Australian Drug and Alcohol Review 1989; 8 : I - 3

Editorial

Legal and iUegal drugs: Targeting the right enemy

In the lead-up to the National Drug Offen- sive in 1984 and early 1985, a vigorous debate took place regarding the relative importance of legal and .illegal drugs. Senior cabinet ministers including the Prime Minister were extensively lobbied to have legal drugs excluded from the Special Premiers' Conference which was held to launch the National Drug Offensive.

Frequently reference was made at that time to estimates of drug-related mortality. An information document, 1 prepared by the Commonwealth Department of Health for use in association with the Special Premiers' Con- ference, referred to an estimated total of 20,533 deaths associated with all drugs of which 16,620 deaths were associated with tobacco (81%), 3,198 with alcohol (15%) 196 deaths with opiates (1%) and an additional 134 deaths were attributed to barbiturates (1%). The difference in mortality between legal and illegal drugs is lessened when years of life lost caused by drug use is estimated? Assuming a normal life expectancy of 70 years, tobacco remains the major cause of years of life lost (45%) with alcohol only slightly behind (43 %) and opiates still making up a relatively insignificant con- tribution (4%). 1 In the early months of the National Drug Offensive, the issue of the relative balance of targeting legal drugs or illegal drugs was a lively one. After a fairly vigourous debate, the position which was finally adopted was that the health conse- quences of legal drugs exceeded that of illegal drugs but the social consequences of illegal drugs were, it was emphasised, of particular concern in the community. It is worth looking back at this debate now, some three years later, to determine whether there is new knowledge or whether any of the facts have changed.

Although it was already known in 1981 that AIDS involved intravenous drug users (IVDUs), at the time of the commencement of the National Drug Offensive the full dimen- sions of this pandemic and the critical role of IVDUs in disseminating the virus responsible for AIDS to the general community were not fully appreciated. Australia in 1988 has the fourth highest incidence of AIDS per capita of Western countries with 943 cases for a popula-

tion of 16.7 million (1 August 1988). 2 This represents 56.5 cases per 1,000,000 population. Of the twelve Western countries most severely affected by AIDS, only Australia and Canada have to date been spared major infection of IVDUs. In Italy and Spain over 50% of the cases of AIDS thus far reported have occurred in IVDUs 3 while 53 % of AIDS cases in New York City are related to drug use2 In 1984 only 2% of AIDS cases reported in Europe were IVDUs but by 1988 30% of newly reported cases were IVDUs.5 The death rate of IVDUs in New York State has risen from 250 in 1978 to 2,000 in 1986. 6 Although some of this increase can be explained by AIDS, most of the deaths have occurred in seropositive IVDUs who have died before developing AIDS. Similar findings have now been reported from Milan. 7

Drug use is also associated with a higher risk of seroconversion in gay men. ~ In the United States, gay men who use cocaine have been shown to have a higher prevalence of HIV infection rate compared to gay men who do not use cocaine, s As alcohol also has a disinhibiting effect on behaviour, it can be expected that there is a greater risk of unsafe sexual practices occurring when either one or both sexual partners are under the influence of alcohol. Sexually transmitted diseases are an important co-factor for the transmission of HIV infection and the recent epidemic of syphillis in young heterosexuals on the East and West coasts of the United States has been attributed to cocaine use which has resulted in prostitution occurring with poor sexual hygiene.

A sudden increase in the availability of cocaine occurred in New York City in 1978. Thereafter retention rates on methadone maintenance programmes decreased. 8 Drug users who use cocaine have a higher prevalence of HIV infection than drug users who do not use cocaine. 8 For all of these reasons, an increase in the availability of cocaine in Australia could lead to a dramatic increase in the spread of HIV infection.

