This inquiry looks into the laws relating to illicit drug use and the misuse of prescription medication, and drug law reform practice in other jurisdictions.
Cohealth’s submission recommends that:
• the framework for drug response shift from a law and order response to one with a health focus, including decriminalisation of illicit substances
• establishing supervised injecting facility and pill testing
• reinvesting policing money into prevention, treatment and harm reduction
• developing responses to people flagged by real time prescription monitoring
• improving harm minimisation and treatment for people in the criminal justice system
Law Reform, Road and Community Safety Committee
Parliament House, Spring Street
EAST MELBOURNE VIC 3002
By email: firstname.lastname@example.org
To the Executive Officer
cohealth welcomes the opportunity to make the following submission to the Law Reform, Road and Community Safety Committee’s Inquiry into Drug Law Reform.
Please do not hesitate to contact us should you require further information or assistance in your inquiry
cohealth acknowledges the considerable community concern that exists in Victoria regarding the use of illicit and synthetic drugs, as well as the misuse of prescription medication. There can be no doubt that each has the potential to cause considerable harm, with clear evidence of long term health and social consequences for some – but not all – users, as well as the broader community.
As a human rights based health organisation with a long history of delivering alcohol and drug services cohealth is committed to drawing on the best available evidence and working directly with communities to design and deliver evidence based and effective responses to reduce these potential harms. Applying this lens, the following submission first reflects on the effectiveness of Victoria’s current approaches to minimising drug related health, social and economic harms, and recommends that:
Similarly, the latter half of the submission then draws on national and international best practice evidence of effective drug policy and approaches to reform, recommending that the Victorian government:
cohealth is Australia’s largest not-for-profit community health service, operating across 14 local government areas. Our mission is to improve health and wellbeing for all, and to tackle inequality and inequity in partnership with people and their communities.
cohealth provides integrated medical, dental, allied health, mental health and community support services, and delivers programs to promote community health and wellbeing. Our service delivery model prioritises people who experience social disadvantage and are consequently marginalised from many mainstream health and other services. This includes people who are experiencing or at risk of homelessness, people who live with serious mental illness, vulnerable families, Aboriginal and Torres Strait Islanders, refugees and asylum seekers, people who use alcohol and other drugs, recently released prisoners and LGBTIQ communities.
cohealth also recognises that health is affected by many factors including social inclusion and participation, education, housing, employment, and access to fresh food, and we are committed to addressing these underlying causes of health inequality. To this end, we work directly with people and in the community to design our services, and deliver advocacy, health promotion and education activities to improve health and connectedness.
coheath’s programs for people who use drugs (PWUD) span the full range of service responses, including:
Beyond this direct service, cohealth is committed to addressing the stigma and discrimination faced by PWUD that can ultimately perpetuate harm, and undertakes community education activities in response to local concerns. Aware of the stigma and discrimination experienced by PWUD, our staff provide community education about the role and purpose of AOD services and respond to any questions from members of the general public. We also auspice the Yarra Drug and Health Forum, which has been responding to community concerns about alcohol and drug activity for 20 years, and will also be responding to this Inquiry.
Finally, cohealth also operates the North West Melbourne Pharmacotherapy Network (NWMPN) to support the community based Opioid Replacement Therapy (ORT) system and increase the number of GPs and pharmacists prescribing or dispensing ORT. Through the network, GPs and pharmacists currently prescribing or dispensing ORT can access individual support and advice, participate in community of practice and attend training, thereby increasing the skill and confidence for these health professional to effectively work with people who use drugs and help reduce harm. Additionally GPs and pharmacists who may be interested in prescribing and dispensing ORT can also attend the Network’s training events or access support and/or secondary consults with Addiction Medicine Specialist and Mentor GPs, thereby increasing the number of health professional in the region who are willing and able to work with PWUD.
“Global prohibitionist drug policy continues to focus efforts primarily on the substances alone. This is wrong.
Of course, the harms associated with some drugs are worse than others. Sometimes these are due to the degree of addictiveness of a particular drug. But most of the harms are due to the way that a particular drug is acquired (for example, in a dark alley versus from a pharmacy), the way in which it is used (as a pill, for example, versus smoking, snorting or injecting), and, even more importantly, the way in which society treats people who use drugs. The vast majority of the horrific harms associated with drug use—crime, HIV and other blood-borne infections, violence, incarceration, death—are clearly fuelled by the prohibitionist drug policies our governments pursue.
