 40.3% between 1981 and 1987. It could be argued that without the generous allocation of resources to law enforcement, mortality would have increased even more markedly.
THE EFFECTIVENESS OF SUPPLY RESTRICTION
The cost of law enforcement of all illicit drugs in Australia in 1988 was estimated conservatively to be A$258 million (Holman et al., 1988). What benefits has the community seen from this not inconsiderable investment in law enforcement? Despite a reasonable literature on the effectiveness of treatment, the beginnings of a literature on the cost-effectiveness of treatment, and a smaller literature on the effectiveness of demand reduction, objective information on the effectiveness and cost-effectiveness of supply restriction is remarkable for its scarcity. At a time of relentless pressure to restrict public expenditure to areas of demonstrable benefit, law enforcement for illicit drugs remains sacrosanct.
Restricting the cultivation or production of illicit drugs forms the first line of defence in efforts to control the supply of illicit drugs and considerable data on global drug cultivation and production are available. The global cultivation of opium and coca (from which cocaine is derived) is assessed by aerial and satellite surveillance which is relatively accurate. Encouraging opium- and coca- growing farmers to substitute the cultivation of cash crops is one of the major techniques used. Attempts are also made to destroy opium and coca growing areas.
The effectiveness of global supply-reduction strategies is assessed annually in the International Narcotics Control Strategy Report (INCSR) produced by the US State Department (1991). Estimated global opium and coca production from 1987 to 1991 and the trends in estimated land used for cultivation of opium and coca during the same period are presented in Tables 3 and 4.
Global opium production increased during the 4 years to 1991 by 59.2% to reach 3429 tonnes. This is equivalent to about 350 tonnes of heroin. Global coca cultivation increased during the same period by 15.8%. Eradication of opium cultivation in 1990 succeeded in destroying 4.1 % of the crop. Although the report notes with some satisfaction that 53 tonnes of coca in Colom- j bia were seized and destroyed in 1990, this should be seen in the perspective of an estimated combined production from Colombia, Peru and Bolivia of 700-890 tonnes.
The INCSR report, which is concerned with drug cultivation, production and consumption rather than drug-related harm, concluded that'for the first time in a decade ... there was a halt in the rise of coca cultivation and opium production. Total coca cultivation, which had been increasing annually by as much as 10-20%, levelled off in 1990 .. .... Opium production, which had also been growing at an alarming rate, dropped by 10% in 1990' (Bureau of International Narcotic Matters, 199 1). Elsewhere the report comments that'drug abuse in a number of countries continues to rise, providing new markets for the traffickers. Serious problems with corruption, ineffectiveness of law enforcement efforts, and lack of will to attack the drug trade vigorously remain in a number of countries. The traffickers and their organisations continue to be strong, rich, and often able to adapt to changing circumstances' (Bureau of International Narcotic Matters, 1991). It is difficult to read this authoritative report and remain convinced that supply reduction is reducing the availability of drugs or diminishing drug-related problems.
Those who might argue that the recent decline in opium production and coca cultivation represents light at the end of the tunnel should ensure that they are not being confused by the headlamp of an approaching locomotive. During the last decade, the production of illicit drugs has increased dramatically. Arguments that global production of illicit drugs may have been even greater without supply-reduction policies have a similar plausibility to suggestions that agricultural production in the former Soviet Union would have Australia has been successful and unaccompanied by been even less without the courageous policies adopted and so strenuously enforced by the Kremlizi. The hypothesis that things might have been even worse is incapable of either proof or falsification. Whether it has face validity is another question.
TABLE 3: Worldwide net production of illicit drugs 1987-1991
|Total opium (tonnes)
|Total coca leaf (tonnes)
|Total marijuana (tonnes)
|Total hashish (tonnes)
Bureau of International Narcotic Matters (199 1).
TABLE 4: Hectares cultivated illicit drugs in 1989 and 1990
||Cultivated drugs in 1989 (hectares)
||Cultivated drugs in 1990 (hectares)
Bureau of International Narcotic Matters (1991).
It should also be noted that reduction of supply will only result in a decrease in harm if there is an approximately dose-response relationship between adverse health consequences and consumption of illicit drugs. This is a valid assumption to make in the case of the legal drugs, alcohol and tobacco which have significant intrinsic toxicity. It is a doubtful assumption for a drug such as heroin for which constipation is the most common dose-dependent side effect.
Although proponents and critics of prohibition alike are often inclined to suggest that attempts to restrict the supply of drugs are either always totally effective or totally ineffective, the truth of the matter is much more complex. There are many examples where prohibition has been successful. For example, there can be little doubt that the prohibition of compound analgesics in Australia has resulted in a reduction in the incidence of analgesic nephropathy without untoward effects. Similarly, the prohibition of methaqualonemelsedin (Mandrax) in several countries including the emergence of undesirable side effects. Prohibition can be expected to be effective in reducing harm when the drug in question is in low demand, when controls are difficult to subvert and when similar drugs are less toxic or unavailable.
The prohibition of alcohol in the USA reduced the per capita consumption of alcohol. Deaths from cirrhosis, generally regarded as a reliable indicator of alcoholrelated medical complications, also declined. However, Prohibition produced unacceptably high levels of social problems including organised crime which ultimately led to its repeal.
