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Alcohol and other drug use is a common feature of human experience, and is unlikely to stop completely. From prehistoric times humankind has used various substances in the hope of alleviating physical pain or altering states of consciousness. Almost all peoples have discovered some intoxicant that affects the central nervous system, relieving physical and mental anguish or producing euphoria (Davenpot-Hines, 2001).
This essay will firstly situate the drug prohibition and harm minimisation paradigms in their recent historical context identifying the social and political conditions that facilitated their evolution. Second, some important contemporary prevention and treatment programmes will be outlined identifying their salient benefits and limitations. Finally, the relevance of these programmes to a proposed restricted drug legalisation model will be reviewed.
Drug prohibition is a globalised legal system that mandates criminal sanctions in an attempt to eliminate the production, supply and use of certain drugs in society. The aim of prohibitionist policy is to create a drug free society. The thinking underlying this aim is simple: people will stop using them and the problem will disappear. The United States is the spiritual home of drug prohibition and remains its primary international driver (Davenpot-Hines, 2001; Ryder, Salmon, & Walker, 2006).
The modern-day 'War on Drugs' began when the United States president, Richard Nixon, characterised the abuse of illicit substances as "public enemy number one" at a press conference given on June 17th, 1971(Wisotsky, 1990). Eleven years later, not long after being sworn into office, United States president Ronald Reagan declared more militant policies in the 'War on drugs'. He promised a "to do what is necessary to end the drug menace" (Wisotsky, 1990,p 3). He signed a drug enforcement bill into law, which granted $1.7 billion dollars to fight the crisis, and ensured a mandatory minimum penalty for drug offences. He even enlisted the aid of the military in a role mainly involving interdiction efforts on United States borders and international waters. But combating illegal drug use requires an international effort, with many implications for United States foreign policy (Wisotsky, 1990).
Harm minimisation grew out of the realisation that drug prohibition is counterproductive (Wisotsky, 1990; Wodak, 1993). Harm minimisation is an overarching paradigm that provides a range of options aiming to improve health, social, and economic outcomes for both individuals and communities. It is a practical and pragmatic approach to reducing the risks and harms associated with legal and illegal drug use. Harm minimisation encompasses three broad strategies: a reduction in the production and supply of illicit drugs; the implementation of strategies designed to prevent the uptake of harmful drug use, including abstinence-orientated strategies to reduce drug use; and strategies designed to reduce drug- related harm for particular individuals and communities (National Drug Education Strategy, 2000). Its major focus has been on responding to the rapidly increasing numbers of HIV infections and associated deaths linked to unsafe injecting drug use in the 1980s(Ryder et al., 2006).
Within the harm minimisation framework, adopted by the Australian
Government as policy in 1985, a strong focus is on preventing the uptake of substance use and associated harms. Prevention is defined as "measures that prevent or delay the onset of drug use as well as measures that protect against risk and prevent and reduce harm associated with drug supply and use" (Ministerial Council on Drug Strategy, 2004, p.5). Prevention interventions for harmful drug use in Australia have focused on controlling access to substances and educating people as to their harmful effects. The success of these measures is widely debated, particularly in terms of the high cost of supply-reduction strategies (Wodak, 2000).
Attitudes and knowledge contribute to, but are only a part of, the complex set of biopsychosocial factors influencing substance use and other related behaviours. Prevention interventions need to target a wider range of factors than just attitudes and knowledge. There are a number of recognised models and approaches to prevention. Prevention initiatives can be defined in a number of ways. The public health concepts of primary, secondary and tertiary prevention refer to the stage of development of a disorder (Spooner, Hall, & Lynskey, 2001).
Primary prevention is aimed at stopping a problem from occurring. In the case of alcohol and other drugs, primary prevention programs might aim to prevent the use of tobacco and illicit drugs, prevent harmful use of alcohol or delay the uptake of these drugs. Some examples of primary prevention are: school drug education programs; comprehensive community prevention approaches involving local government, businesses and community; and health services providing family and youth support,
Schools are a critical setting in terms of prevention of drug misuse. However, school based prevention and early intervention should be much broader than purely drug education classroom activities. There is little evidence to support traditional school drug education programs implemented in isolation. Evidence also shows that some knowledge based drug education programs implemented in schools have increased drug use (Wallace & Staiger, 1998). Despite the expectation that education will change people's behaviour, evidence shows that changing people's attitudes or knowledge about a health-related topic does not necessarily translate into behaviour change. In particular, simply presenting information or relying on scare and fear messages have been shown to be ineffective in preventing harmful substance use (Abadinsky, 2004).
Secondary prevention is directed at people who may be at risk of developing a problem and aims to intervene early to try and prevent that problem from
occurring. For people who are already experimenting with and using substances, prevention approaches aim to divert people from progressing to harmful drug use. Prevention of harmful drug use can include abstinence as a goal, but can also include enabling people to use substances in ways that do not lead to dependence, disease, criminal sanctions, or death. Prevention interventions can vary in focus on preventing uptake or preventing harmful use.
