The development of a controlled availability policy in Australia
REVIVAL OF A DRUG POLICY
In a matter of a few years, the issue of legalization of heroin has changed in Australia from a cause promoted by fringe groups to a campaign espoused by some of the most eminent and distinguished members of our community. The issue has found surprising supporters in recent years. In 1984, the then New South Wales Opposition leader, Mr N. Greiner, said:
If we can bring these drug-addicted people away from having to commit crime to get the money to pay their pusher — that would mean a drop in crime. If we can wean them off the drugs in a controlled system then we are winning. If the demand is not there, the drug bosses have no-one to supply.
These views have subsequently been echoed in Australia by, among others, Mr John Gorton, a former Prime Minister, and Mr Don Dunstan, a former State Premier.
It is important that we consider why this sudden interest in a previously taboo notion has arisen. One of the major factors is an increasing recognition of the high cost of restricting the supply of illicit drugs and a new awareness of the limited effectiveness of such efforts. It is generally appreciated that further intensification of law enforcement strategies will require increasing infringement of civil liberties which are already stretched close to the limits of community tolerance. The possibility that the apparent increase in corruption of the criminal justice system and among senior government officials in Australia in recent years is related to current drug policy is a conclusion drawn by many, including Royal Commissioners. But above all it is the issue of HIV infection which has led to recent calls for a fresh examination of our national drug policies.
LINKS BETWEEN THE DRUG POLICY AND HIV INFECTION
The potential link between AIDS and the drug policy deserves careful consideration in view of the paramount need to contain HIV infection in injecting drug users (IDUs). The most likely source of HIV infection for non-drug-using heterosexuals in most Westem countries is sexual contact with an IDU. The inexorable spread of the virus responsible for AIDS (HIV) in IDUs around the world is an alarming development. Within Europe as a whole it has been anticipated that there will be more injecting drug users among newly diagnosed cases of AIDS than any other risk group including homosexuals. In New York City in 1988, IDUs became the major AIDS risk group overtaking homosexual/bisexual males for the first time. By 1993, 50 per cent of all new AIDS cases in New York City will be injecting drug users with homosexual/bisexual males accounting for 33 per cent of new cases. HIV infection in IDUs is now also appearing in Eastem Europe (Poland), South East Asia (Thailand, Myanmar, India and China), South America (Brazil and Argentina) and the Caribbean.
The spread of HIV infection in IDUs in Australia must be regarded sadly as both inevitable and imminent. The most realistic national goal is to delay and minimize this development.
Policy on the spread of HIV infection must be based on our worst fears rather than our best hopes. We are entitled to hope that a vaccine against HIV will become available. But we must acknowledge the fact that many experts in this field are very pessimistic about the likelihood of ever achieving this development. A vaccine is required which must be effective against a rapidly mutating retro-virus which shares many features with other viruses against which no vaccine has been prepared previously. Experience with the development of simpler vaccines and their actual utilization in practice instructs us to be realistic about the difficulties of immunizing adults on a mass scale and accordingly modest in our expectations. The cost and logistical difficulties of deploying a vaccine against HIV are likely to be substantial. Similarly, although we can be grateful for the rapid advances in the treatment of HIV infections, it would be foolish to ignore the fact that treatment at present is still very expensive, does not return a significant proportion of treated patients to employment and probably does not reduce the risk of further HIV transmission.
It is therefore imperative that close attention is given to all efforts which offer promise in preventing the further spread of HIV infection in the critical population of IDUs. Australia already has a very substantial case load of AIDS by international comparison with the sixth highest per capita incidence of AIDS of all OECD countries. Australia is one of the few Western countries with a high incidence of AIDS but a still very low rate of HIV infection in IDUs. Full advantage must be made of this extraordinary opportunity. If the price for controlling HIV infection in IDUs requires drug policy reform, it is a price worth paying.
