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NDSconsultation@health.gov.au
National Drug Strategy Consultation
MDP 27
GPO Box 9848
Canberra ACT 2601
February 23rd, 2010
Harm Reduction Victoria Submission to National Drug Strategy Consultation
About Harm Reduction Victoria Inc.
Harm Reduction Victoria, formerly VIVAIDS Inc, is a membership driven, not-for-profit organisation
with a mission to reduce drug related harms accruing to people who use drugs and to the wider
community and to promote health. Incorporated in 1987 (as VIVAIDS), the organisation has
played a key role in mobilising the IDU (injecting Drug User) community in response to the threat of
HIV/AIDS. Since the heyday of the HIV/AIDS epidemic, HRVic has taken on a wider brief of drug
user health issues. Through peer education, advocacy, workforce development and community
development processes, HRVic addresses issues such as Hepatitis C, Heroin overdose, ATS
related harms, the needs of drug users in treatment, drug-related harms in the dance-music scene
etc. As the only organisation in Victoria with a mission to represent the needs and perspectives of
people who use currently illicit drugs, HRVic provides advice and input on drug-use issues to the
community, to government at all levels and to agencies and service providers whose work impacts
upon the health and rights of people who use, or have used, illicit drugs. HRVic is an active
member of the national network of peer-based drug users’ health organisations, with AIVL, the
Australian Injecting and Illicit Drug Users League, as our national peak body.
HRVic has sought input to this National Drug Strategy consultation through this submission in our
own right, as well as through our participation in the National Drug Modelling Project’s Drug
Strategy Roundtable, from which a submission based upon the discussions of the experts present
will be tendered. HRVic has also contributed directly to the submission prepared by the Victorian
Alcohol and Other Drugs Association (VAADA) and has held discussions on many of the key
issues with AIVL, which may be refected in their submission to this consultation.
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
1
Summary of Recommendations
1. HRVic strongly affirms the continued appropriateness of an overarching national strategy,
with buy-in from all states and territories, addressing alcohol, tobacco, prescribed and overthe-counter psychoactive medications and illicit drugs.
2. Harm Reduction Victoria urges policy makers to accept the proposition that the overarching
goals and principles for managing currently legal drugs, such as alcohol, and the currently
illegal drugs (bearing in mind that tea, coffee, alcohol and tobacco have all been proscribed
by governments in their times) must be uniform and consistent.
3. Harm Reduction Victoria suggests that the choice and development of policy interventions
should be based upon the best available evidence of the causes and dynamics of harms
arising from problematic use of substances, with the best logic and evidence-base for the
overall effectiveness of the interventions. Policy needs to be pragmatic and rational,
reflecting the world as it is, rather than utopian and moralistic, and to seek to reduce drugrelated harms while respecting the diversity of human behaviours, values and choices and
the inherent human rights and dignity of individuals.
4. HRVIC recommends that the governance structures and processes of the NDS needs to be
clarified and strengthened.
5. The NDS should consist of a high-level document outlining global strategic goals, with a
chain-of logic analysis of the key principles and clear exposition of the evidence base
underlining the strategic directions and the hierarchy of objectives. This should be
supported and executed through lower-level, more specific action plans relating to
particular priority issues (areas of drug related harms), in which resourcing, roles and
responsibilities and progress evaluation measures are made explicit.
6. The Commonwealth should not only involve and include the community in its deliberations
on drug policy, but needs to work with community representatives and other experts to
better inform and engage the broader public on drug policy and the theoretical and
evidence-base underpinning it. Some experts describe this as a need to improve the
general population’s evidence-literacy in the AOD area.
7. The NDS should outline its own policy development goals over the period of the strategy
and prioritise the areas of research / evidence building needed to inform and guide the
development of policy.
8. The mechanisms of Treasury, including productivity and other economic analysis, should
be better used to support whole-of-government effort and to prioritise the place of AOD
policy in the overall business of government and within the health, social inclusion and
related reform agendas.
9. Harm Reduction Victoria recommends that the NDS encourages a rigorous research and
evaluation effort into the efficacy and cost-effectiveness of our current drug laws and law
enforcement activities in achieving benefit to society. Such evaluations must also identify
and asses the potential and actual unintended consequences of such supply control and
law enforcement approaches. The findings from this research should guide the future
development and transformation of AOD policy to meet the needs of the future.
10. In the interim, it is recommended that the current balance of effort and expenditure be
reconfigured, so that harm reduction, education and treatment measures make up the
greater part of the funded effort. In the area of supply control, more consideration should
be given to developing regulatory mechanisms, rather than the enforcement of criminal
sanctions.
11. As one of the most under-resourced and under-evaluated areas of intervention, it is
recommended that the role of harm reductive peer education in working with drug users to
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
2
address specific areas of drug-related risk and harm should be greatly expanded. This
expansion should include provision for the development and evaluation of best-practice
models.
12. Harm Reduction Victoria recommends that the term “Harm Minimisation”, referring to
Australia’s Three Pillars AOD policy since 1985, should be replaced with a clearer, up-front
declaration of one over-arching principle: Harm Reduction.
13. Harm Reduction Victoria strongly cautions against the inclusion of any reference to
“Prevention” in the title of, or as an overarching principle in any new iteration of National
Drug Policy.
14. HRVic recommends that the NDS maintains and extends the current emphasis on reducing
alcohol-related harms in the community. We support the call for more investment in
developing evidence-based interventions and approaches for reducing alcohol-related
harms and recommend that the lessons learned are applied to the broader area of alcohol
and other drugs policy.