Interventions aimed at stopping occasional drug users becoming dependent and promotion of responsible use of alcohol are both examples of
secondary prevention strategies. The use of financial incentives and disincentives, regulation and taxation maybe considered to be both primary and secondary prevention initiatives. They include such measures as restrictions on liquor licensing, levies on certain alcoholic beverages and tobacco products and 0.05 blood alcohol level legislation. Financial incentives and disincentives, regulation and taxation can reduce levels of harmful alcohol use and prevent the uptake of tobacco and alcohol. Some of these initiatives have been found to reduce initiation of use, consumption and harms among young people and are more successful when implemented as part of a comprehensive prevention approach, such as drink driving legislation being backed up by random breath testing and community education campaigns (Spooner et al, 2001).
Tertiary prevention measures are targeted at people with an existing drug disorder. They aim to reduce harms to the individual and community and may include treatment programs, supervised injecting facilities and needle and syringe programs. Many tertiary prevention approaches have been found to be successful in reducing the harm to the individual and the broader community (Spooner et al, 2001).
The treatment and management of alcohol and drug abuse is diverse and
complex. Traditionally, many treatment approaches adopted disease models of addictive behaviours, which characterise the substance user as having a biological predisposition to be unable to control their behaviour. These approaches favoured either a medical approach through pharmacological solutions, or abstinence community-based approaches, such as Alcoholics Anonymous.
There is a large and growing body of research into what constitutes effective treatment, which is being used to develop evidence-based treatments. There is, however, a diversity of evidence-based treatment options, and this is argued to be important for effectiveness and is consistent with the principles of harm minimisation. Miller and Hester (1995) recommend an 'informed eclecticism'; defined as openness to a variety of approaches that is guided by scientific evidence. This approach is based upon four central assumptions: first, there is no single superior approach to treatment for all individuals; second, treatment programs and systems should be constructed with a variety of approaches that have been shown to be effective; third different individuals respond best to different treatment approaches; and fourth, it is possible to match clients to optimal treatments, therefore increasing treatment effectiveness and efficiency.
Substance use has biochemical impacts and there is, therefore, an important role for pharmacological interventions. Pharmacological interventions take two main forms: pharmaceutical assistance with the withdrawal process; and replacement maintenance therapies. Assistance with withdrawal includes pharmaceuticals to ease the symptoms of withdrawal or to gradually wean the person from the dependent substance. Replacement Pharmacological interventions stabilise the individual so that other psychologically based treatment interventions can have greater effect (Abadinsky, 2004).
Nicotine replacement therapy has been shown to double the success rate for quitting (Abadinsky, 2004). Nicotine replacement therapy is available through the use of patches, gums, nasal sprays, inhalers, or non-nicotine bupropion, which all have similar success rates. Several withdrawal and maintenance therapies exist for alcohol dependence. Antabuse interferes with the metabolism of alcohol, producing unpleasant sensations such as sweating, nausea and headaches, which can last from two to four hours, but the evidence of its effectiveness is limited. Naltrexone has been shown to be more effective, and acts by blocking the euphoric effect of drinking alcohol without the negative sensations experienced from Antabuse (Abadinsky, 2004).
For opiate dependence, there are a number of pharmacotherapy options in Australia. Results have shown naltrexone, an opioid receptor antagonist, to be effective for rapid detoxification under light sedation. Naltrexone not only blocks these receptor sites, which prevents any opiates from working, but also displaces any existing opiates that currently occupy those sites (Tucker& Ritter, 2000). There is, however, no evidence that rapid detoxification with naltrexone under anaesthesia provides better outcomes than rapid detoxification under light sedation (Abadinsky, 2004;Tucker& Ritter, 2000).
Naltrexone is also registered as a form of maintenance treatment for those who have stopped using heroin. It blocks both the craving for heroin and the effects of heroin if it is used (Abadinsky, 2004).
The traditional treatment of opioid addiction involves substituting the opioid with an equivalent dose of a longer acting opioid agonist such as methadone, followed by tapering to a maintenance dose. Methadone maintenance therapy does not resolve opioid addiction, but has been shown to result in improved general health, retention of patients in treatment, and a decrease in the risk of transmitting HIV or hepatitis. However, critics of methadone maintenance point out that this strategy substitutes one drug of dependence for the indefinite use of another. Detoxification followed by abstinence is another treatment option, which can be used as the initial treatment of opioid addiction, or offered as a final treatment strategy for people on methadone maintenance (Abadinsky, 2004).
Buprenorphine produces a milder, less euphoric and less sedating effect than full opioid agonists such as heroin, morphine and methadone, but its activity is usually sufficient to diminish cravings for heroin, and prevent or alleviate opioid withdrawal in dependent heroin users. By its dual effects of producing opioid responses while blocking the effects of additional heroin use, buprenorphine reduces continued use of heroin (Abadinsky, 2004).
