Thinking about Burdens and Harms Third Annual ACT Alcohol and Other Drugs Sector Conference All Things Being Equal: Exploring the Burdens of Harm Canberra, 24 June 2010 David McDonald Visiting Fellow, National Centre for Epidemiology and Population Health, The Australian National University Consultant in Social Research & Evaluation

The drug availability/harm dilemma (John Marks/Stephen Mugford) High harm Currently illegal drugs Currently legal drugs The U shaped curve – types of harm, sources of harm – return to this Apparent paradox or dilemma: Question: why do some people advocate reducing the availability of the currently legal drugs while at the same time advocate increasing the availability of the currently illegal drugs through a regime of controlled availability? Answer: different sources and types of harm, so different types of policies required. (Main sources of harm for the illegals are their illegal status and patterns of enforcement. Main sources for the legals are their high levels of consumption.) Optimal point Low harm Supply Low availability High availability

The assessment of harms is … Statistical e.g. incidence & costs of alcohol-related road crashes

Statistical data [Copyrighted slide removed]

The assessment of harms is … Statistical e.g. incidence & costs of alcohol-related road crashes Social e.g. intoxication is acceptable in some social settings Normative (i.e. judgement of ‘what ought to be’) e.g. the death of police office, a drug trafficker or a bystander in a shootout between police and the trafficker

Three key contemporary resources 1. Babor, T et al. 2009, Drug policy and the public good, Oxford University Press, Oxford. 2. Babor, T et al. 2010, Alcohol: no ordinary commodity – research and public policy, 2nd edn, OUP, Oxford. 3. National Preventative Health Taskforce, Tobacco Working Group 2008, Tobacco control in Australia: making smoking history, Technical Report No 2, [Department of Health and Ageing], Canberra (Michelle Scollo, writer).

Which harms? The public health perspective: morbidity, mortality and disability The hidden harms: social harms Goldstein’s taxonomy of the links between drugs & crime: economic (e.g. robbery), pharmacological (inhibitions lifted), drug markets (violence), lifestyles

Social harms (cont.) Community amenity: public nuisance and disorder and vandalism Violence Family: divorce/marital problems, child abuse Education problems Individual & family financial problems Workplaces: injuries and other problems Loss of employment Fiscal impacts National instability – failed states Global terrorism Unintended adverse consequences of drug policies and interventions Etcetera

The mechanisms through which harms are caused Diagram from DP p. 19 harms from dose, use patterns & mode of admin – also deal with toxicity, psychoactive/intox effects & dependence Also deal with context & expectancies and social reactions: drug set & setting Bases of risk: some in DP p. 15: natural or synthetic, how ingested, any medical use, consumption patterns, drug combinations, situational factors, behavioural factors. Source: Babor et al. 2009, p. 19.

Attempts to align policies to the relative harms of different drugs International Conventions (treaties) E.g. Convention on Psychotropic Substances, 1971 Article 4. If the World Health Organization finds: a) That the substance has the capacity to produce i) 1) A state of dependence, and 2) Central nervous system stimulation or depression, resulting in hallucinations or disturbances in motor function or thinking or behaviour or perception or mood, or ii) Similar abuse and similar ill effects as a substance in Schedule I, II, III or IV, and b) That there is sufficient evidence that the substance is being or is likely to be abused so as to constitute a public health and social problem warranting the placing of the substance under international control, the World Health Organization shall communicate to the Commission an assessment of the substance, including the extent or likelihood of abuse, the degree of seriousness of the public health and social problem and the degree of usefulness of the substance in medical therapy, together with recommendations on control measures, if any, that would be appropriate in the light of its assessment. 163 word sentence!

‘A rational scale to assess the harm of drugs of potential misuse’ Source: Nutt et al. 2007, pp. 1047-53.