Containing the spread of HIV infection in IDUs
What is the role of drug policy in containing the spread of HIV infection in IDUs? The following factors deserve careful consideration:
1 In Australia, drug users inject rather than smoke or swallow drugs. This is principally because street drugs are expensive and impure. Injecting expensive, impure drugs achieves maximum 'bang for the buck'. Experience has shown that where street drugs are cheap and pure, users will often inhale or swallow drugs. Current drug policies are evaluated by their success in keeping street drugs expensive and impure. It must be acknowledged that we have little knowledge about the reversibility of drug injecting following policy liberalization although there is reasonable evidence that drug injecting becomes more likely following policy intensification. In order to stem the spread of HIV infection in IDUs, we should ensure that street drugs are cheap and of high purity to minimize the chance of drug injecting with the attendant risk of HIV transmission. Attempts to discourage users from injecting drugs should have the highest priority in drug policy. From a health view point, smoking or swallowing street drugs is preferable to injecting, which always carries the risk of needle sharing and the subsequent development of HIV infection. The extent of drug injection with associated needle sharing is, therefore, partly determined by drug policy.
2 One of the major factors in the sharing of used needles and syringes, and the consequent spread of HIV infection, is the unavailability of sterile injection equipment. In Australia at present there are an estimated 30,000 to 100,000 IDUs injecting anywhere between one and four times a day. This means there may be approximately forty to sixty million individual acts of injections of street drugs in Australia each year. Currently two to three million sterile needles and syringes are provided by authorities in Australia annually to reduce the spread of HIV infection. It is questionable that this level of implementation can be regarded as sufficient to reduce the spread of HIV infection in IDUs in the long term. Although cost and logistical problems are important factors in slowing the expansion of the needle and syringe exchange programmes, drug policies have also been an obstacle. Drug policies in Australia have resulted in the retention of legislation concerning needles and syringes which discourages IDLJs from utilizing the needle and syringe exchanges and from responsibly disposing of used injection equipment. As a result, used equipment is discarded in streets, parks and beaches and public support for the critical strategy of sterile needle and syringe exchange and distribution has declined.
3 A number of studies have shown that drug treatment reduces the risk of HIV infection in IDUs. Therefore, it is likely that HIV spread among IDUs could be reduced by increasing the proportion of drug users who are in treatment. Treatment must be adapted so that it is far more attractive to IDUs, which will require some liberalization of drug policy. The objective of containing the spread of HIV infection in IDUs must be accepted as the paramount consideration.
4 Sharing of needles and syringes and unprotected anal intercourse are common in prisons, although it is difficult to determine their frequency. There is little evidence at present to support the widespread fear that substantial HIV infection occurs in prisons. This lack of evidence may be due to the fact that few relevant studies have been performed. Studies of this kind are very difficult. The harsh conditions of US prisons mean that the few odsting studies, which are American, may not apply in Australia. We must assume that substantial HIV infection does occur in prisons although we can still hope that this is not the case. If we wish to reduce the number of IDUs at risk of HIV infection in prisons, every effort must be made to divert prisoners convicted only of drug related offences from prisons to non-custodial forms of sentencing. This requires liberalization of drug policy.
5 At present, efforts to educate or otherwise modify the behaviour of IDUs is made even more difficult because the target population is ostracized and marginalized. Liberalization of drug policy will help to bring IDUs in to mainstream society so that education has a greater chance of mortifying behaviour.
AIDS is not the only consideration for a national drug policy. But developing a drug policy without due consideration of HIV infection would be an act of negligence. Many options lie between the choice of retention of current policies or the legalization of all drugs. These options need to be developed so that credible alternatives are available for consideration. Australia has much more to learn about the contemporary experience in countries like the Netherlands, Switzerland and Denmark where more liberal policies have been implemented. The relative emphasis accorded to the strategies of reducing the supply of drugs, reducing the demand for drugs and treatment need to be reviewed in the era of HIV.
A number of different approaches to reducing the supply of drugs has been attempted. We need to decide which of these strategies deserve support and what level of support is required.
