Harm+minimization,+are+we+doing+it+right?

Harm Minimization: Are We Doing it Right? Click Play Button Below! media type="file" key="Click Here.mp3" width="240" height="20" By Jenny Prasad Student N6540627 __ **The Artifact** __

The artifact below is an audio clip from 774 ABC Melbourne Radio, reporting on the 2011 rejection of a medically supervised injecting clinic (MSIC) in the suburb of Richmond, Victoria. State premier, Ted Baillieu, vetoed the proposal for a trail clinic following increased pressures from local business owners and residents. The media coverage was in response to Baillieu’s suggestion that more police on the streets and tougher penalties would be a more effective method of reducing drug-use and related harm than an MSIC, which he believed would be viewed as an endorsement of drug use.


 * __ The Public Health Issue __**

The public health issue represented by the artifact is harm minimization in relation to illicit drug use. The principle of harm minimization has formed the basis of the drug policy framework in Australia since 1985 (QPL 2002). The audio clip raises the question whether current government policy, services and attitudes are successful in achieving this goal. By presenting supporting views from a current user, a recovered addict and a staff member from a Sydney MSIC, the interviewer highlights the success that such services can have in improving health outcomes for addicts. Opposing views from local business owners and retailers on same street as the Sydney MSIC however, exemplify societal views of addiction and community opposition to a clinic of this nature. __ **Literature Review** __

Health outcomes for illicit drug users such as overdose, mental health issues, Hepatitis C, B and suicide contribute to 2% of the overall burden of disease in Australia (NDARC, 2007). Between 2001 and 2003, deaths as a result of illicit drug use increased from 1038 to 1705 per year while disability-adjusted-life-years (DALYS) had increased to 51,000 (AIHW, 2007). While lower than the general population, drug use prevalence in regional Australia increased by 77% for heroin, 131% for amphetamines, 37% for cocaine and 47% for cannabis between 1988 and 1998 (Peterson, 2007). This rise represents a 52% increase in the need for services in regional areas, however only a 16% increase in funding has been provided (Peterson, 2007).

Illicit drug use has social, economic, and health consequences on both the individual and the community. While the common goal shared by all governments in relation to illicit drug use is harm minimization, there is a divergence of views in relation to the best approach. The two extremes of the continuum are harsher criminal penalties versus a policy of decriminalization, both aimed to reduce burden of disease of illicit drug use (Hughes & Stevens, 2012).

While Australia supports a strict prohibition policy regarding illicit drug use, harm minimization is a key pillar of the approach (QPL 2002). Health focused services such a methadone clinics, needle and syringe exchange programs (NSEP) and a medically supervised injecting clinic (MSIC) have been successful in reducing harm to illicit drug users. From 2000 to 2009 it has been estimated that NSEPs have directly averted 32,050 new HIV and 96,667 new HVC infections. For each dollar invested in this program, more than four additional dollars were saved in healthcare costs (Lilly, Mak & Fredericks 2013). Australia’s sole MSIC, located in Kings Cross, Sydney has also experienced marked success in terms of harm minimization. In ten years of operation since opening in 2000, the clinic has:


 * Managed 4,400 overdoses without a single fatality
 * Provided more than 9,500 referrals to health and social welfare services
 * Reduced publically discarded needles in Kings Cross by 50%

Source: (Sydney MSIC, 2013)

While Australian policy does incorporate some harm minimization strategies, since 1985, The National Drug Strategy and federal policy has been underpinned by a “zero tolerance” attitude toward drug use (Wellbourne-Wood, 1999). Despite this hardline approach, drug-related arrests have increased by 18.4% in the last five years (ACC, 2012). It has therefore been questioned whether the arrest and criminalization component of the illicit drug policy serves to support the goal of harm minimization, hinder it or makes no difference at all.

South Australia is the only state in Australia to decriminalize marijuana or any illicit drug. While this policy change saw the substitution in the drug using population from harder drugs such as heroin, amphetamines and cocaine to marijuana, the overall heath outcomes were still more positive than before the policy change. The severity of treatment episodes and drug related admissions into hospital decreased significantly as a result of the change (Damrongplasit, Hsiao & Zhao, 2010).