15. HRVic commends the educative and harm reductive approach taken towards tobacco use,
but urges greater mindfulness of the dignity and rights of those who have become
habituated to the drug. Utilising or allowing stigma and discrimination to play a role in
social policy, however worthy the aim, is ultimately harmful to the whole society as well as
to the victims of the stigma.
16. HRVic has similar concerns about the use of taxation and increased pricing to deter
smoking. Undoubtedly, this penalises long-term users, many of whom will face very difficult
if not impossible challenges to becoming abstinent. As many socially and economically
marginalised sections of the community have higher rates of tobacco dependence, the use
of taxation and price to reduce demand many in many respects further entrench poverty
and disadvantage. We urge more investigation of other means of reducing smoking rates,
such as those employed in California, and for research into the unintended social
consequences of increased taxation on tobacco users. We also suggest that subsidised
maintenance or substitution therapies should be investigated as a means of sheltering
highly dependent people who are economically disadvantaged from the impacts of higher
taxes and prices on tobacco.
17. HRVic recommends that the NDS provide leadership and guidance in the management and
reduction of harms from medically prescribed opiates and benzodiazepines. Simply
classifying any problematic use as simply “misuse” and relying solely upon regulatory
controls and the identification of “problem” consumers and prescribers ignores the
iatrogenic origin of such dependence and suggests no solution to the very real problems
experienced by those who have become dependent on these medications. Even where
problematic use has developed, the patient may still have the original legitimate need for
which the drugs were originally prescribed and cannot, with respect to human rights, simply
be “cut off”.
18. HRVic recommends the development of systematic approaches to harms arising from
prescribed psychoactive medications, such as the need for increased access to pain and
addictions specialists to support both patients and prescribers, improved access to opioid
substitution pharmacotherapy, particularly in regional areas and an investigation of the
impact of poor pain management on patient welfare and quality of life.
19. HRVic submits that the discrimination and vilification towards drugs users should be
rejected as a tool of social policy and recognised as harmful to its victims and to the
community at large. The discrimination experienced by people identified as drug users
should be named as one of the principle harms to be addressed through the NDS.
20. All interventions and instruments of alcohol and other drug policy should be assessed for
their potential to inflict or abet discrimination and stigma. Alcohol and other drugs policy
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
3
should include in its aims the social inclusion and integration of all people affected by
alcohol and other drug issues.
21. HRVic calls for greater integration of NDS and BBV policy, with shared support for and
engagement with the affected communities via their user organisations, and greater
emphasis on the development and implementation of peer education approaches, with
respect to BBVs as well as other drug-related harms
22. HRVic recommends that the NDS prioritises an evaluation of national treatment services for
alcohol and other drug services and explores ways in which national coordination of service
improvements can lead to better outcomes for patients and for the community.
23. HRVic calls upon the NDS to establish priorities and processes for improving access to
affordable ORT pharmacotherapy services across Australia and the removal of barriers to
equitable standards of care and the social inclusion and participation of pharmacotherapy
consumers. In particular, the NDS should work with the PBS and with state and territory
health departments to address the issue of fee-related poverty and disadvantage and to
ensure that all Australians have reasonable access to services.
Role and Scope of National Drug Strategy
1. HRVic strongly affirms the continued appropriateness of an overarching national strategy,
with buy-in from all states and territories, addressing alcohol, tobacco, prescribed and overthe-counter psychoactive medications and illicit drugs.
While the economic and cultural contexts, regulatory frameworks, patterns of use and the health
and social consequences pertaining to the multitude of substances thus covered will vary
enormously, the embodiment of a uniform set of overarching principles and policy objectives
continues to be of enormous importance. All of these substances are used voluntarily by
individuals seeking subjective benefits from their psychoactive properties. All have inherent risks
of harms attending their use and all are subject to use in ways that can be deleterious to the health
of the consumer, or which might involve risk of harms to others.
While all potential harmful chemical substances need to be managed, in terms of their purity, safe
manufacture, use and transport, their availability to the public etc, it is the mood or behaviour
modifying properties of the psychoactive chemicals of common use that necessitate a particular
management framework. While we remain short of a consensus agreement on a uniform set of
guiding principles for this management framework, which is complicated my historical, cultural and
political factors, most would agree that the system of management should be based upon respect
for the autonomy of individuals, concern for health and the prevention or reduction of harms to
consumers of drugs (including alcohol) where possible and the protection of the rights of others
from the harmful sequelae of drug using behaviours.
2. Harm Reduction Victoria urges policy makers to accept the proposition that the overarching
goals and principles for managing currently legal drugs, such as alcohol, and the currently
illegal drugs (bearing in mind that tea, coffee, alcohol and tobacco have all been proscribed
by governments in their times) must be uniform and consistent.
If we expect to have credibility with the people who use substances, an essential condition if we
seek to influence their choices and achieve our aims, we cannot appear to be arbitrary or
discriminatory towards them. Aiming to prevent the use of, say, cannabis per se, while being
content to simply reduce the problematic use of alcohol is logically inconsistent. An approach
which condones the use of a drug of majority choice, however harmfully used, and punishes the
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
4
use of drugs of minority choice, which may be less harmful, will be seen as cynical and arbitrary
and not based upon principle, just, or informed by science. Young people are particularly sensitive
to perceived injustice and hypocrisy, so one consequence of our ‘schizophrenic’ approach to drug
control is to severely weaken our capacity to speak credibly to young people about the very real
and substantial risks and harms associated with the use of all drugs.