Different harms in different population groups For example low SES financial strain and smoking cessation outcomes Mental illness comorbidity Aboriginal people note confounders of poverty, access to services, mental health Different distributions of risk factors and protective factors in different population groups

Policy implications of assessing harm potential It is not just the chemical characteristics of the drugs that determine harm, but also how drugs are used, drug interactions, society’s responses to drugs and people who use drugs, etc. Nonetheless, harm potential should be prominent in informing policy decision-making.

Studies of the Burden of Disease and Injury Begg, S, Vos, T, Barker, B, Stevenson, C, Stanley, L & Lopez, AD 2007, The burden of disease and injury in Australia 2003, AIHW, Canberra. Includes topline findings for each State & Territory, but not ATOD and other risk factors – these are provided for Australia only Vos, T, Barker, B, Stanley, L & Lopez, A 2007, The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003, School of Population Health, The University of Queensland, Brisbane. Begg, S, Bright, M & Harper, C 2009, Burden of disease and health adjusted life expectancy in Health Service Districts of Queensland Health, 2006, Queensland Health, Brisbane. Zhao, Y, Guthridge, S, Magnus, A & Vos, T 2004, 'Burden of disease and injury in Aboriginal and non-Aboriginal populations in the Northern Territory', Medical Journal of Australia, vol. 180, no. 10, pp. 498-502. VicHealth, Burden of Disease (BoD) - LGAs and regions 2001, http://www.health.vic.gov.au/healthstatus/bod.

ATODs as risk factors for the BoD Disability-Adjusted Life Years (DALYs) 2003 Combine mortality, morbidity & disability Do not cover the ‘hidden harms’, i.e. social harms Tobacco, alcohol and illegal drugs: 12.1% of the total burden tobacco: 7.8% of the total burden of disease & injury alcohol: 2.3% in net terms illicit drugs: 2.0% ATOD only tobacco: 65% of the drug-related burden alcohol 19% illicit drugs 16% Not available for the ACT by risk factor (Source: Begg et al. 2007 & presenter’s calculations) Some will be surprised at the relatively high impact of illicit drugs, up there with alcohol. The largest component within the illicits is 'heroin & polydrug abuse' (33% of the burden attributed to illicit drugs) which is largely the impact of illicit drug-related mortality. This is followed by the impacts of hepatitis C (23%), with cannabis abuse, suicide & self-inflicted injuries, hepatitis B, benzo abuse and 'other' each contributing 10% or less.

Taxonomy of drug-related harms/costs Type of harms/costs, e.g. Who bears the harms/costs Sources of harms/costs Users, dealers, intimates, employers, neighbourhood, society, etc. Drug use, legal status, interventions, etc. Health Social & economic functioning Safety & public order Criminal justice system This matrix applies in a particular policy setting, for a particular drug or combination of drugs – so five dimensions in all Note that sources of harm in MacCoun et al. are use, illegal status & enforcement which too limited – Rx & prevention can/could also produce unintended negative outcomes It helps to identify the policy levers and policy instruments Incomplete and needs complexifying - how deal with interactions? Gateway dynamics? Challenges in assessing harms include which harms, poor data on the magnitude of the social harms, no common metric for measuring and comparing harms except for dollars but we don't have the date on this (MacCoun et al 1996 p338) Source: adapted from MacCoun & Reuter 2001.

Conclusion ‘Harm’ is a complex concept ‘Where we sit determines what we see’ Thinking about the ACT’s drug-related burden of harm The facts and figures on health & social harms The community’s values and expectations The sources of drug-related harms Who in our community bears the drug-related harms A discussion of burden of harm should lead us to think critically about how complex the concept of harm really is. It leads us to think about how ‘where we sits determines what we see’, that is the social and value issues that relate to identifying and determining the extent and nature of harms, independent of any statistical, factual way of thinking about harms. Unpacking the idea of burden of harms draws attention not only to the extent and nature of harms, but also to the particular harms to be included in our overview. It draws attention to how the sources of those harms are found in the drugs themselves, in drug use, and in societal responses to drugs, drug use and people who use drugs. It draws our attention to who actually bears the harms. Although this is complex, that is the reality of addressing drugs in the ACT community. The type of approach that I have presented -- we can call it a type of policy analysis -- has potential for helping us to select the levers or policy instruments that are going to be most effective and most cost-effective. Such a policy analysis will only work, however, if it deals with both the statistical evidence and with our community’s norms about which harms, borne by whom, need to be addressed, and what might be the thresholds that shift particular types of harm from a low priority category into high priority category. And that will be one of the challenges for the next ACT Alcohol, Tobacco and Other drug Strategy.

