Families and Friends for Drug Law Reform
The Heroin Crisis: Why we need Courage
There is a growing body of research, which supports anecdotal evidence, that the need to fund illicit drug use, particularly heroin use, contributes significantly to increasing levels of property crime and robbery. It has been conservatively estimated that the cost of all these harms to the Australian community is more than $18 billion each year.
In 1998, 14 deaths occurred in the ACT from drug overdoses. That was two-thirds of the ACT road toll for 1998. The financial and human cost of treatment for injecting drug users who overdose (whether or not they survive) is also high. This includes the actual dollar costs to the health system, the police, the courts and the economy, as well as the obvious emotional cost to the family and friends of the victim. Estimates by the National Drug and Alcohol Research Centre show that the number of overdose deaths in Sydney has risen by more than 130 per cent in the past five years and by more than 200 per cent in regional New South Wales.
Injecting drug users are at higher risk of contracting a blood-borne disease than the general population, primarily through injection under unhygienic circumstances. Such injection also risks a variety of other forms of infection and disease. Between 60 and 70 per cent of all injecting drug users have an infection of at least one blood-borne disease. As of 30 September 1997, we estimate that there are 208 people living with HIV in the ACT, of whom 38 have AIDS. Surveillance data show that injecting drug use is a factor in up to 11 per cent of HIV infections in the ACT and there is no reason to believe that this situation is any different throughout Australia.
People with injecting drug behaviour are also at high risk of contracting hepatitis C. Since 1989, the ACT has recorded 1,554 notifications of hepatitis C. According to reliable estimates, at least 143,000 Australians currently have an infection of hepatitis C as a result of injecting drug use since 1970, and 11,000 more are becoming infected each year. We still poorly understand the natural history of chronic hepatitis C, but at least a proportion of those infected will go on to develop severe end-stage liver disease. For every 1,000 injecting drug users newly infected with hepatitis C in a given year, there is an implied $14.32 million in health care spending over the years as the disease manifests, with cumulative total costs of $0.5 billion after 60 years as the costs of successive hepatitis C infected injecting drug users join the prevalence pool. If the estimated 10,000 new HCV infections in injecting drug users in Australia per year were to continue for the next 60 years, total direct health care costs will be around $4 billion over that period.
Reliable estimates calculate that 20 per cent of people with chronic hepatitis and 40 per cent of those with cirrhosis would be unable to work as a result of these illnesses and thus would have an entitlement to a disability pension. The costs of treating some patients with interferon, and compounding factors such as carriage of the hepatitis B virus or increased alcohol has not received consideration in these estimates.
There has also been a recent increase in the numbers of injecting drug users contracting hepatitis A in the ACT. Evidence suggests that a bout of hepatitis A can exacerbate the symptoms in someone already infected with hepatitis C. Hepatitis A is an acute viral infection with a worldwide distribution. Risk factors relevant to injecting drug users include blood-to-blood contact (eg. needle sharing), faecal-oral contact (eg. poor hygiene) and faecal to blood contact (contaminated hands pass infection when injecting). According to a study by Dr Nicole Gilroy in 1998, prior to 1996 there were fewer than 25 reports per year of hepatitis A in the ACT. By June 1998, the ACT Department of Health had reported 42 cases of hepatitis for the year. The most frequently reported risk factors for both 1997 and 1998 were contact with a known case of hepatitis A and intravenous drug use.
As a legislator and as a parent, I find the rising cost of drug abuse to our community completely unacceptable. I must emphasise that I support a harm minimisation framework consistent with the National Drug Strategic Framework. The framework has three elements, namely: reducing supply through law enforcement; reducing demand through education and rehabilitation programs; and reducing harm through maintenance programs and needle exchange programs.
Within this framework, I strongly believe that there is a need to closely examine new approaches such as a heroin trial and safe injecting places. When I first proposed the heroin trial, people suggested that I was being courageous as defined by Yes Minister. As you may recall, Sir Humphrey Appleby said on this program that, "If you wish to describe a proposal in a way that guarantees that a Minister will reject it, describe it as courageous." Nevertheless, it is time for courage in our approach to this issue.
One of the more pleasing aspects of the debate is that people are gradually becoming more prepared to try new approaches in dealing with this issue. The proposed heroin trial, initially put forward by the ACT and then adopted by Victoria, is one such new approach. Prescribed heroin may or may not be an effective treatment for certain addicts although the Swiss results are very encouraging. No two people with heroin dependency are alike, so it is my view that successful treatment programs will make a number of different and flexible approaches available.