The United States of America (USA) and Sweden have both adopted “zero tolerance” policies in regards to illicit drug use with the view of a drug-free society (QPL, 2002). These governments therefore impose harsher criminal penalties upon those who are charged with drug-related offences in order to deter the uptake and continued use of drugs. Research has shown however, that tougher punitive consequences have no effect on the prevalence of illicit drug-use (Maag, 2003), (Wellbourne-wood, 1999), (Model, 1993).

In stark contrast to this approach, in 2001, Portugal moved to decriminalise all illicit substances and shift the emphasis of their policy toward the treatment and rehabilitation of problematic users (Hughes and Stevens, 2012). Those issued with civil notices for drug-related offences would appear before a tribunal of medical practitioners and social workers who would assess whether the level of use was problematic or not and hand down a sentence that would best address the person’s treatment needs.

Hughes and Stevens (2012), reported health outcomes, which included a significant reduction in mortality from 2001 to 2008 as, follows:
 * Reduction in HIV cases from 907 to 267
 * Reduction in AIDS cases from 506 to 108
 * Reduction in TB
 * Decline in problematic drug use with a reduced severity of hospital admissions significantly decreasing
 * Opioid deaths decreased from 95% to 59%
 * Increased uptake of drug treatment services

Despite the decrease in negative health outcomes for users in Portugal, this report found that the number of people using illicit substances has increased by up to 4% since 2001. This growth however, is aligned with that of neighbouring countries, France and Spain and furthermore, does not have a causal relationship with the change in policy.

Like Portugal, The Netherlands has also experienced success in reducing drug related harms through a change of policy in 1976 (QPL 2002). While illicit drugs were not decriminalized, the Dutch authorities tolerate personal, non-problematic use of all illicit substances (Maag, 2003). The policy focuses on the arrest and criminalisation of drug traffickers and producers while offering addicts who commit crimes, rehabilitation programs instead of prison time (QPL 2002). This policy is based on the notion that in prisons, dependant users will not have access to the treatment they require and therefore no reduction in harm to the individual or the society will be achieved. Maag (2003) observed that through needle exchange programs in the 1980s the number of people injecting drugs declined from approximately 330,000 in 1990 to 110,000 in 2010. Today only 4 to 5% of HIV infections in the Netherlands are associated with injecting drug use. HCV incidence dropped from 28% in 1980s to 2% in 2005 and HIV incidence dropped from 8.6% to 0 in 2006. The Netherlands has also observed a lower incidence of overdose in hard drug users over the last decade. A report by the Queensland Parliament Library in 2002 found that while lifetime and recent use of cannabis is in the Netherlands (25.7% and 7.0%) is on par with the European average (23.2% and 6.7%), treatment episodes involving cannabis as the primary substance, has tripled between 1995 and 2009. It is unclear whether this is a result of increased availability of treatment services, changes in drug preferences or increased referral policy.

Although the approach to harm minimization varies significantly from country to country, there is a shared commonality in the success and value of health focused strategies. Evidence from Australia, Netherlands, USA, Sweden and Portugal all indicate that the criminalization of illicit drugs has no relationship with the uptake and lifetime prevalence of use. However, several studies have found associations between criminalization policy and other health and socioeconomic outcomes.

Although cannabis users make up 65% of those arrested in Australia for drug-related activities, this only represents 1-2% of the using population (ACC, 2012). For this small number of users, the outcome of a criminal record could lead to difficulties in gaining employment, restrict travel possibilities and marginalize them as a criminal offender for years, after even a minor offense (Ahern, Galea & Stuber, 2007). Research by Earnshaw and Copenhaver (2012) showed that criminalization policies contribute to the stigmatization of addiction. The prejudice, stereotypes and discrimination that recovering drug addicts and current users face can lead to increased rates of mental illness and even poorer physical health outcomes.

__ **Cultural and Social Awareness** __

Problematic drug users are those who, through dependence, cause harm to themselves, negatively impact the community and contribute to the burden of disease (Drug and Alcohol Office, 2010). These individuals only make up only a small proportion of the using population in Australia. The most vulnerable groups, likely to become addicted to illicit substances are Aboriginal and Torres Strait Islands, rural and remote populations and those with a family history of violence, sexual abuse and trauma (QPL 2002).