A 'drug free Australia' is not an achievable goal. So far, the notion of a 'drug free Australia' has scarcely been considered, even as an option.
The success or failure of control of HIV infection in the third wave of the AIDS epidemic in Australia — i.e. in the non-drug-using heterosexual community — will depend on the success or failure of efforts to control the second wave of the epidemic — i.e. IDUs. Just as IDUs are central in our efforts to delay and minimize the spread of HIV infection in the general community, so too is drug policy central to our efforts to stem the spread of HIV infection in IDUs.
THE OPTIONS FOR DRUG POLICY
The South Australia Royal Commission into the Non-Medical Use of Drugs (1979) set out five possible policy options for cannabis which can equally be applied to other illicit or even licit drugs. The first option is Total Prohibition, whereby the use, possession, cultivation and sale of chugs are all prohibited and regarded as a criminal offence. The second option is Modified Total Prohibition which is colloquially referred to as 'decriminalization'. Personal use, possession and cultivation for personal use are defined as illegal but only attract a nominal fine. Supply is regarded as a criminal offence but the minimum quantity can be varied. The third policy option is that of Partial Prohibition. In this option, personal use and personal cultivation are not considered to be offences. However, public use, commercial cultivation and sale remain illegal and are subject to a set of sliding scale fines. The fourth option is a User Licence System whereby some form of controlled use is permitted following the issue of a licence or registration. The fifth option is Free Availability commonly called 'legalization' where there are minimal or no restrictions on availability.
THE AIM OF AUSTRALIAN DRUG POLICIES
The objectives of Australia's drug policies were clearly set out at the Special Premier's Conference (colloquially known as 'the National Drug Summit') held on 2 April 1985 and attended by the Prime Minister and all State Premiers. The meeting concluded that the aim of Australia's drug policy 'is to minimize the harmful effects of drugs on Australian society' (Department of Health, 1985). The selection of the most appropriate drug policy for each particular drug should be based on a desire to maximize costs. As there is generally considered to be little benefit per se in a drug policy other than the minimization of harm, the cost to the individual drug user and society for each policy option for each drug is the major consideration. Although the benefits of illicit drug use are rarely considered, it is inconceivable that drug users would risk losing health, children, family and liberty if there were no benefits. Clearly it is time to admit that drug users get a great deal of pleasure from using the drugs of their choice — at least in the short term.
Drug use results in health, social and economic costs which have increased in many Western countries in recent years. Health problems associated with illicit and legal drug use cover a diverse range of physical and psychological sequelae. In Australia, AIDS accounts for only a small fraction of the health costs associated with illicit drug use at present, but may in time dwarf all other health costs associated with drug use, possibly eventually outstripping the enormous problems consequent on alcohol use. The infringement of privacy and corruption of senior public officials in the police force, judiciary and politics must be considered products of drug policies designed to reduce drug use rather than the inevitable pharmacological consequences of illicit psychoactive substances.
One of the rarely considered costs of law enforcement is the criminalization of offenders and consequent disrespect for the law arising from the fact that only a srnall percentage of offenders are ever apprehended. Another largely neglected cost of our present drug policies is the diversion of law enforcement resources from more important tasks. A rarely mentioned cost of our current drug policies is the extent to which international terrorist movements (such as the Shining Path movement in Peru) benefit from or depend entirely on profits from international narcotics trafficking.
THE BASIS OF SUPPLY REDUCTION
The fundamental assumption of policies designed to limit supply is that reducing drug use will reduce harm. Even if it is assumed that less drug use occurs (because of the increasing cost to the would-be-user in financial, health and legal penalties), it is by no means clear that supply reduction policies will necessarily result in less drug-related harm either to individuals or the community. This will only occur if supply reduction policies reduce consumption to a greater degree than they raise the costs of drug use.
It may be that more liberal drug policies will result in an increase in drug consumption, but this must remain an assumption until we have more evidence. Even if drug consumption does increase following liberalization of drug policy, the health, financial and legal costs to the user and the community may still fall as these are at present largely consequent on the drugs being illegal in the first place.
