Harm reduction in Australia: some problems putting policy into practice

Harm minimisation has been the cornerstone of Australia's national drugs policy since the birth of the National Campaign against Drug Abuse in 1985. As a guiding principle harm minimisation has provided the rationale for a diverse range of programs targeting an equally diverse range of drug-related harms. However, the potential of Australia's national harm minimisation policy to guide intervention has been weakened by a number of forces. These include the absence of a clear understanding of what harm minimisation is and is not, the existence of a ‘zero-tolerance’ attitude toward illicit drug use among National Drug Strategy leadership and a cumbersome Commonwealth policy-making process. This paper examines these and other related obstacles to the implementation of harm reduction strategies. Some suggestions are made in relation to how Australia's harm minimisation policy could more effectively help guide both government and non-government intervention in the drug field.     

Examining the construction and representation of drugs as a policy problem in Australia's National Drug Strategy documents 1985–2010

BackgroundNational drug policies are often regarded as inconsequential, rhetorical documents, however this belies the subtlety with which such documents generate discourse and produce (and re-produce) policy issues over time. Critically analysing the ways in which policy language constructs and represents policy problems is important as these discursive constructions have implications for how we are invoked to think about (and justify) possible policy responses.MethodsTaking the case of Australia's National Drug Strategies, this paper used an approach informed by critical discourse analysis theory and aspects of Bacchi's (2009) ‘What's the Problem Represented to be’ framework to critically explore how drug policy problems are constructed and represented through the language of drug policy documents over time.ResultsOur analysis demonstrated shifts in the ways that drugs have been ‘problematised’ in Australia's National Drug Strategies. Central to these evolving constructions was the increasing reliance on evidence as a way of ‘knowing the problem’. Furthermore, by analysing the stated aims of the policies, this case demonstrates how constructing drug problems in terms of ‘drug-related harms’ or alternately ‘drug use’ can affect what is perceived to be an appropriate set of policy responses. The gradual shift to constructing drug use as the policy problem altered the concept of harm minimisation and influenced the development of the concepts of demand- and harm-reduction over time.ConclusionsThese findings have implications for how we understand policy development, and challenge us to critically consider how the construction and representation of drug problems serve to justify what are perceived to be acceptable responses to policy problems. These constructions are produced subtly, and become embedded slowly over decades of policy development. National drug policies should not merely be taken at face value; appreciation of the construction and representation of drug problems, and of how these ‘problematisations’ are produced, is essential.     

Assembling the dominant accounts of youth drug use in Australian harm reduction drug education

Education programs are a central element of Australian harm reduction drug policy. Considered less judgmental and more effective than the punitive policies of Australia's past, harm reduction drug education is premised on the goal of reducing ‘risks’ and harms associated with illicit drug use rather than an elimination of use per se. In this article I analyse two sets of key texts designed to reduce drug related harm in Australia: harm reduction teaching resources designed for classroom use and social marketing campaigns that are targeted to a more general audience. I identify two significant accounts of young people's drug use present in Australian harm reduction drug education: ‘damaged mental health’ and ‘distress’. I then draw on some of Deleuze and Guattari's key concepts to consider the harm reducing potential these accounts may have for young people's drug using experiences. To demonstrate the potential limitations of current drug education, I refer to an established body of work examining young people's experiences of chroming. From here, I argue that the accounts of ‘damaged mental health’ and ‘distress’ may work to limit the capacity of young drug users to practice safer drug use. In sum, current Australian harm reduction drug education and social marketing may be producing rather than reducing drug related harm.     

Overview of Substance Use and Treatment from Australia

ABSTRACT

This paper aims to provide an overview of drug and alcohol issues and their management in Australia. Overall, Australia has good health relative to the United States and other similar nations and generally similar rates of substance use disorders. A whole-of-government strategic approach has been developed for managing drug and alcohol problems, with a National Drug Strategy that has adopted a pragmatic approach to substance use problems through 3 “pillars”—demand, supply, and harm reduction. This approach has been attributed to Australia's remarkably low human immunodeficiency virus (HIV) prevalence among people who inject drugs (<2%). Most community primary health care is provided through Australia's universal health care scheme, which provides a rebate for nearly all medical services according to a scheduled fee. Inpatient and outpatient care, including drug and alcohol services, delivered at public hospitals are currently provided with no patient co-payments. The health of Australia's first peoples, Australian Aboriginals and Torres Strait Islanders, remains challenging primarily due to the transgenerational impacts of dispossession, social and economic disadvantage, and some cultural differences. Although substance use is a key issue for Australian Aboriginals, there are currently insufficient dedicated drug and alcohol services for this group. Notwithstanding this important exception, Australia's health and substance use is favorable relative to other developed nations, offering universal health care and a pragmatic drug and alcohol strategy.     

