Australia S National Drug Strategy

AUSTRALIA’S NATIONAL DRUG STRATEGY

BEYOND 2009

A SUBMISSION BY THE

NATIONAL DRUG RESEARCH INSTITUTE,

CURTINUNIVERSITY OF TECHNOLOGY

PERTH, WESTERN AUSTRALIA

Contact Details

Professor Steve Allsop

Director

National Drug Research Institute

P: 08 9266 1600

E:

Postal:

National Drug Research Institute

CurtinUniversity of Technology

Health Research Campus

GPO Box U1987

PerthWA 6845

Introduction

As noted in the consultation paper, the National Drug Strategy (NDS) has served Australia well for more than two decades, and is held in high regard internationally. As one of the national Centres of Excellence and therefore a key stakeholder, the National Drug Research Institute welcomes the opportunity to provide meaningful input into the structure of the post-2010 framework.

In this submission, the Institute briefly addresses key items raised in the ‘Australia’s National Drug Strategy Beyond 2009’ consultation paper, focusing on each of the NDS Principles and Emerging issues and New Developments as outlined in the consultation paper. The points made aim to ensure the 2010-2015 cycle of NDS can achieve optimum outcomes and engage with and create broader acceptance in the community for its goals.

National Drug Strategy Principles

A consistent approach

We agree that the harm minimisation approach – as framed in the Australian context as an overall umbrella principle under which supply reduction, demand reduction and harm reduction fit – has provided a space where a diverse range of stakeholders can be brought together and cooperate toward a shared goal.

While there have been criticisms of the terminology and approach, these have been well weathered. We do not see any reason to change this consistent and proven framework. It may however be appropriate to enhance communication about harm minimisation (we accept there is misinterpretation of what harm minimisation involves) and its positive impact to the community and other key stakeholders.

While there has been a call to find a new terminology other than ‘harm minimisation,’ we believe this is the wrong approach and will imply a step away from the core principles of previous strategies. We concur with the Siggins Miller review that more needs to be done to explain and communicate the causes and consequences of drug-related harm and the ‘three pillars’ approach. To this end, NDRI has published research showing that the principles of harm reduction programs can be readily explained to the general public and providing an evidence-based rationale results in increases in self-reported support for such approaches (Lenton and Phillips 1997). Similarly this approach is enacted in NDRI’s extensive history of evidence-based comment in the media on alcohol and other drug (AOD) issues, which we see as a central role of a research centre of excellence such as our own.

Evaluation Recommendations

The first thing that strikes the Institute is that responses to the recommendations made by Siggins Miller in its evaluation of the National Drug Strategy 2004-2009 are not readily identified in the consultation document. As a simple and striking example, recommendation one is important but it is not clear how the new NDS intends to incorporate any response to this:

Highlight and further develop a shared public understanding of the causes and consequences of drug-related harm and the need to retain the three pillars of supply reduction, demand reduction, and harm reduction, and consider replacing the term ‘harm minimisation’ with words which better communicate the need for prevention of drug use and drug-related harm.

This might easily be dealt with by ensuring that there is a communication strategy to ensure the community is informed about patterns of drug use, related harms and responses to these harms – and how that is relevant to the three pillars approach.

Consistent Terminology

It is imperative that consistent terminology is used throughout the new NDS to avoid confusion and conjecture. For example, on page 4 of the consultation paper harm reduction and harm minimisation seem to be used interchangeably when many stakeholders, both within the AOD field and outside it, define these terms differently. In other instances reference is made to drug use, drug related problems and substance use issues. Consistent terminology should be used and the Institute suggests that drug use is the most useful term. “Substance use” is commonly used in the U.S. terminology but does not have common understanding outside the AOD field.

Furthermore, the discussion about harm minimisation on page 4 should make a stronger and evidence-based case for this principle, particularly given that there is a well-founded desire to continue along this path, and, as the paper states, harm minimisation “continues to be relevant today and is increasingly accepted internationally as a humane and pragmatic approach”. The Institute suggests that a brief explanation of supply reduction, demand reduction and harm reduction in this section would help guide understanding of such terms.

Evidence-based Practice and Policy

We note the statement in the consultation document that ‘policy and practice are, wherever possible, informed by research evidence…’ We support this principle.Wherever possible, policy and practice should be evidence-based, and where evidence is not sufficiently developed, policy and practice should be evidence informed. It is pertinent to re-affirm that decisions made within an evidence-based approach necessarily givepriority and weight to the best available evidence. In a practitioner-client context, the burden falls to the practitioner tointerpret the evidence in terms of the unique needs of the individual and to facilitate informed choice by the individual. We recognise that there are significant gaps in the research evidence and much research evidence has limited or no direct relevance for significant segments of the population. To this end, while we must build the evidence base where it is weak or lacking, we must also ensure that we interpret the evidence in terms of the unique needs and wants of the individual and/or community. Building research capacity should also be matched with building the capacity of the workforce to best use that research, as highlighted elsewhere in the consultation paper.