Heroin is a relatively non-toxic drug with almost all of the present mortality and morbidity resulting from overdoses or from chemical or microbiological contaminants. Overdoses are largely a result of uncertainty about dose which, in turn, is a consequence of the illegal status, of drugs. Chemical and microbiological contamination is caused by adulteration of the drugs as they pass through the illicit distribution system. The problems of overdose and adulteration should therefore be seen as a direct result of the illegality of the drugs rather than as a consequence of their pharmacology. The spread of HIV infection among intravenous drug users may now be added to the list of health problems resulting from attempts to decrease illicit drug consumption.
Another circular aspect of our policy on illicit drugs is the effect of supply reduction on price. It has been noted that
the success of law enforcement in maintaining high prices is also its Achilles heel, creating entrepreneurs whom the law seeks to discourage by enforcement of the very laws which created profitable markets and attracted the entrepreneurs in the first place. Catch 22 if ever there was one.
If our current drug policy is successful in suppressing supply by increasing the retail costs of illicit drugs, it can only do so by increasing the risk of arrest, prosecution and punishment. However, it also follows that if costs are increased, so too are profits, thereby attracting entrepreneurs to drug trafficking. In the long term, the volume of illicit drug trafficking may paradoxically be increased by more stringent enforcement of supply reduction policies. Although enforcement of supply reduction policies appears to reduce the availability of drugs in the short term, in the long term it is quite conceivable that existing drug policies increase the supply of drugs by making drug trafficking more lucrative.
It must be acknowledged that most drug-related problems at present are secondary to drug policy and are not a product of the intrinsic pharmacological properties of illicit psychoactive substances. Although no set of drug policies will ever eliminate drug use or drug-related hann, alternative drug policy options could possibly result in less harm than existing policies. Whether the costs and benefits of existing drug policies are greater or less than the costs and benefits of alternative drug policy options cannot be known for certain at present. The central weakness of the current debate on legalization is the fact that credible alternatives to current policies have not been sufficiently thought through so that their strengths and weaknesses can be adequately assessed and compared to existing policies. It is difficult to envisage that future research vvill entirely illuminate this area. Decisions will need to be based on a balance of probabilities and consideration of comparable experiences. The introduction of methadone maintenance over twenty years ago represented a major drug policy shift which is worthy of review in relation to the current drug policy impasse'.
Methadone is now legally provided to over 8,000 drug-dependent persons in six of eight Australian jurisdictions. No contradiction is seen in allowing this particular opiate to find its way legally into the bloodstream of some drug-dependent citizens, while other opiates are not permitted. In the sense that methadone was first provided to known drug-dependent persons in Australia in 1969, the legalization of illicit drugs in Australia can be considered to have commenced over twenty years ago. The experience with methadone in Australia resembles that of many other Western countries. It is the most attractive treatment option for the majority of IDUs. Retention in methadone treatment is far higher than other treatment modalities. The widespread support for methadone in the community and from politicians in Australia may be an indication of the possibility of more flexible attitudes than is often supposed.
THE COST-EFFECTIVENESS OF SUPPLY REDUCTION
Increased funding for strengthened enforcement of drug policies is now being provided in Australia and overseas despite the otherwise remarkable restraint in government expenditure. At a time when all other sacred cows of government expenditure are subjected to rigorous scrutiny, resources for supply reduction have so far survived unscathed and have even been increased. However, scholarly reviews by authorities do not inspire confidence in this method of reducing drug use or drug problems. Polich concluded an exarnination of the U.S. situation noting 'that more intense law enforcement is not likely to substantially affect either the availability or the retail price of drugs in this country'. He added that 'nevertheless, the answer to adolescent drug use does not seem to lie with increased law enforcement' (Polich et al., 1984). Reuter arrived at similar conclusions stating that :
one cannot say that we should be spending more or less on drug enforcement overall without making assumptions about the alternative use of these funds unless it appears that some spending is either futile or likely to generate unwanted side effects of greater magnitude than its benefits.