It is difficult to conclude categorically that the prohibition of cannabis, heroin, amphetamines or cocaine has been either successful or unsuccessful as the essential data required to make this judgement are simply not available. Our ability to decide whether prohibition was effective or otherwise requires measurements of the costs and benefits of prohibition against the costs and benefits of alternative policies. Although alternative policies have been proposed, implementation has either been sporadic or piecemeal, further denying any possibility of accurate comparison. Nevertheless, the apparently increasing costs of law-enforcement approaches to restrict the supply of illicit drugs and their apparent ineffectiveness to either reduce the supply of drugs or to diminish drug-related harm has led many to form their own conclusions. Theoretical models have also helped assessments of the effectiveness of supply reduction.
More stringent enforcement of supply reduction policies would require increasing expenditure and further curtailment of civil liberties. As argued above, many if not most of the health, social and economic costs of illicit drug use are really costs of prohibition and not inevitable and pharmacologically predictable consequences of drug use. The majority of the health costs are consequences of drug policy intended to deter drug use.
Most of the costs of drug use borne by individual drugusers are passed onto the non-drug- using in embers of the community. This includes the high financial costs of purchasing illicit drugs which are passed on to non-drug users through property crime, and sorne of the serious infections prevalent among drug-injecting populations such as hepatitis B, hepatitis C or HIV which are transmitted to non-drug-using sexual partners prior to more widespread dissemination throughout the community.
Although it is tempting to retreat into a state of paralysed agnosticism resulting from the lack of definiive data on the effectiveness of suppl~-control policy, the HIV epidemic and the public funding crisis in many Western countries has increased the urgency of resolving this very difficult web of questions. Some might argue that attempts to reduce the supply of drugs are successful and deter drug dependent and would-be users alike. Others have argued that supply-reduction policies may inadvertently exacerbate the spread of HIV infection through a varietyof mechanisms. Although it has been possible to decrease unsafe injecting practices among drug users despite a supply-control policy, these policies have undoubtedly delayed the adoption and impeded the implementation of programmes to increase the availability of sterile needles and syringes. In the presence of high prices and low purity of street drugs, generally considered to he the hallmarks of successful interruption of drug supply, it is unlikely that DUs will adopt non-parenteral forms of drug administration which are not associated with the hazard of HIV transmission.
During the last decade, the price and purity of heroin in Australia have changed little overall. This suggests that the availability of street drugs, or more strictly the ratio of supply to demand, has not changed significantly despite an annual expenditure of at least A$258 million (Commonwealth Department of Community Services and Heath, 1990). During the last decade, cannabis availability has, however, decreased markedly and street prices have increased spectacularly. Although this might be considered an achievement by those who regard cannabis as a highly toxic substance, it is still difficult to find well-substantiated evidence of significant morbidity or mortality resulting from consumption of cannabis. During the period that this relatively innocuous, non-injectable substance became almost unavailable in Australia, domestic production of amphetamines increased dramatically so that these drugs are now readily available and are relatively cheap. As a very substantial proportion of amphetamines consumed in Australia is now injected, this does not encourage optimism in the proposition that attempts to reduce the supply of illicit drugs have either been successful in their own terms or in reducing drug-related harm.
Among the different modalities of drug treatment, methadone maintenance is distinguished by its singular ability to attractand retain IDUs in treatment. Independent evaluation, including a small number of ran, domised clinical trials and other less rigorous forms of evaluation, provides considerable evidence for the effectiveness of this treatment modality.
On the basis of the limited evidence available, the adoption and vigorous implementation of supply restriction policies do not appear to have resulted in a sustained reduction in the production, transport, distribution or consumption of illicit drugs. It is even more difficult to conclude that these policies have resulted in a reduction in drug-related problems. On the contrary, most of the adverse health, social and economic problems associated with illicit drug use result from attempts to restrict drug supply rather than from the intrinsic pharmacological properties of currently illicit drugs. On the limited evidence available, there does not seem any likelihood that modification or further intensification of supply-reduction policies would result in more favourable cost-benefit.
Consequently, credible alternative options for providing currently illicit drugs to those determined to use them must be sought urgently. However, there is almost no evidence available with which to compare the effectiveness of supply-reduction policies against alternatives. Controlled availability of illicit drugs has been shown to be a feasible alternative, but there is insufficient available evidence at present to indicate that this is associated with more benefit and less harm than conventional approaches. As there is limited evidence of health problems associated with cannabis but lawenforcement costs are both considerable and of doubtful benefit, alternative policies for cannabis intended to minimise costs require evaluation.
Evidence of the effectiveness of methadone maintenance treatment must now be considered incontrovertible. Methadone maintenance also appears to be highly costeffective and is now one of the most effective measures available to reduce the spread of HIV infection among IDUs. This treatment modality also offers the promise that other forms of substitution therapy might be developed successfully. As HIV infection has became the most serious complication of drug use for both IDUs and non-consumers alike, drug policy mustbe primarily directed to reduce transmission.
The importance of adverse social factors as antecedents for both drug consumption and production requires greater emphasis and greater attempts at correction.
Bureau of International Narcotic Matters, US Department of State (199 1) International Narcotics Control Strategy Report, March.
Collins, D.J. and Lapsley, H.M, (199 1) Estimating the Economic Costs of DrugAbuse in Australia. Monograph Series Number 15. National Campaign Against Drug Abuse. Commonwealth Department of Community Services and Health. Canberra: Australian Government Publishing Service.
Commonwealth Department of Community Services and Health (1990) Statistics on Drug Abuse in Australia, 1989. Canberra: Australian Government Publishing Service.
Holman, C.D.J., Armstrong, B.K., Arias, L.N., Martin, C.A. et al. (I 988)The Quantification of Drug caused Morbidity and Mortality in Australia. Canberra: Commonwealth Department of Community Services and Health.
Dr Alex Wodak, Director, Alcohol and Drug Service, St Vincent's Hospital, Sydney, Australia.