Thinking about drugs policy: s ome core concepts that might underpin the next stage of Australia’s National Drug Strateg

1. 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 McDonaldConsultant in Social Research & EvaluationPO Box 1355, Woden ACT 2606, AustraliaPhone: (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)

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

3. 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.’

4. Distribution curve, e.g. consumption of a drug Number of people Many Few Level of consumption Low High

5. 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.’

6. 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)

7. The prohibition paradox (John Marks) Demand Black market gangsterism Epidemic intoxication Social use Supply Prohibition Control Free market

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

9. The concept of harm in ‘harm minimisation’ and ‘harm reduction’ • Harm is not proportional to use • Total harm = prevalence x intensity x micro-harm

10. Taxonomy of drug-related harms/costs

11. 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.

12. 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, MAR1992, p. 386)

13. 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.