tag:theconversation.com,2011:/id/topics/methamphetamine-30497/articlesMethamphetamine – The Conversation2024-03-14T04:59:09Ztag:theconversation.com,2011:article/2256572024-03-14T04:59:09Z2024-03-14T04:59:09ZIs meth use really going up? Let’s look at the evidence behind the latest scary headlines<figure><img src="https://images.theconversation.com/files/581560/original/file-20240313-30-m9j8q7.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/heavy-drug-methamphetamine-crystal-isoalted-on-1662945838">Dima Sobko/Shutterstock</a></span></figcaption></figure><p><a href="https://www.theguardian.com/society/2024/mar/12/australia-drug-use-wastewater-testing-methamphetamine-increase">Widely reported</a> data released from the <a href="https://www.acic.gov.au/publications/national-wastewater-drug-monitoring-program-reports/report-21-national-wastewater-drug-monitoring-program">National Wastewater Drug Monitoring Program</a> this week appears to show the rising use of methamphetamine (also known as methylamphetamine). You may know it as speed (the powder form) or ice (the crystal form).</p>
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<p>But this reporting appears to contradict data released in recent weeks from the <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey/contents/about">National Drug Strategy Household Survey</a>. This 2022-23 survey shows methamphetamine use is falling and is at its <a href="https://theconversation.com/meth-use-is-declining-in-australia-but-the-public-still-sees-it-as-the-most-worrying-drug-224620">lowest in more than a decade</a>.</p>
<p>So what’s going on? Is methamphetamine use rising or falling?</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/meth-use-is-declining-in-australia-but-the-public-still-sees-it-as-the-most-worrying-drug-224620">Meth use is declining in Australia – but the public still sees it as the most worrying drug</a>
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</p>
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<h2>Looking at wastewater</h2>
<p>The <a href="https://www.acic.gov.au/publications/national-wastewater-drug-monitoring-program-reports">National Wastewater Drug Monitoring Program</a> collects samples of wastewater from sewage treatment plants. University researchers then test samples for traces of different drugs.</p>
<p>The way the samples are analysed differentiates between drugs that have been consumed and drugs that have been disposed of before consumption. This means we know the drugs detected have actually been used and excreted via urine, not just thrown down the toilet.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/581808/original/file-20240313-16-9lc1bf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Finger pressing toilet flush" src="https://images.theconversation.com/files/581808/original/file-20240313-16-9lc1bf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/581808/original/file-20240313-16-9lc1bf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/581808/original/file-20240313-16-9lc1bf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/581808/original/file-20240313-16-9lc1bf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/581808/original/file-20240313-16-9lc1bf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/581808/original/file-20240313-16-9lc1bf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/581808/original/file-20240313-16-9lc1bf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Researchers can tell which drugs have been used and excreted via urine.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-view-womans-hand-pushing-button-2155659743">brizmaker/Shutterstock</a></span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/drugs-in-bugs-69-pharmaceuticals-found-in-invertebrates-living-in-melbournes-streams-106331">Drugs in bugs: 69 pharmaceuticals found in invertebrates living in Melbourne's streams</a>
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</em>
</p>
<hr>
<h2>But there are limitations</h2>
<p>The <a href="https://www.acic.gov.au/sites/default/files/2024-03/Wastewater%2021%20FOR%20WEB2.PDF">report</a> of the wastewater data mentions measuring “consumption”, “demand” and “harm” from drugs. But the wastewater program doesn’t measure these directly.</p>
<p>It only measures overall amount of a drug consumed in the community at a single point in time.</p>
<p>Wastewater data can’t tell us whether a small number of people have used a large amount of a drug or a large number of people each used a very small amount of a drug. It can only tell us the overall volume of a drug used.</p>
<p>Some of the sampling sites have been chosen specifically because the <a href="https://www.acic.gov.au">Australian Criminal Intelligence Commission</a>, which runs the program, has an actual or potential concern that drug use is high in those areas. This kind of targeted sampling may overestimate how much of a drug has been used across Australia or at any given time point.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-ice-and-speed-the-drugs-that-kept-soldiers-awake-and-a-president-young-61002">Weekly Dose: ice and speed, the drugs that kept soldiers awake and a president young</a>
</strong>
</em>
</p>
<hr>
<h2>Surveys give us different answers</h2>