A Balanced Approach

As an overarching statement ‘policy balance’ has the advantage in that it conveys that all elements of the drug problem (illicit and licit) and strategy responses (supply reduction, demand reduction and supply reduction) have been attended to. However, quantifying where the balance in expenditure and effort should be put is a very difficult process.

There is some evidence to consider in this regard (e.g. costs of drug use, current government expenditure, effectiveness of various interventions) however, this evidence base is incomplete. The ‘balance’ decision may always be a value-based one in that it depends on the importance placed on each of these elements.While the net estimated costs of various drug types are important (tobacco and alcohol versus illicit drugs, for example) this does not in itself inform what should be the priorities of a limited intervention budget.

As an example, alcohol and tobacco have been estimated to be responsible for 65% and 19% of the burden of disease in Australia respectively, while all illicit drugs combined are estimated to be accountable for 16% (Begg, Vos et al. 2007). Yet the proportion of State, Territory and Federal Government budgets spent on responding to these drugs have been estimated at 5% for tobacco, 50% for alcohol and 45% for illicit drugs (Collins and Lapsley 2008).

The response to this question of balance is not as simple as matching the proportion of budget expenditure to the proportion of harms. A major reason for this is that legal drugs (tobacco and alcohol) can be subject to powerful and proven statutory and regulatory measures (price, taxation, restrictions on availability, legal age, etc.) where the levers of influence for illicit drugs are far less powerfuland more costly, simply because these drugs are not subject to legal regulation.

The evidence is clear that the harm associated with the use of alcohol and tobacco could be substantially reduced if governments better applied these proven legal and regulatory strategies for these legal drugs (Loxley, Toumbourou et al. 2004).

With regards to illicit drugs, we note Siggins Miller’s estimation that the total expenditurefor AustralianState and Territory Governments is estimated at crime 92%, health 7% and other 1% (Siggins and Miller 2009). We note also that those members of the public surveyed as part of the 2007 National Drug Strategy Household Survey on average recommended for illicit drugs that 40% should be spent on law enforcement, 26% on treatment and 34% on education (Australian Institute of Health and Welfare 2008). As we have previously said, the balance question is primarily a value issue and most of the relevant ‘evidence’ is already in. We note the substantial discrepancy between the estimated 92% of government monies spent on illicit drug law enforcement and the 40% the Australian public believe should be spent on these measures. We concur with Siggins Miller in calling for a re-balance of efforts and investment among supply, demand and harm reduction strategies across legal and illegal drugs but note that this is largely a political decision.

We also note a significant imbalance. Co-existing mental health and drug problems have been noted as a major challenge for mental health, drug specialist, mainstream health and emergency services. A significant factor in responding to this issue is the limited resources that are available to effectively respond, especially in the mental health services, despite welcome increases in investment in recent years. The significant burden created by co-existing mental health and drug problems, for the individual, families, the community and services suggest that some attention, and increased resources, are indicated in this area.

Emphasis on Prevention

The National Drug Research Institute welcomes the additional emphasis on prevention outlined in the consultation paper, with a particular focus on early intervention and targeted prevention activities across the life cycle.

However, the Institute believes that it will be important to identify and communicate key elements of a prevention strategy, such as universal interventions to prevent risky alcohol use, targeted interventions to address vulnerable and disadvantaged groups, and brief interventions for adolescents with emerging risky drug use patterns.

The Institute also has some concern about the comment that prevention activities will “necessarily include targeted and broad based social marketing strategies.” Having made a plea to base the strategy on evidence, we wonder where is the evidence to single out social marketing in this way? In many domains, this is where the evidence for effectiveness is at its weakest. The Institute supports social marketing strategies as having a supporting role in a broader evidence-based approach that includes other proven strategies, but questions the singling out of this approach in this manner. As mentioned earlier, perhaps some unpacking of evidence-based strategies will help and perhaps there needs to be a statement that a range of combined and long-term approaches are required. These are issues that the National Drug Research Institute has focussed on in the past (e.g. Loxley et al 2004, NDRI 2007) and we believe this is a domain where the Institute’s expertise can particularly make a contribution to the NDS.