A great many policy levers are available for influencing the production, availability, trade and
consumption of substances.
3. Harm Reduction Victoria suggests that the choice and development of policy interventions
should be based upon the best available evidence of the causes and dynamics of harms
arising from problematic use of substances, with the best logic and evidence-base for the
overall effectiveness of the interventions. Policy needs to be pragmatic and rational,
reflecting the world as it is, rather than utopian and moralistic, and to seek to reduce drugrelated harms while respecting the diversity of human behaviours, values and choices and
the inherent human rights and dignity of individuals.
Because the alcohol, tobacco and other drugs (AOD) area is so vast and complex, and because
there are so many intersections and cross-overs between AOD issues and other areas of
government policy and administration, eg public health and social services, law enforcement,
justice (inter alia) the advantages of a coherent drug policy reference-point with currency across all
government jurisdictions and the disadvantages of related social policy and services working at
cross-purposes are obvious. Perhaps as importantly, the health and social challenges faced by
the community from the problematic use of psychoactive substances continue to grow. If
significant progress is to be made in reducing harms and enhancing standards of health, a
concerted, consistent and robust national effort is required.
Decline in stature of alcohol, tobacco and drugs policy
HRVic has detected a growing perception amongst many of the experts and opinion leaders in the
AOD area that the profile and importance of drug policy has fallen in the national consciousness.
This may perhaps be reflected in the current Federal Government’s first term reform agenda. The
current workplace relations reforms, the education revolution, the social inclusion agenda, hospital
and health reform and environmental sustainability agendas proceed at great pace and depth,
while drugs policy receives little attention. Given the huge impact of alcohol and other drugs in our
economy, our social lives and our health system, together with the enormous remaining challenge
of developing more effective and appropriate means of reducing drug-related harms, this lack of
commitment towards AOD in the national agenda is regrettable. Without a strong central AOD
policy framework to provide consistent and evidence-based approaches, then where alcohol and
drug issues arise within other major areas of policies, such as indigenous health, there will be a
risk that the AOD policy components will be contradictory or running to divergent agendas.
HRVic suggests that the declining profile of AOD policy in national affairs may be partly due to a
lack of role clarity and chain-of-command developing in the governance and execution of NDS over
the last decade and a half, together with the lessened sense of crisis over HIV/AIDS, which had
impelled robust action in the past. It may also be true that the community as a whole has not been
kept engaged or particularly well informed in this area. Certainly, the temptation by politicians to
play the “public peril / law and order” card when elections are in the air and to avoid at all times any
rational debate or exposition of the evidence-base around drug policy and drug-related harms has
not enhanced to the capacity of governments to progress AOD policy in the overall business of
government, or to stimulate the nuanced understanding in the community that is required if there is
to be any resolute action in the future.
4. HRVIC recommends that the governance structures and processes of the NDS needs to be
clarified and strengthened.
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
5
5. The NDS should consist of a high-level document outlining global strategic goals, with a
chain-of logic analysis of the key principles and clear exposition of the evidence base
underlining the strategic directions and the hierarchy of objectives. This should be
supported and executed through lower-level, more specific action plans relating to
particular priority issues (areas of drug related harms), in which resourcing, roles and
responsibilities and progress evaluation measures are made explicit.
6. The Commonwealth should not only involve and include the community in its deliberations
on drug policy, but needs to work with community representatives and other experts to
better inform and engage the broader public on drug policy and the theoretical and
evidence-base underpinning it. Some experts describe this as a need to improve the
general population’s evidence-literacy in the AOD area.
7. The NDS should outline its own policy development goals over the period of the strategy
and prioritise the areas of research / evidence building needed to inform and guide the
development of policy.
8. The mechanisms of Treasury, including productivity and other economic analysis, should
be better used to support whole-of-government effort and to prioritise the place of AOD
policy in the overall business of government and within the health, social inclusion and
related reform agendas.
Harm Minimisation and balance
HRVic accepts the verdict that public support has declined for the notion of “Harm
Minimisation” (HM) as the guiding principle of the National Drug Strategy. Despite the noise
generated by a minority of anti-harm reductionists, however, this does not mean that there is
coherent demand for a major U-turn in policy away from the harm reduction component of HM.
Rather, the greater public have never really been let into the secret of what Harm Minimisation
actually involves. There has been such a lack of precision and clarity in the way the term
“Harm Minimisation” has been used, that it has been easy for recalcitrant elements (swimming
against the current of evidence) to dismiss it as merely “soft-on-drugs”. The idea of a balanced
policy incorporating demand reduction, supply reduction and harm reduction was, in fact, a
revolutionary development which enabled Australia to lead the world in reconciling AOD policy
with the need for a pragmatic and effective response to the public health crisis posed by the
emerging HIV/AIDS pandemic in the mid 1980s. Since that time, Australia has continued to
enjoy its international reputation for leadership due to its introduction of harm reduction within
the drug policy mix. Ironically, public engagement and support for the concept has been
allowed to falter domestically.
It would not be possible to support with evidence any claim that HM has failed because its
harm reduction elements have weakened or worked against the law enforcement or demand
and supply reduction pillars of our policy. In jurisdictions all over the world where harm
reduction principles and programs have not been supported or implemented, drug control
approaches have failed just as dismally, or even more so, than in this country. If drug policy
generally has failed to deliver upon expectations or hopes, it is suggested that those
expectations either were unrealistic, such as the 1998 UN goal of a “drug-free world by 2008”
or because some of the fundamental assumptions within the traditional drug-control paradigm
were incorrect or inappropriate.