The size and mix of government spending on illicit drug policy in Australia

Aim . To estimate how much governments in Australia spend on reducing and dealing with illicit drug problems. Methods . Government documents and supplementary information sources were used to estimate drug‐related expenditure for the financial year 2002–03, in Australian dollars. Public sector expenditure on reducing drug problems (‘proactive expenditure’) was classified into four policy functions: prevention, treatment, harm reduction and enforcement. Expenditure related to the consequences of drug use (‘reactive expenditure’) was included as a separate category. Results . Spending by Australian governments in financial year 2002–03 on all drug‐related activities was estimated to be $3.2 billion. Proactive expenditure was estimated to be $1.3 billion, comprising 55% on enforcement, 23% on prevention, 17% on treatment, 3% on harm reduction and 1% on activities that span several of these functions. Expenditure on dealing with the consequences of drug use was estimated to be $1.9 billion, with the majority the result of crime‐related consequences. Conclusion . Several insights result from estimating these expenditures. First, law enforcement is the largest drug policy component, with Australian governments also spending significant amounts on treatment and prevention programmes. Secondly, apart from the prevention component, Australia's drug policy mix is strikingly similar to recent international estimates. Finally, expenditures associated with dealing with the consequences of illicit drugs are large and important for assessing drug‐related public sector expenditure.     

1985 and all that: The establishment of Australia's Drug Strategy

A national drug summit in the mid‐1980s played a pivotal role in the establishment of Australia's National Drug Strategy. It transformed the delivery of drug policies in Australia and gave us the instruments to understand our drug problem, namely national Centres of Excellence, including the National Drug Research Institute. This paper examines how a ‘bundle of compromises’ came together in the political context of the mid‐1980s to give rise to, for the first time, a cooperative national campaign that continues to drive Australia's drug strategy today.[Blewett N. 1985 and all that: The establishment of Australia's Drug Strategy. Drug Alcohol Rev 2009;28:96–98]     

More-than-harm reduction: Engaging with alternative ontologies of ‘movement’ in UK drug services

Over the last ten years, UK drug policy has moved towards making abstinence-based recovery rather than harm reduction its primary focus. Drawing on ethnographic fieldwork involving participant observations and interviews at two London drug services, we explore how this shift towards recovery materialises through the practices of drug service delivery as an ‘evidence-making intervention’. We understand recovery's making in terms of ‘movement’. Where previous policies performed harm reduction through ‘getting people into treatment’ and ‘keeping them safe in treatment’, new policies were said to be about ‘moving people through treatment’. Approaching movement as a sociomaterial process, we observe how movement is enacted in both narrow ways, towards abstinence from drugs, and more open ways, in what we call ‘more-than-harm reduction’. We think of the latter as a speculative practice of doing or ‘tinkering with’ recovery to afford a care for clients not bound to abstinence-based outcomes. This is important given the limits associated with a recovery-orientated policy impetus. By engaging with these alternative ontologies of movement, we highlight an approach to intervening that both subverts and adheres to perceptions of recovery, embracing its movement, while remaining critical to its vision of abstinence.     

The definition of harm reduction

Welcome to the Harm Reduction Digest, where in each regular edition of Thug and Alcohol Review invited co-authors will contribute to pieces on the theory and practice of harm reduction. While the focus of subsequent HR Digests will be accounts of the practice of harm reduction interventions, programmes and policies from around the world, it was decided that the first Digest ought to address the definition of Harm Reduction. Consequently the style of this digest is probably more formal than most that will follow it. Many of you will have read DAR's special issue on harm reduction (1995, 14(3)) where Alex Wodak, Bill Saunders, Patricia Erickson, Eric Single and Nick Heather all addressed the issue of definition in their respective contributions. Since this there have been a handful of papers and reports which have also grappled with the issue of definition. Co-author of this piece is Professor Eric Single, from the Department of Public Health Sciences at the University of Toronto. Eric addressed issues around the definition of harm reduction in the 1996 Dorothy Black lecture in London and, with Professor Timothy Rohl, as independent evaluators of Australia's National Drug Strategy, wrote on the topic in their report ‘Mapping the Future’.     