Furthermore, the reference to the role that schools can play ignores the evidence for the importance of early intervention in the pre-school period, particularly for vulnerable populations. The transition periods in children’s lives – to primary school, into secondary school and post-school education, training and employment – are also important.As such, we suggest that the recommendation of the Siggins Miller evaluation regarding the development and implementation of a national prevention agenda should be strengthened and include a reference to early intervention.

Emerging Issues and New Developments

The consultation paper’s focus on emerging issues is a prudent and clear-thinking approach to AOD issues in Australia.

In particular, the Institute strongly supports the inclusion of new technologies as an area of focus. While we acknowledge that this has implications in terms of law enforcement as outlined in the discussion paper, we suggest that there should be at least equal focus on the potential of new technologies to expand prevention and harm reduction activities, ranging from delivery of interventions and the monitoring of AOD use patterns to the provision of information to drug consumers and the wider community.

Key emerging issues that are touched on in the paper but that the Institute believes require particular focus include:

• The need to focus on Indigenous populations. The evidence indicates that – despite a range of interventions – there has been little or no decrease in levels of harmful alcohol and other drug use and that in some communities problems are probably getting worse.
• New technologies provide new challenges and opportunities – i.e. how they impact on drug supply, promotion (e.g. of alcohol and tobacco) patterns of use and provide opportunities for intervention.
• The need to focus on populations that do not access treatment services (e.g. the overwhelming number of people affected by alcohol use; a large proportion of people who use ecstasy).
• The need to invest in better and more timely indicators of patterns of drug use and harm.
• Better engagement of mainstream services in identifying and responding to AOD related harm, and investing in approaches that coordinate effort across sectors.
• More investment in broad preventive effort (e.g. engaging children in school; interventions that target vulnerable families and populations).
• Investment in evidence-based controls on alcohol availability.
• Facilitating the collaboration among sectors that is discussed in the consultation paper requires investment and resources e.g. contracts and funding formulae, performance indicators etc.

Cross sectoral approaches

We agree with the sentiments expressed in the Strategy document regarding linking up the variety of policy priorities and programs that relate to the AOD field. With regard to the questions about suggested structures and other sectors of engagement, in addition to those mentioned in the document, we would also add corrective services and prisoner health and the Australian Taxation Department, particularly in light of the Henry Taxation Review and the potential implications of recommendations for alcohol taxation in Australia.

We also note the reference on page 7 of the consultation paper that “The next phase of the National Drug Strategy will need totake account ofthe Preventative Health Strategy” [our emphasis]. This is rather passive and meaninglessphrasing. To the Institute, it seems that work in the area of preventative health is of direct relevance to the goals and outcomes of the NDS, and vice versa, and rather than taking account of the Agency’s work, there should be a strong and direct collaboration between the NDS and the Preventative Health Strategy where their objectives overlap.

We think it is timely to ask the question about IGCD and MCDS and their engagement with external advice. In our view, while these structures have served the Australian community well t we believe that their capacity to respond to a changing drug-using environment can be further enhanced by revising the structures and mechanisms for expert input. While it is hard to judge from the outside whether the National Expert Advisory Panel (NEAP) structure is functioning optimally there is a danger that where experts are invited in on an ‘as needs’ basis that such requests will be piece-meal and diminish over time.As a consequence, the committees to which they would have reported become more concerned with process rather than content. Although there is a risk that external expert advisory groups can become thorns in the side of government, as per the recent experience with the ACMD in the U.K., the advantage is that they can provide up-to-date information about new and emerging trends, issues and potential responses which can invigorate and inform and stimulate timely consideration.

We believe that there is an opportunity here to facilitate expert input to both MCDS and IGCD from a breadth of stakeholders both within and outside the AOD sector. We recommend that an expert working group be established to explore options and mechanisms and report back to IGCD and MCDS, and the wider AOD community, within a specific timeframe, such as six months.

One suggestion may be creating an expert advisory group or council including a core group of stakeholders from the AOD sector along with experts from other related sectors, including: Aboriginal and Torres Strait Islander services, housing, employment, social welfare, corrective services, finance and taxation. From within the AOD field, representatives should be includedfrom each of the National Drug Research Centres of Excellence (NDRI, NDARC, NCETA) along with drug researchers from other research centres (e.g.Turning Point), the Alcohol and other Drugs Council of Australia, the Australian Drug Foundation, the Australian National Council on Drugs, the Public Health Association and the Chapter of Addiction Medicine along with law enforcement research bodies, such as the Australian Institute of Criminology.