It is certainly possible to make a case that the harm reduction elements of drug policy have
been undermined by inherent conflict with the law enforcement elements. We suggest that part
of the explanation for the decline in public understanding and support for HM has been
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
6
because there are internal contradictions between the still extant prohibitionist framework and
the harm reduction approach that have not been openly discussed or resolved. Health experts
and AOD practitioners speak about drug use in terms of public health and reducing harms,
whereas politicians, newspapers and other opinion leaders frame drugs issues in terms of Law
and Order. This has led to the community becoming confused, disillusioned and disengaged
around alcohol and drugs policy, and has opened the door to populist reaction against harm
reduction and increased stigma and marginalisation for individuals, families and professions
involved with alcohol and illicit drugs issues. The most lamentable result has been the
emasculation of the political will to take risks and to champion innovation, or even to openly
support evidenced-based practice in the alcohol and drugs arena.
Let us contrast this with the atmosphere following Prime Minister Hawke’s tearful disclosure in
1985 that his daughter had heroin-related problems. Where shame and stigma had kept the
tens of thousands of similarly affected Australian families isolated, voiceless and silent, Mr
Hawke’s revelations opened the door for the first time to a public re-appraisal of what the
paramount issues were. A summary of such shared concerns might look something like this:

Family members with illicit drug use problems faced social and economic
marginalisation and disengagement from education and employment, with poorer social
expectations.

Family members using drugs like heroin were at risk of engagement with the criminal
justice system, with poor future prospects as a result.

People who used heroin were at risk of fatal overdose

People who injected drugs were at risk of contracting HIV/AIDS and other infectious
diseases.
Such a prominent leader shedding his tears and expressing these fears allowed the
community, already alarmed by the escalating epidemic of HIV, to consider and discuss the
purpose and objectives of our traditional approach to (illicit) drugs policy. Abstract
moralistic concerns about whether or not people should use drugs were put aside. Many of
the nation’s children were using drugs; the risk of harm they faced was of much greater
moment. The practical and primary aim of drugs policy, it was increasingly realised, should
be the reduction of those obvious harms.
Harm reduction was not totally new. In relation to alcohol use, education to reduce risky
alcohol-related behaviours – without aiming to stop alcohol use per se – has always been
an important and growing part of the policy approach, as is using regulatory means as well
as social marketing to influence patterns of alcohol consumption that were associated with
harms in the community. The new approach, formulated in the National Campaign Against
Drug Abuse, was to employ a similar range of strategies to the harms associated with illicit
drugs. While the apparatus of prohibition was left intact, the new policy direction required
an acknowledgement that some level of illicit drug use would continue to occur and that, as
well as measures aimed at reducing the availability and demand for drugs, priority needed
to be given to developing means of reducing the high order drug-related harms.
The most immediate of those harms was HIV/AIDS, which created a need for bold and
timely action. In order to secure passage of these measures through parliament, those
wedded to the traditional law enforcement approach needed to be appeased. We now
have the evidence to confirm the effectiveness of measures such as needle and syringe
programs, the expansion of Opioid Replacement Therapy (ORT), or pharmacotherapy
maintenance and the engagement of drug users with credible, peer mediated health
education in preventing a major HIV epidemic amongst injectors, and in reducing other
drug-related harms.
Regrettably, there has been no concerted effort to evaluate or establish an evidence base
for the traditional elements of drug-control policy. This has been left alone because it was
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
7
obviously seen as being politically risky to antagonise the law and order fraternity or to
open governments and political parties to easy attacks on their credibility by opponents
willing to engender and inflame the moralistic fervour, misinformation and stigma that,
regrettably, had been part of the propaganda war on drugs since the 1930s. Over the
intervening years, we have seen politicians and governments growing progressively less
inclined to challenge the “fundamentals” of the prohibitionist drugs control paradigm and
increasingly ready to employ the “red-badge of courage” cynically conferred by appeals to
law and order, public safety and drug warrior status in the course of electioneering.
In the absence of any rigorous evaluation of the effectiveness of drug control laws and
strategies to reduce the quantum and impact of harm experienced by the community, we
currently rely on our experiences from daily practice and the reports from our communities,
as well as such published data as exist. From these sources, it is clear that the efficacy of
the Law Enforcement / Supply Reduction framework, as it currently operates, is by no
means self evident. International organisations such as LEAP (Law Enforcement Against
Prohibition) and the International Drug Policy Consortium argue strongly that the
prohibitionist legal framework and the activities of law enforcement in the interdiction of
manufacture, use and trade in drugs achieve little more than to guarantee the massive
profitability and continued resilience of the global trade in currently illicit drugs. They claim
that the consequent costs to the community are unacceptably high in terms of lives ruined
by criminalisation and imprisonment, the distortion of economies and international
development, in official corruption, in criminal violence and the high levels of preventable
disease and death amongst users of illicit drugs.
In many ways, even the “successes” of drug law enforcement may not reduce the overall
quantum of harm, but simply shift the trade and use of drugs into other directions that can
involve greater risks of harm. In Victoria, police sniffer (PAD) dogs are deployed in public
places and at targeted entertainment venues, with the stated aims of disrupting the trade in
harmful drugs and thus reducing drug-related harms and promoting public safety. The
most prevalently used and the most easily detectable of the illicit drugs is cannabis, a bulky
and odorous commodity.. One of the drugs of increasing concern to health authorities,
however, is GHB (gamma hydroxyl butyrate) and its analogues such as GBA and 1,4B.