The mean age of drug users entering treat- ment has been increasing for some years in the

United Kingdom, the United States, Canada and the Netherlands which is generally con- sidered to mean that there has been a decline in the recruitment of young drug users. How- ever, there are also fears that the international use of stimulants, including amphetamines and cocaine, is on the increase. The yield of opium in the Golden Crescent and the area under coca cultivation in South America are reported to have increased. The ending of the wars in Afghanistan and the Persian Gulf may lead to a further increase in opium cultivation. There is every reason to fear that opium and cocaine will not be in short supply during he next few years.

Drew and Taylor 9 have recently estimated that an infection rate of 50% among 30,000 intravenous drug users in Australia within two years could result in 9,000 AIDS and ARC cases in five years, with 6,000 deaths and expenditure of $214 million in direct health costs. They estimate that over a similar five to six year period, 3,551 deaths would normally be expected from all drugs other than tobacco and alcohol, but emphasise that the trans- mission of H I V infection to the general com- munity is potentially an even bigger hazard. Surveys of IVDUs generally fred a male:female ratio of approximately 7:3. It could therefore be assumed that approximately half of the male IVDUs will have non-drug using regular female sexual partners. A substantial propor- tion of female IVDUs and some male IVDUs work as prostitutes. If each infected IVDU infects only one non-drug using person per year through casual sex or prostitution, spread to the general community would be exceedingly rapid. 80 % of women infected by heterosexual transmission in New York City have been infected by male IVDUs. 4

The Federal Minister for Community Ser- vices and Health has recently noted that " T h e harsh reality of the Australian situation is that the arduous and painfially long haul is only just beginning; if we falter at these early fences, the a l r eady harsh prognos is will becom e bleaker". 1° Opening the 2nd National AIDS Conference, he also emphasised that "Any ac- tion, however well meaning, however well in- tentioned, which impedes efforts to monitor, assess and contain the spread of the disease should be rejected. ''11 The advent of AIDS must have enormous implications for national drug policies. Projections of the likely direct and indirect effect on the community of H I V infection in IVDUs require policy makers to

re-examine the relative emphasis on legal and illegal drugs. Alternatively, it could be argued that a comprehensive approach to drug use generically may be the wisest course especially as it is recognised that early adolescent legal drug experimentation appears to be linked to experimentation with illegal drugs. 12 Further consideration is required for the recognition that any movement away from injectable drugs must be encouraged during the era of AIDS. Accordingly, a relaxation of policies on can- nabis may have the benefit of encouraging cross substitution from injectable drugs to cannabis, and thus this policy requires urgent considera- tion. More broadly it may be considered that supply reduction strategies for illicit drugs may impede our efforts to contain H I V infection within IVDU. For example, legislation which defines the possession of a used syringe con- taminated with illicit drugs as an offence may be regarded as an impediment to efforts to remove used needles and syringes from circu- lation.

The serenity prayer of Alcoholics Anony- mous reminds us to change what we can, accept that which we cannot change and to have the wisdom to know the difference. For several decades now, illicit drug policies have been steadily t ightened with ever - increas ing resources allocated to reducing supply. The recognition in May 1986 that the Australian economy had declined to banana republic status requires that scarce resources are allocated carefully. This may be an appropriate time to recognise that Australia can have only a very limited effect on the growth of opium in the Golden Crescent and coca in South America. The relative ineffectiveness of inter- diction of illicit drugs is also well known. Heroin and cocaine in Australia cost three to five times as much as the Netherlands where these drugs are available at twice the purity. 1~ Yet Australia has at the most conservative estimate, 30,000 IVDUs 1. while the Nether- lands has an estimated 20,000 drug users with only a slightly smaller population. 15 The cur- rent national emphasis on law enforcement in Australia is unsustainable and only serves to further marginalise IVDUs. Drug policies required in Australia for the 1980's and 1990's must be made consistent with the overriding aim of the National Campaign Against Drug Abuse which is " to reduce harm resulting from drug use in Australia".16 Attempts to eliminate drug use are not now, and probably never have been, the most effective way of reducing drug

problems; they are not the most effective way to contain HIV infection in IVDUs.