Economic, social and environmental disadvantage are shared factors between these groups, which not only lead to poorer health outcomes but also an increased risk of drug dependence (Peterson, 2007). Addiction is driven by the fulfillment of emotional and psychological needs of the user. Therefore studies suggest that external factors are responsible for the increased risk of ones’ drug use turning from recreational to problematic. (AIHW, 2007). As research points to the equity gap in our community playing an important role in driving problematic drug use, policy and services should focus on addressing the root causes of these issues. However, this is not currently the outcome of a criminalization policy.

There is a moral panic in our society that drug users are non-compliant with social norms, are focussed on getting high at the expense of other people’s safety and furthermore, that they are out of control and untrustworthy (Armstrong, 2007). This moral panic is perpetuated by the media and reinforced by government policy, which discriminates and marginalises drug addicts (Bright et, al. 2007). A study by Armstrong (2007) found that these attitudes in our society actually alienate people who require professional help in rehabilitation or other health issues. By classifying them as criminals, we are excluding addicts from normal society and creating an environment where users are encouraged to hide their addiction rather than facing judgement if they seek help.

The multifaceted view that research presents of the risk factors associated with addiction, can be described by the socialist view of “structure”. This theory accepts that environmental factors play a significant role in determining whether an individuals’ drug use becomes problematic or not. The opposing view of this social theory is “agency”. This is represented by society’s view of addiction; that it is a lifestyle of choice for an individual and furthermore, in the control and capacity of the user to change.

At present, the population lacks education and understanding about the nature of addiction and the causal risk factors; in place of this knowledge is a moral panic, which influences Australia’s approach toward harm minimization (Bright, et, al., 2013). Not only does public opinion shape government policy, government policy in turn, drives the attitudes of a society. Unless there is a cultural and societal shift in attitude to recognize addiction as a medical condition, which requires treatment, there will continue to be a disassociation between the evidence base for harm minimization and the illicit drug policy in Australia. To readdress this issue, addiction must be approached like any other condition, which is a determined by a range of environmental factors. Therefore the government policy should reflect a tolerant and accepting attitude, which supports addicts to overcome the causes of their continued dependence.

__ **Analysis of the Artifact** __

Although the Sydney MSIC has proven successful in reducing death, disease and increasing public safety in the suburb of Kings Cross and in over 90 other clinics globally, the Victorian government refused to implement the program in Richmond, following public pressure. This response, which completely ignores the irrefutable amount of evidence on harm minimization, mirrors that of the current Australian policy in most states and territories today.

The second major issue represented by this interview is the moral panic surrounding addiction. One shop owner refers to the clients of the clinic as, “…the kind of people you don’t want hanging around”, while another retailer suggests that immediately after exiting the clinic, clients seek out another person to, “…take more drugs with, somewhere else.” The same business owners suggest that the clinic deters people from walking down the same street as the clinic to avoid the clients. This is a good example of the negative attitudes that community has toward drug-users.

A staff member of the clinic suggests that the Victorian premier is, “…making decisions based on opinion polls rather than evidence.” This statement is a good case in point of the overall complex interplay between politics and morality of policy making that this audio clip represents.

Although an overwhelming amount of evidence suggests that there is a far better way to approach harm minimization, this is ignored by the community and by policy makers. There has been a long-standing negative connotation in our community regarding the nature of addiction and drug use. I believe that if the community isn’t educated to understand the cause of problematic drug use better, we will continue to waste resources on an ineffective policy of criminalization which while offers the illusion that something is being done about the issue of problematic drug use, is making no difference at all.