These cheap, odourless liquids are associated with respiratory paralysis, coma and death,
especially if consumed with alcohol. They are industrial chemicals that are easy to access
and are correspondingly cheap. GHB has a sharp dose response, which means that a
small increment in dosage can result in severe adverse effects, making this a particularly
risky drug to be packaged, traded and consumed under completely unsupervised
conditions. Concomitant use of alcohol greatly increases these risks. The “success” of
PAD dog patrols in deterring and detecting the carriage of cannabis into entertainment
venues may very well be associated with the increased prevalence in use and harm from
GHB.
As well as GHB, recreational users of drugs may be more likely to carry or to purchase and
use drugs like methamphetamine and LSD, because they are perceived as less liable to
detection than cannabis. The recent interruption of supplies of quality MDMA in Australia,
which law enforcement activities may have contributed to, may mean that young people
intent on using drugs in the context of entertainment and socialising will be accessing and
using more risky and dangerous concoctions of ersatz “E”, which can contain ketamine,
methamphetamine and the potentially fatal chemical PMA (Para-Methoxy-Amphetamine)
and other adulterants, or to experiment with newly developed “research chemicals” about
which little is known.
9. Harm Reduction Victoria recommends that the NDS encourages a rigorous research and
evaluation effort into the efficacy and cost-effectiveness of our current drug laws and law
enforcement activities in achieving benefit to society. Such evaluations must also identify
and assess the potential and actual unintended consequences of such supply control and
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
8
law enforcement approaches. The findings from this research should guide the future
development and transformation of AOD policy to meet the needs of the future.
10. In the interim, it is recommended that the current balance of effort and expenditure be
reconfigured, so that harm reduction, education and treatment measures make up the
greater part of the funded effort. In the area of supply control, more consideration should
be given to developing regulatory mechanisms, rather than the enforcement of criminal
sanctions.
11. As one of the most under-resourced and under-evaluated areas of intervention, it is
recommended that the role of harm reductive peer education in working with drug users to
address specific areas of drug-related risk and harm should be greatly expanded. This
expansion should include provision for the development and evaluation of best-practice
models.
12. Harm Reduction Victoria recommends that the term “Harm Minimisation”, referring to
Australia’s Three Pillars AOD policy since 1985, should be replaced with a clearer, up-front
declaration of one over-arching principle: Harm Reduction.
Harm Reduction, prevention and drug control
The primacy of Harm Reduction as the overarching principle and aim of drug policy does
not necessarily mean that Demand Reduction or Supply Control mechanisms should not
feature in the policy mix. But these are means towards an end, and that end should be
recognised as the reduction of alcohol and drug-related harms in the community.
Internationally, the terms Harm Minimisation (HM) and “Harm Reduction (HR) are more or
less synonymous. This causes confusion in this country, where some (but not all) use HM
“correctly” in its broader, collective sense, yet others appear to consider the two terms as
interchangeable. Adopting the reduction of harms as the fundamental principle in AOD
policy, ie. harms involving the people using drugs, those around them, or the broader
community to which they belong, establishes purpose and direction for the management of
all psychotropic substances, whatever the pattern of use, or the nature of associated health
or other consequences. It also serves as practical guide and first step in assessing any
given situation and formulating an appropriate response. The principle covers all types of
substance and any pattern of use, but does not needlessly constrain or dictate the choice of
intervention.
Some critics of the HM policy have complained that Harm Minimisation, probably meaning
its Harm Reduction component, is at best a reactive and insufficient “band aid” process,
where the origins and drivers of the harm are not addressed, nor necessarily even
identified. HRVic acknowledges the superficial appeal of this argument, but considers it
somewhat naive. There is understandable frustration and fatigue in the community about
the perceived lack of progress in the “fight” against drug “abuse” [Sic] and the relentless,
perennial and intransigent nature of the “drug problem” The publicised victories in the War
on Drug(-user)s, such as huge hauls of contraband at the ports, successful prosecutions of
entire criminal networks etc, seem to make no difference, ultimately. The drugs are still just
as available, at more or less the same price; the same harms appear to recur over and
again without respite. Where one drug problem wanes, another waxes.
Under the previous government, harm reduction came under sustained attack, and talk of
“tough on drugs” and “Harm Prevention” became current. To the credit of the Howard
Government, however, dedicated funding for harm reduction programs such as the COAG
Needle and Syringe Program and Hepatitis C Education and Prevention initiatives
continued. With new state and territory funding agreements now investing more discretion
on health matters (including AOD) with the States, the prospect of continued adherence to
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
9
Harm Reduction as a driving force in AOD policy appears ever more precarious. One of
the consultation papers informing this current review of NDS asks the question as to
whether a Prevention focus should supersede “Harm Minimisation”. Harm Reduction
Victoria, together with other groups advocating for drug users’ health are experiencing a
real fear that this “economically conservative” reformist government might be looking to
Prevention as a likely banner to hang over a reorganisation of AOD policy.