(Reuter and Kleiman, 1986)
The curious assumption that if heroin is legalized it will inevitably be promoted is contradicted by everyday experience. For example, gelignite and other explosive substances can be legally bought and sold in Australia but cannot be promoted or advertised. There is no universal law which automatically requires advertising of any product which is legally available.
Prescription of 'take away' drugs for intravenous application by the user would be a major departure from current medical practice. Undoubtedly, changes in drugs policy will have major implications for medical practice that need to be anticipated. However, intravenous morphine, cocaine and amphetamines have been made available legally in the past in the United States and are legally available currently in parts of the United Kingdom. The consequences of a change in policy for medical practice are not a reason to reject 'legalization' but rather emphasize the importance of cautious surveillance of medical practitioners in any liberalized drug policy.
The suggestion that the federal nature of the Australian Commonwealth requires that all states (and territories) must maintain similar policies is contradicted by present-day experience with cannabis. Victoria, South Australia and the Australian Capital Territory have all recently liberalized policies on cannabis. This does not appear to have resulted in these jurisdictions becoming the 'drug capitals of Australia'. Differences in policies regarding the availability of treatment services, specifically methadone treatment, resulted in significant movement of patients between Queensland and New South Wales within the last decade. Therefore, it is reasonable to assume that this consideration is a relative factor but not an absolute consideration.
Even if heroin were to be 'legalized' it is unlikely that the community would ever countenance unrestricted availability. If there is to be a change in Australian drug policy, it is likely that in the first instance government clinics will be the major outlets. Presumably, criteria for selection and exclusion will be developed similar to those which have been established for methadone.
It has been suggested that if certain people are to be refused heroin, there will be nothing to prevent their seeking to 'qualify' to receive it by intensifying their criminal involvement or increasing their dose. This consideration is also a problem for present-day methadone maintenance programmes. It has not, however, prevented the establishment or Steady expansion of methadone programmes. Selection of suitable patients is still one of the many difficulties of clinical methadone management. But the real question which has to be answered is: Should the presence of some minor clinical difficulties in the operation of substitution treatment programmes involving drugs other than methadone prevent their establishment even if there are other perceived benefits?
Some argue that if heroin is legalized to undercut the black market, then all drugs will have to be legalized and made available to anyone seeking them. Consumption of illicit drugs in one country or city is not necessarily followed by the consumption of the same drugs in adjacent cities or countries. Canada and the United States share a long land border and, presumably, traffic of illicit drugs across this liorder would be relatively simple. Yet there are vast differences in the consumption of illicit drugs on both sides of this border. As discussed above, the decriminalization of cannabis in some Australian states does not seem to have led to a discernible population shift. And even if, after the introduction of controlled availability of heroin, it was decided to extend the policy to other drugs, the question is not whether this would be a 'good' or a 'bad' thing, but whether this would be a lesser evil than the current system.
Currently, heroin of unknown concentration, adulterated with every imaginable and dangerous impurity, is readily available to anyone of any age with sufficient cash throughout Australia twenty-four hours a day, without supervision, on a take-home basis and at high cost to user and the community alike. The present system must be compared with an alternative whereby pure heroin and other drugs of known concentration and purity are carefully provided to selected users with the possibility that some diversion will also regrettably occur. Which scheme is preferable — the status quo or controlled availability?
At present, Australia imports an estimated 1,000 kg of illegal heroin per year of which 5-10 per cent is intercepted. This leaves 900-950 kg of illegal heroin left to supply the illicit market. If an additional 50 kg of licit heroin were to be diverted to the illicit market to add to the 900-950 kg illegally distributed, would th_is be an unmitigated evil, especially if a benefit was achieved in improving the health of drug users, reducing corruption, reducing the spread of HIV infection, and reducing law enforcement costs?