<p>The <a href="https://www.aihw.gov.au/about-our-data/our-data-collections/national-drug-strategy-household-survey">National Drug Strategy Household Survey</a> is a sample of, usually, around 20,000-25,000 households in Australia. It asks one person from each household aged 14 years and over about their use of a range of drugs in the past year and in their lifetime. Researchers refer to this as “self report”.</p>
<p>The survey asks about quantity, frequency and harms of drug use, and reports the data by a range of demographic measures such as age and gender. It also surveys the community’s attitudes to drugs. So the data is much more detailed than wastewater data.</p>
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<h2>Surveys have limitations too</h2>
<p>The National Drug Strategy Household Survey relies on people being honest about their drug use. </p>
<p>People tend to forget or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9726603/">downplay their use</a>, especially for illicit drugs, so the survey results likely underestimate use. But the underestimate is probably similar across years because the way the data is collected has remained very similar across time.</p>
<p>However, as the survey is anonymous and there are no consequences to disclosing this information (for example, no risk of being arrested for drug use) it’s probably reasonably accurate.</p>
<p>The survey is best for looking at trends over time.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/young-people-are-drinking-less-in-real-life-but-film-and-tv-paints-a-different-picture-223854">Young people are drinking less in real life. But film and TV paints a different picture</a>
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</em>
</p>
<hr>
<h2>So what can we make of this?</h2>
<p>Over the years, there have been some ups and downs in methamphetamine volumes reported in the wastewater data. However, the average national volume (in kilos) of methamphetamine reported in the latest wastewater <a href="https://www.acic.gov.au/sites/default/files/2024-03/Wastewater%2021%20FOR%20WEB2.PDF">report</a> is pretty close to the average for the past seven years.</p>
<p>The most recent report shows an increase in <em>consumption per 1,000 population</em> in regional areas, but a decrease in capital cities, representing an overall decrease. The <em>total volume</em> of methamphetamine used has increased, however. But as the population has also increased during that time, this complicates the picture.</p>
<p>Changes up and down in volume of drug used could also be seasonal or in response to short-term changes in availability. So it’s better to look at long-term changes over time together with other data.</p>
<p>The proportion of the population who report using methamphetamine in the National Drug Strategy Household Survey has <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/meth-amphetamine-ndshs">fallen</a>, continuing a long-term trend.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/2-200-deaths-32-000-hospital-admissions-15-7-billion-dollars-what-opioid-misuse-costs-australia-in-a-year-137712">2,200 deaths, 32,000 hospital admissions, 15.7 billion dollars: what opioid misuse costs Australia in a year</a>
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</em>
</p>
<hr>
<h2>What’s the take-home message?</h2>
<p>These two datasets measure different things at different time points using different methods.</p>
<p>The wastewater data found the average <em>volume</em> of methamphetamine had increased, but <em>consumption per 1,000 population</em> had decreased. This drop in consumption is in line with the survey, which found a drop in the percentage of people reporting methamphetamine use, the lowest in over a decade.</p>
<p>So is methamphetamine use in Australia rising or falling? Both sets of data actually suggest use is falling, even though you’d never know it from the recent headlines.</p>
<p>It’s a good demonstration of why we shouldn’t take data in isolation and why we need to consider a range of factors in interpreting data.</p>
<p>The last thing we want is sensationalised headlines, leading to the type of stigma that makes it harder for people who use drugs to ask for support.</p>
<hr>
<p><em>If you are worried about your own or someone else’s drug use or just want further information you can call the free and confidential National Alcohol and Other Drug Hotline on 1800 250 015 or contact <a href="https://www.counsellingonline.org.au">Counselling Online</a>. Both services are available 24/7.</em></p><img src="https://counter.theconversation.com/content/225657/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee works as a paid consultant in the alcohol and other drug sector. She has previously been awarded grants by state and federal governments, National Health and Medical Research Council and other public funding bodies for alcohol and other drug research. She is a Board member of drug checking organisation The Loop Australia. She is CEO at Hello Sunday Morning, which receives funding from the Australian government.</span></em></p>One report says methamphetamine use is rising. Another says it’s falling. So what’s going on?Nicole Lee, Adjunct Professor at the National Drug Research Institute (Melbourne based), Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2246202024-02-29T05:22:58Z2024-02-29T05:22:58ZMeth use is declining in Australia – but the public still sees it as the most worrying drug<figure><img src="https://images.theconversation.com/files/578820/original/file-20240229-28-o17b54.jpg?ixlib=rb-1.1.0&rect=8%2C4%2C2986%2C1989&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/silhouette-sad-teenage-girl-looking-out-370131206">Max kegfire/Shutterstock</a></span></figcaption></figure><p>Methamphetamine, also known as ice or meth, is the drug Australians most associate with a drug problem and the drug they’re most concerned about, according to the latest <a href="https://pp.aihw.gov.au/reports/alcohol/perceptions-alcohol-drugs">National Drug Strategy Household Survey</a>. </p>