It needs to be stated clearly that, in essence, preventing the uptake of drug and alcohol use
and / or preventing problematic patterns of consumption from developing are not
inconsistent with harm reduction (though they may be inconsistent with respect for the
dignity and autonomy of the private citizen). Not taking drugs, or not binge drinking are
clearly valid ways in which to reduce the occurrence of drug-related harms. But to promote
the notion of Prevention as a driving force in AOD policy would be both counterproductive
and regressive. As mentioned above, a stated aim of preventing the use of some popular
drugs, but no visible inclination to prevent the consumption of alcohol, perpetuates a huge
credibility gap with young people who use or are likely to use illicit drugs. This lack of
credibility weakens the prospects of working in partnership with the very populations we are
most concerned about. It also makes the business of conveying critical harm reduction and
health information to those at risk much more difficult.
The biggest problem with the notion of prevention, however, is that a policy framed around
it would be perpetuating something of a deception on the community and a disconnect
between those promoting such a policy and the real world that most of us live in. Rather
than an idea whose time has arrived, prevention has been the foundation stone of the drugcontrol edifice since the early twentieth century,. For all its emotive appeal and promise (“if
only we were more determined, if only we had the resources, if only we got tough and
increased sanctions”), prevention, at least as a stand-alone strategy, has one major, tragic
flaw: It simply doesn’t work; it has not worked; it can not work.
Life is complex, diverse and in many ways unpredictable. However obvious a solution
preventing drug use might seem, 80 odd years of evidence are against it. Not only has the
drug-prevention agenda failed to meet its own objectives, its unintended consequences,
repercussions and reverberations have caused incalculable harms. Internationally, we
have witnessed the fiasco of a UN policy aiming at “a drug free world by 2008”. People
have always used psychoactive substances and, to some extent, individuals will always
exercise choices about what they ingest and about their own psychoactivity. To sustain
utopian beliefs that the levels of drug-related harm we see in the community can be
significantly reduced by somehow preventing the use of alcohol and other drugs does
Australia a disservice.
Preventing problematic use Clearly, education and other means to reduce the age of
onset of alcohol and other drug use, or to address phenomena such as binge drinking are
not incompatible with Harm Reduction principles. Were reference made in the new NDS to
preventing problematic use, or preventing harm (not just reducing it), however, it is highly
likely that the temptation to reduce this simply to “Prevention (of use)” would prove too
great. This in turn would perpetuate the myth that getting tougher legislation, more
enforcement and exemplary punishments for those who get caught would lead to a
reduction in the quantum and severity of harms experienced by the community.
13. Harm Reduction Victoria strongly cautions against the inclusion of any reference to
“Prevention” in the title of, or as an overarching principle in any new iteration of National
Drug Policy.
Alcohol
Over recent years there has been an increasing recognition that alcohol-related problems
are amongst the most serious of all the drugs-related issues facing the community. At state
and local levels, more rigorous application of regulation has been called for. Nationally, the
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PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
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volumetric taxation of alcohol continues to play a part in moderating demand. Health
Promotion providing information on the risks of excessive alcohol consumption has stepped
up, with labelling of bottles now reflecting the number of standard drinks, and the NHMRC
guidelines around safer and riskier levels of drinking are gaining broad currency. There are
some calling for the labelling of alcohol containers with the kind of graphic health warnings
used with cigarettes. Communities are demanding their streets back from the mobs of
alcohol-fuelled thugs who take over inner city precincts and look to police, the licensing
authorities and the courts to achieve these aims. We continue to be concerned about
binge-drinking, especially amongst teenagers, and experiments such as higher taxation on
pre-mixed drinks have been part of the search for solutions to reduce these risky
behaviours. Health promotion campaigns addressing the risks of drink driving, together
with criminal sanctions against those who imperil the safety of others, have been
increasingly successful.
Yet no-one has suggested that we should be preventing the use of alcohol per se. There
are no stated aims to even ban alcohol advertising. Indeed, our overall approach to
alcohol, our most consumed psychoactive drug, is one of Harm Reduction. Harm
Reduction does not preclude the application of criminal sanctions against those whose drug
use imperils the safety and rights of others, provided such measures are based on
evidence and evaluated for cost-effectiveness and efficacy.
14. HRVic recommends that the NDS maintains and extends the current emphasis on reducing
alcohol-related harms in the community. We support the call for more investment in
developing evidence-based interventions and approaches for reducing alcohol-related
harms and recommend that the lessons learned are applied to the broader area of alcohol
and other drugs policy.
Tobacco
Tobacco has a unique place in the spectrum of commonly used psychoactive drugs. While
up to 20% of the adult population might use the drug, it (arguably) conveys the least
subjective benefit to its users and bears the most overwhelming burden of evidence as to
its deleterious effect on health. It is difficult to conceive of any way a person might reduce
their risk of harm from tobacco without ceasing to use it altogether. Yet as a society, we do
not ban the drug or impose criminal sanctions against those who trade or consume it.
Increasingly, we try to regulate where the drug can be used and to control the places and
the ages at which it can be purchased. We apply taxation, education and leadership within
the community in our national effort to reduce the use of and harmful consequences from
this drug and over time the smoking rate has dropped markedly.
Increasingly, however, the dignity and the rights of individuals who use this drug are
beginning to suffer. It should be remembered that tobacco smokers have become
habituated to or dependent upon a drug that was legally sold to them and taxed by the
government. Furthermore, all individuals deserve respect as autonomous human beings.
15. HRVic commends the educative and harm reductive approach taken towards tobacco use,
but urges greater mindfulness of the dignity and rights of those who have become
habituated to the drug. Utilising or allowing stigma and discrimination to play a role in
social policy, however worthy the aim, is ultimately harmful to the whole society as well as
to the victims of the stigma.