Sources and notes (1) Babor, T et al. 2010, Alcohol: no ordinary commodity - research and public policy, 2nd edn, OUP, Oxford. Babor, T et al. 2009, Drug policy and the public good, Oxford University Press, Oxford. Bennett, T & Holloway, K 2009, 'The causal connection between drug misuse and crime', British Journal of Criminology, vol. 49, no. 4, pp. 513-31. Goldstein, PJ 1985, 'The drugs/violence nexus: a tripartite conceptual framework', Journal of social issues, vol. 15, no. 4, pp. 493-506. Kendzor, DE et al. 2010, 'Financial strain and smoking cessation among racially/ethnically diverse smokers', American Journal of Public Health, vol. 100, no. 4, pp. 702-6. Kleiman, MAR 1992, Against excess: drug policy for results, Basic Books, New York, NY. Kleiman, MAR 2009, When brute force fails: how to have less crime and less punishment, Princeton University Press, Princeton. MacCoun, R, Reuter, P & Schelling, T 1996, 'Assessing alternative drug control regimes', Journal of Policy Analysis and Management, vol. 15, no. 3, pp. 330-52. MacCoun, R & Reuter, P 2001, Drug war heresies: learning from other vices, times, and places, Rand Studies in Policy Analysis, Cambridge University Press, Cambridge, UK McKie, J & Richardson, J 2003, 'The rule of rescue', Social Science and Medicine, vol. 56, no. 12, pp. 2407-19. Mrazek, PJ & Haggerty, RJ (eds) 1994, Reducing risks for mental disorders: frontiers for prevention intervention research, National Academy Press, Washington DC. Mugford, S 1991, 'Drug legalization and the 'Goldilocks' problem: thinking about costs and control of drugs', in MB Krauss & EP Lazear (eds), Searching for alternatives: drug-control policies in the United States, Hoover Institution Press, Stanford, Calif. Mugford, S 1993, 'Harm reduction: does it lead where its proponents imagine?' in N Heather, A Wodak, EE Nadelmann & P O'Hare (eds), Psychoactive drugs and harm reduction: from faith to science, Whurr, London. National Preventative Health Taskforce, Tobacco Working Group 2009, Tobacco control in Australia: making smoking history, Technical Report No 2, including addendum for October 2008 to June 2009, [Department of Health and Ageing], Canberra, writer: Michelle Scollo. Nutt, D, King, LA, Saulsbury, W & Blakemore, C 2007, 'Development of a rational scale to assess the harm of drugs of potential misuse', The Lancet, vol. 369, no. 9566, pp. 1047-53. Roche, AM 1997, 'The shifting sands of alcohol prevention: rethinking population control approaches', Australian and New Zealand Journal of Public Health, vol. 21, no. 6, pp. 621-5 . Rose, G 1981, 'Strategy of prevention: lessons from cardiovascular disease', British Medical Journal (Clinical Research Ed.), vol. 282, no. 6279, pp. 1847-51. Rose, G 1992, The Strategy of Preventive Medicine, OUP, Oxford.

David McDonald’s contact details Director Social Research & Evaluation Pty Ltd 1004 Norton Road, Wamboin NSW 2620 Phone: (02) 6238 3706 Mobile: 0416 231 890 Facsimile: (02) 9475 4274 Email: david.mcdonald@socialresearch.com.au Online: www.socialresearch.com.au Visiting Fellow National Centre for Epidemiology & Population Health The Australian National University Canberra ACT 0200 Email: david.mcdonald@anu.edu.au