********************************************************** Thinking about drugs policy: some core concepts that might underpin the next stage of Australia’s National Drug Strategy A presentation to the Families and Friends for Drug Law Reform, Canberra, 22 May 2003 ********************************************************** David McDonald Consultant in Social Research & Evaluation PO Box 1355, Woden ACT 2606, Australia Phone: (02) 6231 8904 (national); +61 2 6231 8904 (international) Email: David.McDonald@xxxgpo.com.au (remove the xxx from the email address; including it here it is an anti-spam measure) Acknowledgement of country NGO/community role in development of local and national drug policy Evaluation of NDS being conducted now and next phase of NDS commencing July 2004

Overview Origins of Australia’s harm minimisation policy The prevention paradox The prohibition paradox Unpacking and refining the concept of ‘harm’

Feb 1985 DA:NA Workshop Conclusion: ‘While there are still the traditional polarised views on the use of drugs, there is now increasingly a common ground within the Australian community on appropriate action on the abuse of drugs.’ Recommendation 1: ‘The objective of a national policy on drug use should be to minimise the harmful consequences of the use of drugs to individuals, their families, and the community as a whole including the needs of special groups. Therefore a national, comprehensive approach will be needed.’ Wksp run by ADFA (Alc & Drug Fdn, Aust) at request of Cwlth Minister for Health Dr Neil Blewett Source: Brown, VA, Manderson, D, O'Callaghan, M & Thompson, R 1986, Our daily fix: drugs in Australia, Australian National University Press, Rushcutters Bay, N.S.W. Emphasis in original. DA:NA = Drugs in Australia: National Action

Distribution curve, e.g. consumption of a drug Number of people Many The Prevention Paradox – where to target interventions - consider both shape of the consumption function and optimal points of intervention (mode; tail; or shift the curve to the left) Single distribution or distribution of consumption theory: French social scientist Sully Ledermann (1956). ‘Ledermann argued that a single function, a lognormal curve, provides an accurate estimate for the distribution of alcohol consumption in any society. Given the addictive properties of alcohol, some might have expected alcohol distribution to be bimodal, with one peak level among moderate or "social" drinkers and a second peak level among those who are physically dependent on alcohol. Contrary to this expectation, Ledermann found a unimodal distribution which is continuous and highly skewed. Perhaps the most controversial aspect of Ledermann's work is the contention that the dispersion of this distribution is relatively invariate and can be estimated from the mean.’ (Single, E 1992, The Myth of the Single Distribution; Guest lecture presented at Simon Fraser University May 26, 1992, Canadian Centre on Substance Abuse, viewed 08 Feb 2002, <http://www.ccsa.ca/docs/sfu.htm>) Few Level of consumption Low High

The prevention paradox Geoffrey Rose 1981; 1992: ‘A large number of people exposed to a small risk may generate many more cases than a small number exposed to high risk.’ ‘A preventive measure that brings large benefits to the community offers little to each participating individual.’ The converse of the prevention paradox : ‘When many people each receive a little benefit, the total benefit may be large.’ The actual paradox a la Rose is ‘A preventive measure that brings large benefits to the community offers little to each participating individual.’ Rose, G 1981, 'Strategy of prevention: lessons from cardiovascular disease', British Medical Journal (Clinical Research Ed.), vol. 282, no. 6279, pp. 1847-51. ---- 1992, The Strategy of Preventive Medicine, OUP, Oxford.

Contemporary challenges to the prevention paradox (Ann Roche) The shift away from measures of mean consumption, as the principal indicator of use and problems, towards an incorporation of temporal patterns of use alcohol may represent an exception to the population health models based on mean distributions; there is no prevention paradox if episodes of intoxication are examined instead of mean consumption levels; it is more useful to focus on at-risk drinking than attempt to locate groups of at-risk drinkers; harm minimisation offers a constructive conceptual vehicle by which to shift the focus from consumption to consequences of use. ***************************************************************** Policy implication for drugs generally: we need to get the right mix of: universal interventions (focusing on the whole community); targetted interventions (focusing on at-risk population groups); and indicated interventions (focusing on people already exhibiting risky behaviour) Part of the rationale for harm reduction (narrow definition) ‘This paper identifies seven major conceptual and perceptual shifts which have occurred in the alcohol field in recent years and which influence approaches to the prevention of alcohol-related problems. The paper highlights the shift away from measures of mean consumption, as the principal indicator of use and problems, towards an incorporation of temporal patterns of use. No longer is the traditional parameter of mean per capita consumption seen to be the predominant measure by which alcohol and its associated problems are assessed. Also examined are the relative merits of prevention strategies that include the whole population and those aimed at people at high risk. The key shifts identified are: …’ Source: 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. Taxonomy of prevention source: Mrazek, PJ & Haggerty, RJ (eds) 1994, Reducing risks for mental disorders: frontiers for prevention intervention research, National Academy Press, Washington DC.