16. HRVic has similar concerns about the use of taxation and increased pricing to deter
smoking. Undoubtedly, this penalises long-term users, many of whom will face very difficult
if not impossible challenges to becoming abstinent. As many socially and economically
marginalised sections of the community have higher rates of tobacco dependence, the use
of taxation and price to reduce demand many in many respects further entrench poverty
and disadvantage. We urge more investigation of other means of reducing smoking rates,
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PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
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such as those employed in California, and for research into the unintended social
consequences of increased taxation on tobacco users. We also suggest that subsidised
maintenance or substitution therapies should be considered as a means of sheltering highly
dependent people who are economically disadvantaged from the impacts of higher taxes
and prices on tobacco.
Problematic use from prescribed medications
The problematic use of prescribed medications mainly concerns two major classes of
psychoactive drugs. These are benzodiazepines and opioid analgesics.
Opioid analgesics
In many rural and regional parts of Australia, where there are no
developed heroin markets, dependence and misuse of prescribed opioid analgesics can be
the predominant form of opioid dependence.
Those experiencing dependence and other harms from prescribed opioids include those
individuals with legitimate, chronic pain, as well as others who obtain diverted supplies from
pain patients. Individuals from either class may be involved in “doctor-shopping” or
prescription fraud, but this is by no means ubiquitous. It should also be borne in mind that
“doctor shopping” may often involve people with legitimate needs approaching other service
providers when one or more have failed them.
It is probably that in some areas, family GPs are maintaining individuals who have
dependence problems with prescribed opioids because other opioid replacement therapies
such as methadone or buprenorphine are not available in the area, or are thought to be
inappropriate to the circumstances of the individual patients.
Because issues of chronic pain management and iatrogenic opioid dependence are often
involved, advocacy and patient support can be extremely complex in this area, with regulatory
issues adding to the complexity for service providers.
Benzodiazepines
This group of minor tranquilisers, sedatives and anxiolytics has been
theoretically available from any GP, with minimal regulation and it is now widely recognised
that benzodiazepines have been generally over-prescribed. As with prescribed opioid
analgesics, however, it needs to be noted that many if not most people with benzo-use
problems and dependence are using a legitimately prescribed medication for a genuine
complaint.
Benzodiazepine dependence can be severe and difficult to treat. It may often be associated
with underlying nervous and psychiatric disorders.
Benzodiazepines are often a component in patterns of poly-drug use in which the harms
associated with other drugs, ie alcohol or opioids can often be magnified or accelerated.
While the medical system seeks to impose greater surveillance and regulation to address the
over-prescription of benzodiazepines and to reduce the inappropriate supply of some of the
particularly problematic varieties such as Xanax (alprazolam), little thought is generally given
to the on-going needs and rights of those currently dependent upon these legally obtained
drugs.
17. HRVic recommends that the NDS provide leadership and guidance in the management and
reduction of harms from medically prescribed opiates and benzodiazepines. Simply
classifying any problematic use as simply “misuse” and relying solely upon regulatory
controls and the identification of “problem” consumers and prescribers ignores the
iatrogenic origin of such dependence and suggests no solution to the very real problems
experienced by those who have become dependent on these medications. Even where
problematic use has developed, the patient may still have the original legitimate need for
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which the drugs were originally prescribed and cannot, with respect to human rights, simply
be “cut off”.
18. HRVic recommends the development of systematic approaches to harms arising from
prescribed psychoactive medications, such as the need for increased access to pain and
addictions specialists to support both patients and prescribers, improved access to opioid
substitution pharmacotherapy, particularly in regional areas and an investigation of the
impact of poor pain management on patient welfare and quality of life. Any planned
reduction in the availability of a commonly used drug of dependence should be matched
with an appropriately increased investment in treatment and support for those affected.
Social inclusion and discrimination
Illicit drug users, especially people who inject, are amongst the most marginalised and stigmatised
members of the community. One of the most damaging and regrettable outcomes of 80 years of
prohibition and criminal sanctions against users of certain drugs is that non-users are given
licence, whether by design or default, to shun, revile and preach hatred against people who, in the
first instance, do no harm to others. Australia has a number of antidiscrimination, equal
opportunity and human rights instruments across various jurisdictions to prevent discrimination,
vilification and unfair treatment in many other areas of life. None of these instruments, however,
names people who use illicit drugs as people to be protected form unfair treatment, the denial of
services and opportunities or from vilification.
If it is recognised that some of the drug-related harms we most fear, especially with respect to our
children, is that they will be disconnected from social participation, opportunity and achievement,
then marginalisation, discrimination and stigma around drug use should be recognised as some of
the serious harms that our policy should aim at minimising.
The only group in society more stigmatised and marginalised than drug users are former prisoners,
who typically face life-long discrimination, despite having paid their debts to society for past
wrongs. Attaching criminal penalties to users of drugs, such as exemplary gaol sentences for even
small-scale user-dealers, is a “gift that goes on giving”. In many areas, breaking the connection
between drug use and crime is seen as an important policy imperative, and police and court
referral to treatment schemes have evolved in many jurisdictions as alternatives to custodial
sentencing for minor offences.
It is clear, however, that it is the nexus between drug use and the application of criminal sanctions
as a method of control that has played a large part in the continued social stereotyping and stigma
that attaches to anyone whose illicit drug use becomes known. The illegality of illicit drug use is
also a factor in the failure of antidiscrimination and equal opportunity legislation to offer protection
to illicit drug users.