**__ Reference List __** Ahern, J., Stuber, J., Galea, S. (2007). Stigma, discrimination and the health of illicit drug users. //Drug and Alcohol Dependance, 88//, 118-196. doi:10.1016/j.drugalcdep.2006.10.014

Armstrong, E. (2007). Moral Panic over Meth. Contemporary Justice Review, 10:4, 427-442. DOI:10.1080/10282580701677519

Australian Crime Commission (ACC). (2012). Illicit Drug Data Report 2011-2012. Retrieved from http://www.crimecommission.gov.au/publications/illicit-drug-data-report

Australian Institue of Health and Welfare (AIHW). (2007). Statistics on drug use in Australia 2006. Retrieved from AIHW website http://www.aihw.gov.au/ publication-detail/?id=6442467962

Bright, S., Bishop, B., Kane, R., Marsh, A., Barratt, M. (2013). Kronic hysteria: Exploring the intersection between Australian synthetic cannabis legislation, the media and drug-related harm. //International Journal of Drug Policy, 24//, 231-237. Retrieved from http://dx.doi.org/10.1016/j.drugpo.2012.12.002

Bright, S., Marsh, A., Smith, L., Bishop, B. (2007). What can we say about substance use? Dominant discourses and narratives emergent from Australian Media. //Addiction Research and Theory, 16:2//, 135-148. DOI: 10.1080/16066350701794972

Damrongplasit, K., Hsiao, C., Zhao, X. (2010). Decriminalization and Marijuana Smoking Prevalence: Evidence from Australia. //Journal of Business & Economics, 28:3//, 344-356. DOI: 10.1198/jbes.2009.06129

Drug and Alcohol Office, Government of Western Australia. (2010). Drug trends and crime tracking: Relationships between indices of heroin, amphetamine and cannabis use and crime. Retrieved from http://crimeprevention.wa.gov.au/uploads/file/Drug %20Trends %20and%20Crime%20Report.pdf

Earnshaw, V., Smith, L., Copenhaver, M. (2012). Drug Addiction Stigma in the Context of Methadone Maintenance Therapy. //International Journal of Mental Addiction, 11,// 110-112. DOI 10.1007/s11469-012-9402-5

Hughes, C., & Stevens, A. (2012). A resounding success or a disastrous failure: Re-examine the interpretation of evidence on the Portuguese decriminalization of illicit drugs. //Drug and Alcohol Review, 31//, 101-113. Doi; 10.1111/j.1465-3362.2011.00383.x

Lilley, G., Mak, D., Fredericks, T. (2013). Needle and syringe distribution trends in Western Australia, 1990 to 2009. //Drug and Alcohol Review, 32//, 320-327. DOI 10.1111/j.1465-3362.2012.00510.x

Maag, V. (2003). Decriminalization of cannabis use in Switzerland from an international perspective – European, //American and Australian Experiences. International Journal of Drug Policy, 14,// 279-281. doi:10.1016/S0955-3959(03)00069-0

Model, E. (1993). The Effect of Marijuana Decriminalization on Hospital Emergency Room Drug Episodes. //Journal of the American Statistical Association, 88//, 737-747

National Drug and Alcohol Research Center (NDARC). (2007). Illicit drug use in Australia: //Epidemiology, use patterns and associated harm. (2nd Edition).// Retrieved from Department of Health website http://www.health.gov.au/internet/Drugstrategy /publishing.nsf/Content/17B917608C1969ABCA257317001A72D4/$File/mono-63.pdf

Peterson, G. (2007). Harm minimization strategies: opinions of heath professionals in rural and remote Australia. //Journal of Clinical Pharmacy and Therapeutics, 32//, 497-504. DOI 10.1198/jbes.2009.06129Publications/ResearchBriefs/2002/2002006.pdf

Queensland Parliament Library (QPL). (2002) //Minimizing the Harm of Illicit Drug Use: Drug Policies in Australia.// Retrieved from Queensland Parliament Library website http://www.parliament.qld.gov.au/documents/explore/Research

Sydney MSIC. (2013). Fact Sheet: Sydney Medically Supervised Injecting Center. Retrieved from http://www.sydneymsic.com/images/resources/pdfs/fact%20 sheets%20msic_aug%202010_singles.pdf

Wellbourne-Wood, D. (1999). Harm reduction in Australia: some problems putting policy into practice. //International Journal of Drug Policy, 10//, 403-413. Doi: 10.1198/jbes.2009.06129