It doesn’t take a rocket scientist to show that criminalising drugs and drug use has directly and indirectly led to a dramatic increase in drug related harms, and that controlling and regulating the production and distribution of all drugs would go a long way towards reducing those harms. So long as we continue to define the drug user as ‘other’ and define the drug itself as the problem, we will be trapped in our misguided and harm-inducing programmes and policies.”
– Craig McClure, Former Executive Director, International AIDS Society, in ‘After the War on Drugs: Blueprint for Regulation”
Increasingly, academics, policy think tanks, health service providers, law enforcement agencies, and legislators around the world are declaring the war on drugs to be an abject failure. Fifty years and many trillions of dollars after the war commenced, the supply of and demand for illegal drugs remains unchanged. At the same time, there is vast body of evidence that repressive, law and order based responses to drug use in fact drive additional harms, including the spread of blood borne viruses such as Hepatitis C and HIV and overdose fatalities. Furthermore such law and order responses often create barriers to help seeking and consume considerable financial resources that could instead be spent on education, harm reduction and treatment services.
The reality in Victoria is that our current laws, procedures and regulations relating to illicit and synthetic drugs, and the misuse of prescription medication are primarily framed through a law and order/tough on crime lens – one that perpetuates, rather than minimises drug related health, social and economic harm. Consider just two examples, as follows:
“We cannot arrest our way out of the ice problem”
– former Victorian Police Chief Commissioner and Head of the National Ice Taskforce Ken Lay
The situation regarding methamphetamines here in Australia is a stark demonstration of the ineffectiveness of criminalisation in reducing the sale, supply, use and harms associated certain substances. Despite two-thirds of government spending on illicit drugs being directed towards policing, and record drug seizures and arrests during 2014, the Australian Crime Commission found that the price of methamphetamines had remained stable or even fallen. At the same time, overall levels of use in the population have remained stable, emergency department presentations have increased, and community perceptions of, and concerns about, drug related, and particularly methamphetamine related, crime and other anti-social behaviour remain high.
By contrast, and as outlined in the second section of this submission, there are numerous international jurisdictions who have seen a reduction in drug related harms by instead decriminalising and/or regulating the production, sale, supply and use of drugs such as cannabis, heroin, cocaine, amphetamines and ecstasy.
Victoria currently prohibits health professionals from legally delivering two, well-evidenced public health interventions – namely supervised injecting/consumption, and pill testing. As a consequence, people who use drugs (PWUD) are unable to access support and assistance at their time of greatest risk – the moment when they consume a currently illicit substance. The statistics from the last twelve months in Victoria speak for themselves – 172 people died from accidental heroin overdose in 2015, the highest number in a decade; and three people died, with twenty more hospitalised in the course of just weekend due to a ‘bad batch’ of MDMA sold around the Chapel Street nightlight district.
By contrast, and again as outlined in more detail in the next section, experiences from elsewhere in Australia, and the world, have demonstrated that both supervised injecting facilities, and pill testing are an effective method of saving lives, as well as delivering a range of other social and economic benefits.
Case Study: Ms T*
Ms T was a young mother of three small children.
She lived and struggled with a heroin addiction for many years. A regular user of cohealth’s services, she frequently accessed our local needle and syringe program (NSP) and had developed trust and rapport with the workers who staffed the service.
On what was to be the final day of her life, Ms T again visited the NSP in order to access clean injecting equipment and seek advice. Having managed to not use for a period of time, and having heard that the heroin in current circulation was stronger than usual, she was concerned about the risk of accidentally overdosing.
Our cohealth worker did everything right, providing Ms T with clean equipment and providing her with the very best information and advice about strategies she could deploy to try and minimise the risk of overdose.
However our worker was prevented, by Victorian law, from offering one of the most effective interventions available to prevent overdose – namely medical supervision whilst Ms T injected her drugs.
As a result, Ms T left the service in order to consume her drugs. Entering a public toilet block not far from the NSP, injected, overdosed, and died.