When looking at stigma and discrimination towards other groups, however, we recognise that
arbitrary and unfair treatment and vilification are wrong in themselves; not just because a person is
a particular age or gender or race, or hold to particular religious beliefs or cultural practices, but
because arbitrary and unfair treatment and vilification detract from the innate dignity of human
beings. We suggest that simply choosing to exercise some control over what one does with ones
own body should not disqualify a person from the same right to respect and fair treatment.
It is also recognised that discrimination and stigma are destructive forces. They undermine the
capacity of individuals to deal with their own problems, isolate them and often prove to be selffulfilling prophecies – ie if you tell someone they are no good, expect them to behave as if they are
no good and treat them as if they are no good, it should not be any surprise that some will end up
believing it and acting it out. Equally, stigma, discrimination and vilification are destructive to
harmonious communities. They appeal to humanity’s basest instincts, result in divisiveness and
undermine amity, communal effort and tolerance. Undoubtedly, the social shame attaching to illicit
drug users has historically been utilised as a tool of demand reduction and prevention and perhaps
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for this reason legislators have not seen fit to extend antidiscrimination protections to people who
use drugs.
19. HRVic submits that the discrimination and vilification towards drugs users should be
rejected as a tool of social policy and recognised as harmful to its victims and to the
community at large. The discrimination experienced by people identified as drug users
should be named as one of the principle harms to be addressed through the NDS.
20. All interventions and instruments of alcohol and other drug policy should be assessed for
their potential to inflict or abet discrimination and stigma. Alcohol and other drugs policy
should include in its aims the social inclusion and integration of all people affected by
alcohol and other drug issues.
Blood Borne Virus (BBV) Policy and NDS
Hepatitis C continues to be one of the major health issues affecting people who inject illicit drugs.
Some 200,000 individuals are though to be living with this chronic disease, at least 80% of whom
contracted it through unsafe injecting. Each year, an estimated 10,000 people are believed to
contract the disease, more than 90% of whom are injecting drug users. Australia has had in place
national and state Hepatitis C and HIV/AIDS strategies at national and state levels, with a new
iteration of the national BBV strategies currently nearing completion. HRV suggests that there
should be greater consonance of vision, aim and principle, shared resourcing and administrative
cross-over between NDS and the national Hepatitis C Strategy. With many of the generation of
IDUs whose contracted the disease in the 1980s now reaching the 25 to 30 years of chronic
infection at which end-stage liver disease and liver cancer become more probable, Hepatitis C is
surely one of the greatest harms experienced by illicit drug users. An estimated 200,000
Australians, predominantly injecting drug users, have already become chronically infected, with
around 10,000 new infections continuing to occur each year. This is unacceptably high and can be
considered as a mark of failure, not only of the Hepatitis C Strategy, but also of the NDS.
Reducing those harms could be better achieved, it may be argued, within the context of addressing
the broader harms that IDUs face as a group, rather than dealing with Hepatitis C in isolation.
While drug users are identified as having particular needs within the BBV strategies, the overall
tenor of these strategies is disease-specific, rather than population responsive. Given the vital role
that IDU peer education has played in the prevention of HIV and should be playing in the response
to Hepatitis C, it is disappointing that the relative role of drug users’ peer-based health advocacy
organisations within the BBV strategies is minimal. But such funding as state and national drug
user organisations get comes mainly from state or national BBV sources.
21. HRVic calls for greater integration of NDS and BBV policy, with shared support for and
engagement with the affected communities via their user organisations, and greater
emphasis on the development and implementation of peer education approaches, with
respect to BBVs as well as other drug-related harms.
Treatment and pharmacotherapy
Across Australia, access to AOD treatment services is chronically under-serviced, especially in
regional areas. With the advent of new health funding arrangements with the states, there is an
urgent need for the NDS to highlight and champion the need for greater access to, better choice of
and better quality of treatment services.
The role of Opioid Replacement Therapy, (ORT) or pharmacotherapy, needs to be recognised as
going beyond just treatment to address a wide spectrum of drug-related issues, such as
reintegration into the workforce, reduction in crime, improvements in general health. The
widespread lack of access to pharmacotherapy services across Australia, particularly in regional
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areas, means that people with opioid dependencies are being denied equitable access to the
health services they need and that the wider social aims of the program are not being met.
Additionally, administrative factors such as the cost of pharmacotherapy dispensing to the
consumer, the restrictive nature of many bureaucratic and clinical guidelines and the difficulties for
patients who need to travel, work or study militate against the therapeutic objectives of the
treatment programs. While each state manages its own program, the PBS arrangements around
methadone and buprenorphine are national responsibilities, and the need for national coordination
and improvements in services can better be achieved with leadership from the NDS.
22. HRVic recommends that the NDS prioritises an evaluation of national treatment services for
alcohol and other drug services and explores ways in which national coordination of service
improvements can lead to better outcomes for patients and for the community.
23. HRVic calls upon the NDS to establish priorities and processes for improving access to
affordable ORT pharmacotherapy services across Australia and the removal of barriers to
equitable standards of care and the social inclusion and participation of pharmacotherapy
consumers. In particular, the NDS should work with the PBS and with state and territory
health departments to address the issue of fee-related poverty and disadvantage and to
ensure that all Australians have reasonable access to services.
End
Damon Brogan
Executive Officer,
Harm Reduction Victoria Inc
NDS Submission, Harm Reduction Victoria
PO Box 12720 A’Beckett Street, Melbourne VIC 8006 Fax 03 9329 1501
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