In June 1995, Dr Gabrielle Bammer and her team from the National Centre of Epidemiology and Population Health at the Australian National University presented to me their report about a proposed trial. This report built upon the recommendations of the ACT Legislative Assemblys Select Committee on HIV, Illegal Drugs and Prostitution 1989-91 chaired by Mr Michael Moore. The proposed trial would follow the same processes as for a new medical drug and would have three stages: firstly, a first pilot study containing 40 volunteers who had been participating in the ACT methadone program. If the first stage was successful, there would be a larger study with 250 participants and the same eligibility as the first trial; and if the second stage was successful, a full-scale clinical trial would be conducted involving 1,000 participants from three cities including Canberra and Melbourne. At the end of the trial process, we would have evidence-based assessment of the role of heroin in maintenance treatment, the subgroups in whom this treatment is most likely to be useful, and other information. This would allow a more balanced perspective on medical prescription of this drug.
The report recommended that the ACT Government establish a task force representing a broad cross-section of the community to seek the views of the public and to determine whether or not stage one of the trial, involving 40 participants, should go ahead. As a new government, we knew that this would not occur without political pain. After extensive consultation, the task force, chaired by former New South Wales State Coroner Kevin Waller, recommended that stage one should proceed. My government took the view that there was no point in going ahead with a limited trial without the support of a majority of states and financial support from the Commonwealth.
I sought national support for the trial at the 1996 and 1997 Ministerial Councils on Drug Strategy. The 1997 Ministerial Council agreed to support a trial together with other new treatments such as buprenorphine and naltrexone. Subsequently. the Federal Cabinet advised us that the Federal Government would not provide financial support for an ACT heroin trial or allow the dispensations under the relevant legislation needed to conduct the trial. The Prime Minister advised me at the Premiers Conference that the position of the Federal Government had not changed.
Nevertheless, other nations have been prepared to hold heroin trials, notably Switzerland and the Netherlands. While results from the Netherlands trial are not yet available, the results from Switzerland are very encouraging. Switzerland held a trial between 1 January 1994 and 31 January 1996. The narcotics tested in the program included morphine, methadone and heroin for intravenous and oral use. In addition, the program also tested use of both heroin and cocaine in cigarette form. The Swiss researchers established 16 treatment centres treating 1,146 patients. The admission criteria stipulated: a minimum age of 20 years; a history of heroin dependency of at least two years; and failed participation in other treatment programs on several occasions.
The objectives of the study were to ascertain the effects on the health, social integration and dependent behaviour of the research participants; the suitability of this treatment for heroin dependents whose previous therapy had been unsuccessful; and effectiveness of this treatment compared with that of other therapies currently available.
The trial of injectable heroin proved to be successful against these criteria. The recruitment of patients, retention rate and level of compliance were better with the prescription of injectable heroin than with that of injectable morphine and methadone. Injectable heroin also proved to have fewer side-effects. Participants income from illegal and semi-legal activities declined from 69 per cent to 10 per cent. According to police and patient records, both the number of offenders and the number of criminal offences dropped by approximately 60 per cent. The illicit use of heroin and cocaine decreased markedly whereas benzodiazepine use decreased slowly and the consumption of alcohol and tobacco hardly declined at all. The participants housing situation rapidly improved and stabilised.
The fitness for work of participants increased markedly. The number of people with permanent employment more than doubled (from 14 per cent to 32 per cent) and the number of unemployed fell by more than a half (from 44 per cent to 20 per cent). The improvements in physical health which occurred during treatment also proved to be stable over the course of one and a half years and in some cases continued to increase. In physical terms, this relates especially to general and nutritional status and injection-related skin diseases.
As a result of the success of the heroin trial, the people of Switzerland decided in a referendum for it to continue. The overall majority for the proposition was 70 per cent and a majority of voters in every canton voted yes.
Another innovation worth considering is the provision of safe injecting places for addicts. A number of reports, including the Wood Royal Commission in New South Wales, have recommended provision of safe injecting places. It is important to emphasise that safe injecting places must form an element of a broadly based approach, because to focus on them in isolation exaggerates their importance. They have proven to be useful and indeed essential elements to the approaches being taken elsewhere, but they are only one of the many elements we need to have in a properly planned harm minimisation approach. The ACT Assembly will consider establishing a safe injecting place in the ACT later this year.