The 'appropriate dose' of heroin is determined at present by drug users buying an uncertain quantity of unknown concentration of illicit drugs of unknown purity. If the consumer stops breathing following injection of heroin, then the 'appropriate dose' has been exceeded. If the consumer does not feel an adequate effect from the product, a further sample is consumed. Which system is to be preferred? A clinical system with some inherent uncertainty or an illegal system which is totally uncontrolled and unsupervised? Presumably, there will be some individuals who will continue to consume heroin for their lifetime if this option is made available through legal channels, just as there are presumably some individuals who wish to use illegal heroin throughout their lifetime. Again the question is whether it is preferable for a person to obtain contaminated heroin of unknown concentration through illegal channels over which the government has no control, or pure samples of known concentration through a govemment-sponsored clinic?
MORE OBSTACLES TO DRUG POLICY REFORM
Proceeding from a set of familiar but apparently ineffective policies to an alternative set of options which might be more effective is not an easy matter. In the case of drug policy reform, alternative options are generally considered to lack credibility. In part, this displays a lack of awareness of the historical experience of controlled availability in the United States, the United Kingdom and, more recently, with contemporary experience in some European countries. In part, there are legitimate concerns regarding appropriate safeguards and regulations to ensure that legal, pharmaceutical and medical practice remains reputable. Drug policy reformers have an obligation to develop these areas so that the potential costs and benefits of alternative options can be compared against existing policy.
International considerations also represent an obstacle to drug policy reform. Although it is often considered that corrunitment to international treaties may prevent any experimentation with controlled availability of illicit drugs, it is by no means certain that this is the case. In fact, the Single Treaty, to which Australia is a signatory, permits the controlled dispensing of specified substances (including heroin) under medical supervision.
A series of false comparisons and misunderstandings have also obstructed adequate consideration of drug policy reform. Controlled availability of illicit drugs is often interpreted as unfettered availability and compared by critics to a halcyon state where illicit drugs are unknown. Confusion also often arises because of the inappropriate comparison with legal drug availability. In the case of the legal drugs alcohol and tobacco, the correlation between the risk of negative consequences and quantity ingested holds good for both individuals and communities. The effects of a reduction in the intensity of law enforcement policies on illicit drug use is unknown. But even if consumption of these drugs was to increase following a relaxation of policies, it is conceivable that drug-related problems would still decline as these are more closely linked to supply reduction policies than to intrinsic pharmacological toxicity.
THE TIMING OF CHANGE
The rapid and widespread adoption in Australia of pragmatic HIV prevention policies, including sterile injection equipment programmes and changes to methadone programmes, has stimulated a lively debate on drug policies. Although initially opposed to a debate on drug policy, the Commonwealth Minister for Health acknowledged publicly in late 1989 his support for a vigorous public discussion of drug policies.
As economic considerations are now pre-eminent in most policy areas in Australia, it is likely that the final decisions on drug policy will be made by accountants and not by advocates for public health.
It would be misleading to describe the debate in Australia in the early 1990s as having reached the 'pre-contemplation level'. On the other hand, it is undeniable that there has been a major shift in public opinion as demonstrated by opinion polls. Australia's relative isolation has not been sufficient to prevent drug trafficking but may be enough to allow the drug policy debate to be resolved earlier than in many other countries.
Department of Health (1985) National Campaign Against Drug Abuse, Canberra: Australian Government Publishing Service.
Greiner, N. (1984) Sydney Sun-Herald (10 Junc).
Polich, J. M., Ellickson, P. L., Teuter, P. and Kahan, J. P. (1984) Strategies for Controlling Adolescent Drug Use, Rand Corporation.
Reuter, P. and Kleiman, M. A. R. (1986) 'Risks and prices: an economic analysis of drug enforcement', in M. Tonny and N. Morris (cds) Crime and Justice, An Annual Review of Research, V ol 7.
South Australia Royal Comrnission into the Non-Medical Use of Drugs (1979) Final Report (Professor Sackville, Chairman), Adelaide: The Commission.
Wisotsky, S. (1986) Breaking the Impasse in the War on Drugs, New York: Greenwood Press.