Had our staff been allowed to supervise Ms T’s injection that day it is a certainty that she would not have died. Qualified staff could have immediately administered naloxone, reversing the effects of the drug and provided oxygen and other interventions as required. It would have saved her life – and in so doing, prevented three young children from losing their mother, and avoided distress for our health services staff and the member of public who discovered Ms T’s body.
The Victorian Government should deliberately and proactively shift the framework for Victoria’s drug response from one grounded in prohibition and law and order responses, to a health focused response informed by international and national evidence.
cohealth applauds the Victorian Government for taking seriously, and seeking to respond to, the 300+ annual fatalities involving prescription medication – a death toll that is higher than that attributed both to road accidents and deaths arising from illicit drugs. We note that in response, the Government announced a package in the 2016/17 Budget that would fund:
Whilst it is clearly far too early to provide comment on the effectiveness of this particular approach, we do note that the international evidence regarding the effectiveness of real time prescription monitoring is mixed. The published research suggests that real time prescription monitoring may be effective for changing prescribing behaviour, reducing “doctor shopping,” and reducing prescription drug abuse, but also that there is a possible link between the restriction of access to prescription drugs and an increase in the use of illicit drugs and related overdose . Effectiveness appears to be improved when monitoring systems allow for the updating and accessing of information in real time, and when they are accompanied by clear prescribing guidelines, comprehensive training for health professionals, and the provision of assertive and skilled support to patients who are flagged on the system and experiencing addiction .
In light of the available evidence, cohealth commends the Victorian Government for constructing a scheme that will operate in real time and is accompanied by training and guidelines, given these approaches are likely to improve overall effectiveness.
However we also have concerns about what the introduction of this real time prescription monitoring will mean for people with addiction who are currently accessing their drugs of addiction through legal means. We are especially concerned about the potential risks to such individuals should they switch to, or seek to ‘top up’ with illicit substances such as heroin. Their likely inexperience with these substances, combined with the highly variable strength of street based drugs (as opposed to prescription drugs) and the further risks that arise through using multiple types of drugs places this group potentially at very high risk of overdose and accidental death. To this end, we are pleased at the Government’s commitment to additional resources to AOD counselling and treatment services, and to expanding peer workforce supports, but remain concerned about:
The Victorian Government should work with consumers and AOD service providers to codesign an effective process for identifying and responding to people with addiction who are flagged by the real time prescription monitoring system; and to ensure that GPs and pharmacists receive training in appropriate responses to, and referrals for, this same patient group.
cohealth remains extremely concerned at the prohibition on providing proven, effective harm reduction interventions within Victorian prisons – specifically needle and syringe programs. There is clear evidence of a very high prevalence of Hepatitis C infection amongst Victorian prisoners and according to Dr Mark Stoove of the Burnett Institute, the current practice of providing bleach to inmates to clean injecting equipment with is estimated to only reduce the risk of transmission by 65%.
By contrast, there are needle and syringe programs currently operating in more than 60 prisons across several countries including Spain, Moldova, Romania, Germany, Luxembourg, Tajikistan and Kyrgyzstan, and whilst the exact models differ, independent evaluations are consistently positive. Notably, prison based needle and syringe programs have been found to:
Perhaps most significantly, no prison with an NSP to date has recorded a case of HIV or hepatitis C infection due to injecting drug use since the implementation of the program, nor have there been any recorded instances of prisoners using needles as weapons or corresponding increases in injecting drug use.
Given both the Victorian and Federal governments are currently making significant investment into providing Hepatitis C treatment to the population, including prisoners, the failure to undertake preventative activities within prisons has to be seen to be working at cross-purposes at best, and actively harming drug using prisoners at worst.
Corrections Victoria should move immediately to introduce needle syringe programs to all Victorian prisons modelled on international best practice.
There is also an urgent need to improve the treatment and counselling services available within Victorian prisons, and to improve the pre-release planning and post-release referral for inmates with a history of drug and alcohol problems.