<p>Yet the survey, released today, shows recent use of methamphetamine has been declining. It’s at its lowest in more than a decade, with <a href="https://pp.aihw.gov.au/reports/illicit-use-of-drugs/meth-amphetamine-ndshs">1% of Australians</a> using methamphetamine in the past 12 months.</p>
<p>So why are Australians still worried about this drug, and why does it matter?</p>
<p>There’s a global trend in viewing drug use as a health rather than criminal justice issue. The Australian Capital Territory <a href="https://www.act.gov.au/our-canberra/latest-news/2023/october/drug-law-reform-changes-commence">recently decriminalised</a> methamphetamine and a range of other illicit drugs for personal use. Other states are <a href="https://adf.org.au/insights/decriminalisation-australia/">considering whether to take this step</a>, which means the public’s opinion is increasingly important. </p>
<p>Let’s take a look at the reasons why some drugs are viewed more negatively than others (such as alcohol and cannabis). We know it’s not always to do with <a href="https://theconversation.com/history-not-harm-dictates-why-some-drugs-are-legal-and-others-arent-110564">the level of harm they cause</a>. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/history-not-harm-dictates-why-some-drugs-are-legal-and-others-arent-110564">History, not harm, dictates why some drugs are legal and others aren't</a>
</strong>
</em>
</p>
<hr>
<h2>How do we develop attitudes about drugs?</h2>
<p>Messages conveyed by news media and government advertising affect public beliefs and attitudes about many important social and health issues <a href="https://onlinelibrary.wiley.com/doi/10.1111/dar.13622">including alcohol and other drugs</a>.</p>
<p>Media reports about drug use tend to focus on the negative aspects of illicit drugs rather than presenting it as a health or social issue. People who use methamphetamine are <a href="https://www.tandfonline.com/doi/full/10.1080/09687637.2019.1679089">framed as criminal, deviant or dangerous</a>. A review of articles in print media found stories about methamphetamine were <a href="https://onlinelibrary.wiley.com/doi/10.1111/dar.13622">disproportionately focused</a> on crime or justice-related topics.</p>
<p>Methamphetamine use, especially the use of the crystal form (ice), has been called a “<a href="https://time.com/4737800/meth-australia-ice-crystal-methamphetamine-methylamphetamine/">crisis</a>” and an “<a href="https://www.smh.com.au/national/nsw/ice-epidemic-amount-of-illegal-stimulants-seized-in-nsw-more-than-doubles-in-a-year-20211019-p5917s.html">epidemic</a>”.</p>
<figure class="align-center ">
<img alt="A person reading a newspaper on a bench." src="https://images.theconversation.com/files/578508/original/file-20240228-21-raiir5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/578508/original/file-20240228-21-raiir5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/578508/original/file-20240228-21-raiir5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/578508/original/file-20240228-21-raiir5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/578508/original/file-20240228-21-raiir5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/578508/original/file-20240228-21-raiir5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/578508/original/file-20240228-21-raiir5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Media coverage affects public attitudes to drugs.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/man-sitting-on-bench-reading-newspaper-_Zua2hyvTBk">Roman Kraft/Unsplash</a></span>
</figcaption>
</figure>
<p>Interaction with <a href="https://www.tandfonline.com/doi/full/10.1080/09687637.2017.1397602">people who have experience of drug use</a> has been shown to decrease stigmatising attitudes, but with such a low rate of use, most Australians wouldn’t know anyone who uses methamphetamine. </p>
<p>As a result, many Australians hold misconceptions about methamphetamine and its effects. A <a href="https://www.jmir.org/2021/8/e29026">survey of 2,108 Australians</a> found more than half (57.4%) thought methamphetamine was the most popular illicit drug in Australia and one-quarter (25.5%) believed most teenagers had used methamphetamine.</p>
<p>But <a href="https://pp.aihw.gov.au/reports/illicit-use-of-drugs/illicit-drug-use">methamphetamine use is low</a> compared with other drugs such as cannabis (11.5%), cocaine (4.5%) and ecstasy (2.1%). The most commonly used drugs among young people are alcohol, cannabis and cocaine. </p>
<p>Methampehtamine use has <a href="https://cracksintheice.org.au/how-does-ice-work">short-term effects including</a> increasing heart rate and body temperature, disrupting sleep, and making you feel alert or agitated. Long-term use of methamphetamine <a href="https://onlinelibrary.wiley.com/doi/10.1080/09595230801923702">can lead to</a> heart or lung problems, exhaustion and dependence. But most people who try methamphetamine <a href="https://pp.aihw.gov.au/reports/illicit-use-of-drugs/meth-amphetamine-ndshs">don’t go on to use it regularly</a>. </p>