In the ACT, we would develop this service as an entry point for injecting drug users to access services and support, including detoxification services, methadone or other treatment programs. Clients would be able to access sterile injecting equipment, to inject in a clean, safe environment and dispose of equipment safely. It would also provide more immediate and reliable medical attention for those who overdose, as well as provide a safer work environment for ambulance officers attending an overdose, as they would know the location and that it would be well-lit and safe.
It would improve the public safety implications of injecting drug use. By reshaping the circumstances under which a person injects, a safe injecting facility not only has the potential to improve the health of the person, but to reduce the criminal and public nuisance impact of intravenous drug use. There is considerable community concern about the use of public toilets and places such as parks for injecting activities, associated with the injury and infection of non-users from poorly-disposed-of needles. Although only a small number of Australian residents inject drugs, the impact of this use is significant. In 1997-98, the ACT Government collected 15,387 syringes from public toilets and 7,571 syringes from public places. The provision of safe disposal facilities would reduce the risk associated with injury from discarded injecting equipment.
Frankfurt in Germany has had safe injecting places for nearly ten years. There have been amazing improvements in terms of blood-borne diseases, overdose deaths and crime rates. For example, in 1991, 147 people overdosed and died in Frankfurt. In 1997, that number was down to 22. In 1992, the ambulance services were dealing with 15 drug-related emergencies every day. Now they deal with two per week.
In 1992, between 70 per cent and 80 per cent of heroin addicts in Frankfurt had HIV. Now only 18 per cent have HIV. The numbers of homeless people have decreased. There has also been a decrease in crime over the past decade with break-ins to cars down by 30 per cent and robberies down by 20 per cent.
One of the more pleasing aspects of the debate is that discussion of our drugs problem is now on the agendas of the Prime Minister, Premiers and Chief Ministers as well as Health and Police Ministers. The Premiers Conference of April 1999 devoted a large part of the agenda to the discussion of alternative options and the Commonwealth Government offered additional funding for these programs.
With a couple of exceptions, it developed a useful set of guidelines for progressing a national approach to illicit drug use. Heads of governments agreed to work together to make a new investment in prevention, early intervention, education and the diversion of drug users to counselling and treatment.
The states and territories agreed to strengthen their attack on drug pushers and their responses to drug use within schools and noted the importance of education in preventing growth in illicit drug use and existing school-based initiatives.
The Commonwealth is to provide resources to increase the capacity of schools and school communities to respond to illicit drug use. Heads of governments also agreed to work together to put in place a new nationally consistent approach to drugs in the community. The ACT Government supports additional diversionary mechanisms for people confronting the criminal justice system because of drug-related crime.
There are only limited additional funds and they will not achieve the substantial expansion of treatment programs that the Commonwealth appears to think are necessary. The ACT will examine priorities for treatment funding, highlighting the best opportunities for diverting people who are drug dependent.
The Premiers Conference noted that drug use in prisons is common and a large proportion of prisoners are in jail for drug-related crime. The states and territories agreed to develop and fund programs to intercept the supply of drugs to prisons and be tough on dealers within prisons; and to develop and trial diversionary treatment programs within the jail system so that dependent users can break their addiction.
The ACT Government supports the Commonwealths commitment to making alternative treatments more readily available. The Commonwealth will fast-track consideration of listing naltrexone on the Pharmaceutical Benefits Scheme. While this is a step forward, naltrexone is not a cure-all and there are other pharmacological treatments which are worthy of consideration and Commonwealth support.
One of the most important things to emerge from the Premiers' Conference is the commitment to a partnership approach. The Commonwealth, states and territories have agreed to work together to better manage the issue of illicit drugs. This means carefully drawn, explicit and practical links between education, law enforcement and treatment efforts at all levels of government and the wider community. The ACT will respond to this challenge. I will be working with my ministerial colleagues to develop practical ways to both improve the situation for drug-dependent people in the ACT, and to reduce the number of such people.
Kate Carnell has been the Chief Minister of the Australian Capital Territory since 1995. She is the most successful female political leader in Australian history having won two successive elections in 1995 and 1998. Her government commissioned a study into the feasibility of a heroin trial in the ACT in 1995 and she has made a significant contribution to the policy debate since then.