Alcohol supply,demand, and harm reduction: What is the strongest cocktail?

The concept of harm reduction emerged from the drug field in the 1980s in response to the urgent need to reduce the risk and spread of blood-borne viruses in people who continued to inject illicit drugs. The concept has since become increasingly influential in the alcohol and even tobacco fields. While there are many different applications of the term today, the distinction used by the International Harm Reduction Association (IHRA) between strategies relying on ‘use reduction’ and those that primarily strive for harm reduction without necessarily requiring reduction in consumption is used here. The evidence base for the effectiveness of harm reduction strategies on the one hand, and efforts that require a degree of use reduction via demand or supply reduction on the other hand, is summarised based on a comprehensive review funded by the Australian government. In the alcohol field, the concept of harm reduction has sometimes been proposed as an alternative to the view that alcohol-related harm will only be reduced via a reduction of the total population consumption of alcohol. This paper will present evidence to suggest that, in order to be most effective, a comprehensive policy to reduce alcohol-related harm needs also to include interventions to reduce the quantity of alcohol consumed per occasion. Furthermore, it is highly unlikely in most modern drinking societies that significant reductions in alcohol-related harm can occur without also a significant drop in total population consumption. Nonetheless, harm reduction is an important and influential principle in alcohol policy that can be incorporated alongside such effective strategies as controls on the physical and economic availability of alcohol and the routine delivery of brief interventions in primary health care settings.     

Modification of a traditional motivational interviewing-based brief intervention training for hospital staff: The approach and refer method

Under the new Alcohol Harm Reduction Strategy for England published by the Prime Minister's Strategy Unit in , there has been an increasing focus on crime and public order issues and alcohol-related harm experienced by ‘vulnerable’ or ‘at risk’ groups. Prisoners have been identified as a vulnerable group who have high rates of dependence on alcohol and problems with alcohol-related offending. In late 2004, the Prison Service launched its first alcohol strategy. Based on an analysis of key policy documents, official enquiries and research, this paper explores how the ‘problem’ of alcohol can be defined within the prison setting and the issues it raises for both the individual prisoner and the institution. It examines the lack of policy and strategic direction prior to the publication of the new prison alcohol strategy and the possible reasons for the complacency around alcohol in prisons in contrast to illicit drugs. The paper critically assesses the new strategy in relation to the testing and treatment initiatives proposed and the lack of research and resources underpinning them. There is a real risk that the strategy will fail unless adequate resources are forthcoming to expand treatment provision. Given the neglect and complacency around alcohol, policy champions or policy entrepreneurs are needed to lobby for funding and keep the prison alcohol issue on the policy agenda.     

Will modifying inhalants reduce volatile substance misuse? A review

Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction. In this paper we look at drug users' aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behaviour or to become abstinent from their drug use. The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland. Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying ‘abstinence’ as the only change they hoped to achieve on the basis of attending the drug treatment agency. By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited ‘reduced drug use’, and 7.4% cited ‘stabilization’ only. Less than 1% of respondents identified ‘safer drug use’ or ‘another goal’, whilst just over 4% reported having ‘no goals’. The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence. On the basis of these results there would appear to be a need for harm reduction services to be assiduous in explaining to clients the reason for their focus and for ensuring that drug users have access to an array of services encompassing those that stress a harm reduction focus and those that are more oriented towards abstinence.     