Again, there is abundant international evidence that demonstrates that effective drug and alcohol treatment programs both within and outside of prison settings can reduce drug use and recidivism, with community based therapeutic programs and narcotic replacement programs found to be especially effective. In spite of this, Victorian prisoners have minimal access to treatment whilst incarcerated, with those on sentences of six months or less often receiving no support, and the remainder of inmates only able to access group, rather than individual treatment and counselling. Furthermore, a majority of inmates – especially those who have served a full sentence without parole – are released without any referral or connection to health providers and/or other appropriate community based supports. This creates a high likelihood of relapsing and reoffending, whilst research has also shown that it places recently released prisoners at a very elevated risk of drug overdose and death.
The Victorian Government should develop and pilot programs for community health services to deliver bundled care and support to people with a history of drug use who have recently exited prison.
cohealth is presenting four proposed reforms below, each of which has a strong evidence base behind it and support from consumers. It is our view that decriminalisation and regulation of all non-medical drugs must be the ultimate objective, but recognising that this is a long term reform, we also advocate for medical prescription, supervised injecting facilities, pill testing, and new service responses to help reduce drug related harms immediately.
In 2001, Portuguese legislators enacted one of the most extensive drug law reforms in the world, decriminalising low-level possession and consumption of all illicit drugs and reclassifying these activities as administrative violations. A person found in possession of personal-use amounts of any drug in Portugal (quantified as less than a 10 day supply, or 1 gram in the case of substances such as cocaine, heroin, MDMA and methamphetamines) is no longer arrested, but rather ordered to appear before a local “dissuasion commission” – comprised of legal, health and social services professionals. The commission makes a determination as to whether and to what extent the person is addicted to drugs, and can then refer that person to a voluntary treatment program, or order them to pay a fine or impose other administrative sanctions. While drug use and possession no longer trigger criminal sanctions, they remain illegal. Further, drug trafficking offenses remain illegal and are still processed through the criminal justice system.
Results of the Portuguese experience over the subsequent fifteen years demonstrate that drug decriminalisation – accompanied, critically, by, the reinvestment of justice money into a significant expansion of treatment and harm reduction services – can significantly improve public safety and health. Overdose deaths decreased from 80 in the year that decriminalization was enacted to only 16 in 2012 – a rate of death per million residents that is five times lower than the European average. In addition, Portugal also saw decreases in HIV transmission, injecting drug use, and offenders ending up in the criminal justice system, and dramatic increases in the number of people accessing drug treatment and support.
The Victorian Government should advocate through the Council of Australian Governments for
and should take steps to explore options for decriminalisation & regulation within the State.
In advocating for a move towards the decriminalisation and regulation of currently illicit substances it should be emphasised that cohealth is not advocating for an abrupt and sudden decriminalisation of all currently illicit substances. We recognise that legal regulation of the production, supply and use of such substances represents a very significant realignment of existing drug policy, and like any such significant policy reform is not without risks. Reform would need to be enacted slowly and carefully using a phased approach, with the impact of each incremental change carefully assessed before the next one is introduced.
To this end we note and recommend to the Committee the excellent work of the Transform Drug Policy Foundation in the book Blueprint for Regulation, which lays out a set of practical and pragmatic options for a regulatory system for non-medical drugs. Drawing on existing approaches currently in use for the regulation and management of alcohol, tobacco, cannabis and prescription medications, it proposes a number of regulatory options for each separate class of drugs, as well as approaches for phased implementation and careful monitoring of effects.
In response to a recent significant year on year increase in heroin overdose deaths, Canada has introduced regulations that allow doctors to prescribe medical grade heroin (in the form of diacetylmorphine) to treat patients with heroin dependence. Patients who are prescribed heroin are also supervised by medical staff when they are injecting the drug, further reducing the risk of overdose death.
Canada’s approach mirrors that already taken in Switzerland, Germany, the Netherlands and Denmark, with previous studies showing that patients receiving prescription heroin are more likely to be compliant with their treatment, less likely to use illegal drugs, and that, in the case of the Swiss program, no one has died from a heroin overdose during its 22 years of operation.
Medicalised heroin programs have also been shown to have a number of other positive health and social benefits, including reduced crime, reduced new user rates, and overall cost savings to the taxpayer.
As in other locations around the world, the introduction of a medical prescription regime in Victoria could significantly reduce heroin overdose deaths and other social and economic drug-related harms by:
Similar benefits may also be seen for the introduction of a medical prescribing regime for other types of drugs, although the evidence for these approaches is currently not well established.