The prohibition paradox (John Marks) Demand Black market gangsterism Epidemic intoxication “Prohibition peddles use - Controls control use - Free market promotes use” Alcohol approaching top right; tobacco close; prescribed pharmaceuticals near optimal point; heroin near top left; cannabis between top left and optimal point. …the happy medium of controlled availability: ‘This occurs where the elastic demand is squeezed to a minimum and the inelastic demand is satisfied legally, that is, where those with self-control are given every reason to assert it, and those without self-control are sustained until they develop it.’ (Marks 1990, p. 9) Marks, J 1990, 'The paradox of prohibition', in J Hando & J Carless (eds), Controlled availability - wisdom or disaster? Papers from the National Drug and Alcohol Research Centre Annual Symposium, University of New South Wales, February 1989, National Drug and Alcohol Research Centre, University of New South Wales, Kensington, NSW, pp. 7-10. Marks, J 1993, 'The paradox of prohibition', in C Brewer (ed.), Treatment options in addiction: medical management of alcohol and opiate abuse, Gaskell, London. Social use Supply Prohibition Control Free market

The prohibition paradox (Stephen Mugford) Harm Currently illegal drugs Currently legal drugs 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 Supply Low availability High availability

The concept of harm in ‘harm minimisation’ and ‘harm reduction’ Harm is not proportional to use Total harm = prevalence x intensity x micro-harm Unpacking ‘harm’ in harm minimisation/harm reduction: Harm is not proportional to use – so need to differentiate HR/HM policies from use reduction policies – tho use reduction is part of HM - different but overlapping policies needed Source for total harm = prevalence x intensity x micro-harm is MacCoun, RJ & Reuter, P 2001, Drug war heresies: learning from other vices, times, and places, Rand Studies in Policy Analysis, Cambridge University Press, Cambridge, UK.

Taxonomy of drug-related harms/costs Type of harm/costs Who bears the harm/costs Sources of harm/costs Users, dealers, intimates, employers, neighbourhood, society Drug use, legal status, interventions 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 Source: 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, RJ & Reuter, P 2001, Drug war heresies: learning from other vices, times, and places, Rand Studies in Policy Analysis, Cambridge University Press, Cambridge, UK.

Our responses to drug-related problems lack coherence Responses are characterised by:- lack of information on how to develop and implement interventions in particular contexts; lack of information on what is implemented and how; lack of information on the short-term outcomes and longer and deeper impacts of interventions; lack of information on the cost-effectiveness, cost-benefit and cost-utility of the interventions; and responding to problems after they have developed, rather than anticipating them and giving primacy to prevention. Our society’s responses to drug-related problems – policies, strategies and on-the-ground interventions – lack coherence in parallel with our relatively poor understanding of the nature, extent and causes of the problems. One response to this is the proposal by a small consortium of Australian researchers (with international advisers), led by Professor Margaret Hamilton, to undertake a major study titled ‘Responding to illicit drug problems in Australia - what is the best return on investment? The core research question will be What is the optimal mix of interventions that will produce the minimum level of net illicit drug-related harm in Australia?

The ‘net harm’ approach ‘Policies have unwanted side effects. Taxes create moonshining, regulation creates evasion and corruption, prohibition creates black markets, programs cost money and often create perverse incentives. Since all drugs are dangerous and all policies are costly, we ought to consider, for each drug and for all of them together, what set of policies would create the least onerous overall problem, adding together the damage done by drug abuse and the damage done by attempts to control it.’ (Kleiman, MAR 1992, p. 386) The norm is for particular policies and interventions to be developed and implemented with little or no reference to their likely impacts on other interventions. These impacts could be positive (e.g. where a particular style of street-level policing facilitates drug users’ entry into treatment) or negative (e.g. where a particular style of street-level policing causes heroin users to inject quickly, increasing their risk of overdose). The issue becomes, then, addressing net harm, i.e. taking into account, and weighing, both the positive and negative consequences of interventions, and looking broadly to identify the consequences of one intervention for other interventions. Despite all the money spent by governments, community organisations, businesses, etc. to address drug problems, and Australia’s 18 years of experience with a centrally-coordinated National Drug Strategy, decision-makers still have little idea what are the optimal points to intervene and, especially, what are the optimal mixes of strategies needed to attain desired goals. The framework given above – the taxonomy of harms – provides a starting point for a net harm analysis. But we need far more information from both careful trials and observational studies to learn more about how to minimise net harm – to learn what is the optimal mix of interventions in a given setting.

Sources and notes Slide 3: The Drugs in Australia: National Action workshop was run by the Alcohol & Drug Foundation, Australia. See Brown, VA, Manderson, D, O'Callaghan, M & Thompson, R 1986, Our daily fix: drugs in Australia, Australian National University Press, Rushcutters Bay, N.S.W. Emphasis in original. Slide 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. Slide 6: 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. Mrazek, PJ & Haggerty, RJ (eds) 1994, Reducing risks for mental disorders: frontiers for prevention intervention research, National Academy Press, Washington DC. Slide 7: Marks, J 1990, 'The paradox of prohibition', in J Hando & J Carless (eds), Controlled availability - wisdom or disaster? Papers from the National Drug and Alcohol Research Centre Annual Symposium, University of New South Wales, February 1989, National Drug and Alcohol Research Centre, University of New South Wales, Kensington, NSW, pp. 7-10. Marks, J 1993, 'The paradox of prohibition', in C Brewer (ed.), Treatment options in addiction: medical management of alcohol and opiate abuse, Gaskell, London. Slide 8: Mugford, S. 1995, pers. com. Slide 10: 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, RJ & Reuter, P 2001, Drug war heresies: learning from other vices, times, and places, Rand Studies in Policy Analysis, Cambridge University Press, Cambridge, UK. The authors list the sources of harm as drug use, legal status and enforcement. Since drug education and other prevention programs, and drug treatment, are also potential sources of harm/costs, the broader term ‘interventions’ is used here. Slide 11: One response to this is the proposal by a small consortium of Australian researchers (with international advisers), to undertake a major study titled ‘Responding to illicit drug problems in Australia - what is the best return on investment? The core research question would be What is the optimal mix of interventions that will produce the minimum level of net illicit drug-related harm in Australia? Slide 12: Kleiman, MAR 1992, Against excess: drug policy for results, Basic Books, New York, NY.