A re-consideration of our current drug problems and anticipated drug problems sug- gests that a comprehensive approach to demand reduction is likely to yield improved results. Although harm reduction has been accepted as the central aim of NCADA, it requires more emphasis in the objectives and strategies of our national drug policies for both legal and illegal drugs. Policies on cannabis have for long been a contentious matter but the AIDS pandemic requires that policies on cannabis are reviewed with a new perspective. It is unlikely that Australia could, or should, change policies on the trafficking of large quan- tities of heroin or cocaine but in an era of shrinking resources, it would be prudent to reduce the emphasis on supply reduction strategies while increasing resources for demand reduction. Drug policies are not only a matter for the supply reduction side. Treat- ment policies for the AIDS era may be more effective if we separate out drug users who desire abstinence from those who wish to con- tinue using drugs but desire to do so more safely. The question of provision of injectable substances for intractable drug users or others selected carefully should be considered as a component in a multi-modal treatment system. For some decades, Australian drug policies have been characterised by a contradictory polarity: supply reduction has been the mainstay of illicit drug policies despite being acknowledged as being relatively ineffective although highly popular with the electorate. Conversely our policies on legal drugs have almost ignored supply reduction strategies although these are likely to be effective but politically difficult to implement.

The AIDS epidemic in seven short years has brought about many rapid social changes. More realistic national drug policies could be one of the enduring and beneficial effects of AIDS, so that we change what we can and begin to accept what we cannot change. The AIDS epidemic requires that our drug policies are re-examined to ensure that they reduce drug-related harm.

A.D. Wodak Alcohol and Drug Service St Vincent's Hospital, Darlinghurst, Sydney, NSW

References 1. Commonwealth Department of Health.

"Statistics on Drug Abuse in Australia". February 1985. Australian Government Publishing Service, Canberra.

2. NHMRC Special unit in AIDS Epidemiology and Clinical Research.

3. WHO Collaborating Centre. March 31, 1988. Paris.

4. Joseph S.C., "Current Issues concerning AIDS in New York City". New York State Journal of Medid~. (1988) 88: 5: 253-258.

5. Brunet J-B. "AIDS and HIV Infection in Europe". IVth International Conference on AIDS. Stockholm. 12-16 June 1988. Plenary Session, 12 June 1988.

6. Des Jarlais D.C. "HIV Infection among persons who inject illicit drugs: problems and prospects". IVth International Conference on AIDS. 12-16 June 1988. Stockholm. Plenary Session, 12 June 1988.

7. Galli M., Carito M., Cruccu V. et al. "Causes of death in IV drug abusers (IVDAs): a retro- spective survey on 4,883 subjects". Poster IV International Conference on AIDS. 12-16 June 1988. Stockholm. Plenary Session, 16 June 1988.

8. Hartel D., Selwyn P.A., Schoenbaum E.E., Klein R.S., Friedland, O.N. Methadone Main- tenance Treatment and reduced risk of AIDS and AIDS-specific mortality in intravenous drug users. IV International Conference on AIDS. Stockholm 12-16June 1988. Volume II, 395. Abstract 8546.

9. Drew L.R.H., Taylor V.K. Intravenous Drug Use and the AIDS epidemic: A review. NHMRC. June 1988.

10. Blewett N. IIIrd National Conference on AIDS. Opening Address. 4-6 August 1988. Hobart.

11. Blewett N. IInd National Conference on AIDS. Opening address. Sydney. October 31, 1986.

12. Kendal D.B., Logan J.A. (1984). Patterns of drug use from adolescents to young adulthood: I. Periods of risk from initiation, continued use, and discontinuation. American Journal of Public Health, 74: 662-666.

13. Buning E. Personal communication. 14. National Drug Abuse Data System. Common-

wealth Department of Community Services & Health. March 1988.

15. Buning E. "Stemming the AIDS epidemic among intravenous drug users". IIIrd National Conference on AIDS, Hobart. 4-6 June 1988.

16. Commonwealth Department of Health. National Campaign Against Drug Abuse. Australian Government Publishing Service. Canberra 1985.