Gender,intoxication and the developing brain: Problematisations of drinking among young adults in Australian alcohol policy

In this article, we draw on recent scholarly work in the poststructuralist analysis of policy to consider how policy itself functions as a key site in the constitution of alcohol ‘problems’, and the political implications of these problematisations. We do this by examining Australian alcohol policy as it relates to young adults (18–24 years old). Our critical analysis focuses on three national alcohol policies (1990, 2001 and 2006) and two Victorian state alcohol policies (2008 and 2013), which together span a 25-year period. We argue that Australian alcohol policies have conspicuously ignored young adult men, despite their ongoing over-representation in the statistical ‘evidence base’ on alcohol-related harm, while increasingly problematising alcohol consumption amongst other population subgroups. We also identify the development of a new problem representation in Australian alcohol policy, that of ‘intoxication’ as the leading cause of alcohol-related harm and rising hospital admissions, and argue that changes in the classification and diagnosis of intoxication may have contributed to its prioritisation and problematisation in alcohol policy at the expense of other forms of harm. Finally, we draw attention to how preliminary and inconclusive research on the purported association between binge drinking and brain development in those under 25 years old has been mobilised prematurely to support calls to increase the legal purchasing age from 18 to 21 years. Our critical analysis of the treatment of these three issues – gender, intoxication, and brain development – is intended to highlight the ways in which policy functions as a key site in the constitution of alcohol ‘problems’.     

‘Enjoying the kick’: Locating pleasure within the drug consumption room

BackgroundHarm reduction policy and praxis has long struggled to accommodate the pleasures of alcohol and other drug use. Whilst scholars have consistently highlighted this struggle, how pleasure might come to practically inform the design and delivery of harm reduction policies and programs remains less clear. The present paper seeks to move beyond conceptual critiques of harm reduction’s ‘pleasure oversight’ to more focused empirical analysis of how flows of pleasure emerge, circulate and, importantly, may be reoriented in the course of harm reduction practice.MethodsWe ground our analysis in the context of detailed ethnographic research in a drug consumption room in Frankfurt, Germany. Drawing on recent strands of post-humanist thought, the paper deploys the concept of the ‘consumption event’ to uncover the manner in which these facilities mediate the practice and embodied experience of drug use and incite or limit bodily potentials for intoxication and pleasure.ResultsThrough the analysis, we mapped a diversity of pleasures as they emerged and circulated through events of consumption at the consumption room. Beyond the pleasurable intensities of intoxication’s kick, these pleasures were expressed in a range of novel capacities, practices and drug using bodies. In each instance, pleasure could not be reduced to a simple, linear product of drug use. Rather, it arose for our participants through distinctive social and affective transformations enabled through events of consumption at the consumption room and the generative force of actors and associations of which these events were composed.ConclusionOur research suggests that the drug consumption room serves as a conduit through which its clients can potentially enact more pleasurable, productive and positive relations to both themselves and their drug use. Acknowledging the centrality of pleasure to client engagement with these facilities, the paper concludes by drawing out the implications of these findings for the design and delivery of consumption room services.     

Secondary harm mitigation: A more humanitarian framework for international drug law enforcement

This article introduces the concept of ‘secondary harm mitigation’ as a framework for improving the humanitarian credentials of international drug law enforcement agencies. The concept is rooted in a critical analysis of the compatibility of the harm reduction philosophy with Australia’s international drug law enforcement practices. On a utilitarian level, the net benefits of international drug law enforcement are determined to be, at best inconclusive, arguably counterproductive and in most cases, incalculable. On a humanitarian level, international drug law enforcement is also determined to be problematic from a criminological standpoint because it generates secondary harms and it is indifferent to the vulnerability of individuals who participate in illicit drug trafficking. Accordingly, the article concludes that a philosophy of harm reduction grounded in the public health perspective is inadequate for mitigating secondary harms arising from Australia’s efforts to combat international illicit drug trafficking. A tentative list of secondary harm mitigation principles is presented and the article argues that secondary harm mitigation should replace supply reduction as a core tenet of Australia’s National Drug Strategy. The article also concludes that secondary harm mitigation may provide a viable framework for stimulating a productive dialogue between those who advocate prohibition and those who call for decriminalisation at the global level.     

Harm reduction in Argentina: a challenge to non-governmental organisations

In Argentina, the prevailing drug policy is based on a ‘drug free society’ approach. It is worth pointing out that since the 1970s there has been an important influence by USA drug policy on drug policy in Argentina. We find a high incidence of HIV transmission among injecting drug users and high levels of social exclusion. In the Argentinean context NGOs can play a fundamental role in reversing the trend of segregation and discrimination towards drug users. Nowadays, to promote harm reduction as an HIV/AIDS preventive policy more than as a drug use policy is a better strategy, considering the climate of abstinence. We are a better condition than a few years ago to reinforce its application in Argentina because of the following factors: (1) UNAIDS support; (2) the regional impact of the International Summit ‘Large Urban Cities and their Drug Plans’ (Medellin, October 1997), and the IX International Conference on the Reduction of Drug Related Harm (São Paulo, March 1998); (3) the increasing diffusion about international harm reduction experiences in the mass media; (4) discussions with university research teams; and (5) the creation of the Latin-American Harm Reduction Network.     