It is important to consider that pharmacological interventions are currently available for only some of the more dependence-producing substances; namely, tobacco, alcohol and opiates. They are not currently available for other substances such as cannabis and amphetamines
A wide range of psychological treatment options are available that vary in their approach depending on the goals of treatment (Abadinsky, 2004). The most widely accepted treatment options have expanded to incorporate approaches based on psychological principles of behaviour change, such as cognitive behavioural therapy. The central elements of cognitive behavioural therapy strategies are based on established principles of social learning theory. Cognitive behavioural therapy focuses on the functional analysis of substance abuse identifying cognitions associated with substance abuse. The emphasis is on identifying, understanding, and changing underlying beliefs about the self and the self in relationship to substance abuse. Cognitive behavioural therapy approaches can provide clients with practical skill development, enhance their feelings of self-efficacy, and address issues underlying the substance use, including the affective states that may act as triggers for substance use (Abadinsky, 2004).
According to Wodak (1993), current drug prohibitionist policies have failed to contain illicit drug use, as indicated by increasing quantities of illicit drug seizures, increasing numbers of people applying for entry to methadone maintenance, and increasing numbers of illicit drug-related deaths. Wodak (1993) maintains that the illegality of heroin, cocaine, and amphetamines encourages intravenous drug use as the most efficient way to extract the maximum effect from impure and expensive black market drugs. Prohibition also contributes to overdose deaths because users have no assurance about the potency and purity of the drugs they are using. Lack of access to clean injection equipment leads to the sharing of contaminated needles and syringes, and hence to the transmission of hepatitis and HIV between injecting drug users.
Increasing the penalties for possession, use and sale is like imposing a tax on illicit drugs, which is collected by the traffickers (Ryder et al., 2006). The huge profits to be made from producing and trafficking in illicit drugs attract criminals into the industry. Increasing the effectiveness of interdiction and law enforcement simply selects more ruthless and violent criminals. The consequence of all these policies is the high cost of illicit drugs, which encourages addicts to become involved in criminal activity to support their habits (Davenpot-Hines, 2001;Wodak, 1993). The commission of property offences is the most obvious way of raising money, one that the public subsidises by paying higher household insurance premiums. Drug dealing is also an effective way of raising revenue which contributes to the spread of drug use (Ryder et al., 2006). A successful approach will be based on an understanding of what is realistically possible to achieve; clearly the aim of a drug free society is an impossible outcome (Davenpot-Hines, 2001).
The term 'legalisation' presents difficulties in that it covers proposals that range from literally removing illicit drugs from the criminal law system, to those which would limit their availability to adults much as alcohol and tobacco are now regulated (Goode, 1997). The most likely outcome is the adoption of more specific proposals, which would allow access to illicit drugs through clinics or other health services only to those with established habits and partially decriminalise the possession of small quantities of illicit substances such as marijuana.
This holistic approach incorporates reduction in demand and control of supply with the continuation of harm minimisation initiatives and is most likely to be able to deliver some degree of effective outcomes (Ryder et al., 2006). For example, a low rate of HIV infection is the direct result of this important strategy, and one which has not been achieved in countries which did not adopt harm minimisation to address HIV and injecting drug use. They include USA, and countries within South East Asia and parts of United Kingdom (Abadinsky, 2004;Ryder et al., 2006).
The most likely outcome for this model of legalisation will be an intensification of ambivalence reflected in the coexistence of a medical model approach to addicts, and a punitive approach to criminal activity. Thus, drug policy will be framed by a drive toward the partial decriminalisation of illicit drug use. This will result in the continued diversion of users from the criminal justice system into treatment; a continuation of needle-exchange programmes to reduce the transmission of HIV; and the adoption of heroin by prescription in which carefully screened and registered long term heroin users are given the drug under strictly controlled conditions. This would also serve to attract more users into treatment.
Most people with harmful substance use problems do not attend specialist alcohol and drug services, but instead seek no help or are engaged with other services within the health, welfare and criminal justice systems. Evidence shows that up to 80% of people who experience drug-related problems resolve these without any formal treatment at all (Ryder et al., 2006). Consequently, it is essential to recognise the potential for self-initiated change and self-help, and the treatment role of a wide range of sectors and professional groups. This is unlikely to change with the advent of this model of legalisation.
In Sum, Australia's illicit drug policy is founded on prohibition similar to the United States model. Harm minimisation was introduced into Australia in 1985 in an attempt to limit the spread of blood born viruses by issuing clean syringes to injecting drug users. By and large harm minimisation has been an attempt to ameliorate the harsh effects of prohibition.
In the last few decades, major advances have been made in the field of prevention and treatment of the use and abuse of drugs. Primary, secondary and tertiary interventions have proved promising. However, drug education is problematic as it lacks sufficient empirical support. Contemporary treatment programmes are based on the rationale that behavioral and pharmacological treatments operate by different yet complementary mechanisms that produce potentially additive effects.
A restricted legalisation of illicit drugs model consistent with the principles of harm minimisation will lead to a diversion of resources away from law enforcement to increased funding of prevention and treatment programmes. Many of these will attract more users into treatment and consequently have to be expanded. The partial decriminalisation of illicit drug use will be subject to the same regulation that alcohol and tobacco are now.