It should be further noted that success of such an initiative will be dependent on the willingness of GPs, pharmacists and other specialists to prescribe and dispense medicalised heroin. Experience within the existing ORT system would indicate that this can be a considerable barrier and so we would advocate for compulsory training of all GPs regarding ORT and, if implemented, prescription heroin.
The Victorian Government should instigate a trial of medically prescribed heroin modeled on international best practice.
The first supervised injecting facility (SIF) was opened in Switzerland in the 1980s. There are now approximately 90 SIFs worldwide, the majority of which are in Europe, with two in Canada and one located in Sydney. Evaluations of Sydney’s Medically Supervised Injecting Centre (MSIC), located in Kings Cross, have found that (as of 2011) the Centre had managed more than 4400 drug overdoses without a single fatality. In addition the MSIC had:
These findings mirror those from evaluations of SIFs all over the world, and there have been long standing calls for a SIF to be established within the Richmond/Victoria Street Precinct in the City of Yarra in particular, with strong support from the Council, local traders association, and residents. cohealth strongly supports these calls, and recommends that a supervised injection or consumption facility be established in this key hot spot as a matter of priority. Using language such as ‘harm reduction and community safety hub’ to refer to this type of service may assist in overcoming stigma and resistance in some quarters.
We further note however that the experience from both NSW and indeed all over the world indicated that it would beneficial to establish sites at other potential hot-spot locations in order to deliver an overall reduction in harm.
To this end, we note that a number of SAPHs currently operate throughout metropolitan Melbourne ‘hotspots’, incuding:
Existing SAPHS operate needle and syringe programs, provide education and health promotion services, and enable people who use drugs to access comprehensive medical services. SAPHS have established relationships with many people who inject drugs, experienced and qualified staff, and in many instances operate from physical premises that could be easily modified in order to accommodate supervising injecting facilities.
SAPHs staff are experienced in engaging with people who use drugs about their drug use, education about safer drug use, managing physical and mental health issues, providing brief interventions and supporting access to treatment and other support services. These services strongly respond to the need of people using drugs within the SIF environment and would provide a complementary service. Additionally, given that people who use drugs experience barriers to access health services, access to the SAPHs services may be increased through the SIF pathway.
Locating a supervised injecting facility within an existing SAPH or SAPHs is therefore likely to be cost effective and will ensure that clients using the service can also access and benefit from a broad range of other offering, including potential referrals to treatment.
The Victorian Government should take steps to make the necessary changes to allow for the legal operation of supervised injecting/consumption facilities by health services in Victoria.
Priority should be placed on establishing a service in Richmond, and funding existing SAPHs to expand to also provide these services.
Pill testing, also known as ‘drug checking’ is a harm-reduction intervention provided by community and local governments, and currently available in several European countries including the Netherlands, Switzerland, Austria, Belgium, Germany, Spain and France.
The published evidence reveals a number of benefits from this approach. Notably:
The Victorian Government should take immediate steps to establish pill testing services in the State, modelled on international best practice.
In the late 1980’s and early 90’s Australia responded to the looming catastrophe of HIV by responding swiftly and courageously to implement evidence-based strategies to reduce the risk of transmission. As much of the rest of the world prevaricated, we introduced needle exchange programs, addressed many of the laws criminalising at risk behaviours and populations, and worked with affected communities to find solutions. Our response was world’s best, and the entire community benefitted with the HIV epidemic well contained.
Thirty years on as the overdose deaths pile up, and community concern grows about the negative health, social, and criminal consequences of some drug use, it is bewildering and distressing to find that national and State governments in Australia, including here in Victoria, appear to have lost the courage and commitment to do what’s needed to prevent death and harm.
The evidence as to what works is even stronger than that which we relied on to combat HIV – it is neither radical, experimental, or unclear as to the kinds of reforms that need to be introduced to drug policy to save lives and reduce harm. It is our sincere hope that this Parliamentary Inquiry can provide a set of clear, evidence based recommendations to the Parliament on a way forward, and the that Victorian Government can in turn demonstrate the political will to commence the process of reform.
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