Social construction and the evidence-based drug policy endeavour

‘Evidence-based policy’ has become the catch-cry of the drug policy field. A growing literature has been dedicated to better realising the goal of evidence-based drug policy: to maximise the use of the best quality research to inform policy decision-making and help answer the question of ‘what works’. Alternative accounts in the policy processes literature conceptualise policy activity as an ambiguous and contested process, and the role of evidence as being only marginally influential. Multiple participants jostle for influence and seek to define what may be regarded as a policy problem, how it may be appropriately addressed, which participants may speak authoritatively, and what knowledge(s) may be brought to bear. The question posited in this article is whether the conceptual shift offered by thinking about policy activity as a process of social construction may be valuable for beginning to explore different perspectives of the evidence-based drug policy endeavour. Within a constructionist account of policy, what counts as valid ‘evidence’ will always be a constructed notion within a dynamic system, based on the privileging and silencing of participants and discourse, and the contestation of those many positions and perspectives. The social construction account shifts our focus from the inherent value of ‘evidence’ for addressing ‘problems’ to the ways in which policy knowledge is made valid, by whom and in what contexts. As such, social construction provides a framework for critically analysing the ways in which ‘policy-relevant knowledge’ may not be a stable concept but rather one which is constructed through the policy process, and, through a process of validation, is rendered useful. We have limited knowledge in the drug policy field about how this happens; how ambiguity about the problems to be addressed, which voices should be heard, and what activities may be appropriate is contested and managed. By unpicking the values and assumptions which underlie drug policy processes, how problems are constructed and represented, and the ways in which different voices and knowledge(s) come to bear on that process, we may begin to see avenues for reform which may not at present seem obvious.     

Exploring the micro-politics of normalisation: Narratives of pleasure,self-control and desire in a sample of young Australian ‘party drug’ users

This article explores the micro-politics of recreational use of illicit ‘party drugs’ in a social network of young Australians. These young people often engage in extended sessions of concurrent alcohol and other drug use, and regularly emphasise the pleasures associated with this use. However, as well-integrated young people, they are also exposed to the discourses of non-using friends, family and the wider society, which represent illicit drug use as a potential moral threat. Some group members invoked the need for self-control in relation to illicit drug use and had developed a number of strategies to cease or regulate their use. However, they struggled to regulate pleasure and drew on popular understandings of ‘excessive’ drug use as indicative of flawed neo-liberal subjectivity. Other group members rejected the need for self-control, choosing instead to emphasise the value of unrestrained bodily pleasure facilitated by the heavy use of illicit drugs. These co-existing discourses point to the complex ways in which illicit drug users try to challenge the stigma associated with their drug use. Our analysis suggests that future accounts of illicit drug use, and harm reduction initiatives, need to be more attentive to the micro-politics of normalisation. How should harm reduction respond to those who articulate its ethos but pursue pleasure in practice? What should harm reduction say to those who reject regulation on the grounds that it stifles pleasure? Discussing ways to incorporate pleasure into harm reduction should be central to the future development of policy and practice.     

Alcohol and harm reduction in Brazil

Alcohol consumption is an important health issue in Brazil. This paper provides an overview of alcohol-related problems in the country and explores some of the initiatives employed to address these problems. Although the notion of alcohol harm reduction is relatively new in Brazil, much work has been done to incorporate it further into the country's drug policy. The paper discusses some of the federal and state government efforts in the realm of alcohol harm reduction and provides examples of good practice from a variety of other actors, such as NGOs and universities. Looking forward, a number of challenges are outlined, such as providing better treatment to all in need of assistance, establishing a fruitful and consistent partnership between private and public sectors, measuring the size and consequences of illicit alcohol production, and addressing alcohol-related problems among Brazil's indigenous populations. In general, there is a lack of national drug and alcohol data in Brazil. Further research related to alcohol consumption, therefore, is necessary in order to provide Brazil's decision-makers with comprehensive and reliable data that could guide public health policies.