<p>The <a href="https://pp.aihw.gov.au/reports/illicit-use-of-drugs/meth-amphetamine-ndshs">National Drug Strategy Household Survey</a> also found Australians in poorer areas were more likely to have used crystal methamphetamine, while those in wealthier areas were more likely to use its powdered form, or speed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-does-ice-use-affect-families-and-what-can-they-do-41186">How does ice use affect families and what can they do?</a>
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</em>
</p>
<hr>
<h2>Why do attitudes to illicit drugs need to change?</h2>
<p>Negative attitudes lead to stigma, isolation and unfair treatment of people who use drugs, and their friends and family. </p>
<p>Stigma toward people who use crystal methamphetamine <a href="https://www.sciencedirect.com/science/article/pii/S0955395920303200?via%3Dihub#bib0014">is common in Australia</a>, with one in three people who use crystal methamphetamine reporting they have felt discriminated against by other people (for example, community members or health workers) because of their drug use. </p>
<p>Stigma leads to psychological distress for people who use drugs and has been linked with <a href="https://journals.sagepub.com/doi/10.1177/1468017308101818">low self-worth and shame</a>. We know <a href="https://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-020-00288-0">stigma is a barrier</a> to help-seeking and treatment. This can make the problem worse because people who need help aren’t able to get it, and continue to use drugs. According to one participant in a study by <a href="https://cracksintheice.org.au/">Cracks in the Ice</a>: </p>
<blockquote>
<p>There’s this big stigma around drug use, especially with crystal methamphetamine. Because of that, you tend to hide a lot of what you’re going through.</p>
</blockquote>
<p>Reducing stigma is important as often <a href="https://adf.org.au/reducing-risk/aod-mental-health/prevention-early-intervention/">the sooner someone gets help</a>, the better the outcome is and the <a href="https://espace.curtin.edu.au/handle/20.500.11937/55464">better for the community</a> (for example, less absences from work, less crime, and fewer visits to health care). The harms and costs of drug use are higher for people dependent on drugs.</p>
<figure class="align-right ">
<img alt="One person holds another person's hand across a table." src="https://images.theconversation.com/files/578823/original/file-20240229-30-w6923r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/578823/original/file-20240229-30-w6923r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/578823/original/file-20240229-30-w6923r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/578823/original/file-20240229-30-w6923r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/578823/original/file-20240229-30-w6923r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/578823/original/file-20240229-30-w6923r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/578823/original/file-20240229-30-w6923r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stigma affects the degree to which people will seek support.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/person-in-black-long-sleeve-shirt-holding-white-ceramic-mug-xM4wUnvbCKk">Priscilla Du Preez/Unsplash</a></span>
</figcaption>
</figure>
<h2>So, what can we do to change people’s attitudes?</h2>
<p>We know accurate information improves knowledge and understanding, and can lead to more empathetic attitudes. </p>
<p>A number of free evidence-based resources are available for all Australians, such as the <a href="https://cracksintheice.org.au/">Cracks in the Ice toolkit</a>. When <a href="https://www.jmir.org/2021/8/e29026">it was evaluated</a>, people who visited the website knew more about crystal methamphetamine and held less negative or stigmatising attitudes towards people who use it. </p>
<p>The media also have an important role to play by not sensationalising drug use. Guidelines such as those from <a href="https://mindframe.org.au/">Mindframe</a> set out advice for accurate and non-stigmatising reporting on suicide, mental health and alcohol and other drugs.</p>
<p>These include Mindframe guidelines specifically developed for <a href="https://mindframe.org.au/alcohol-other-drugs/communicating-about-alcohol-other-drugs/crystal-methamphetamine-in-the-media">methamphetamine reporting</a>. Using Mindframe guidelines has been shown to be <a href="https://pubmed.ncbi.nlm.nih.gov/19261565/">effective in improving media reporting</a>.</p>
<p>Similarly, <a href="https://www.aodmediawatch.com.au/">AOD Media Watch</a> highlights examples of good and stigmatising reporting in the media. </p>
<p>Language is <a href="https://adf.org.au/talking-about-drugs/power-words/">really important in reducing stigma</a>. If we talk about drugs openly, focusing on health and wellbeing rather than crime, it provides better support for people to make informed decisions and improves access to help when people need it. This in turn helps reduce the problems associated with methamphetamine and other drugs.</p>
<hr>
<p><em>For free and confidential advice about alcohol and other drugs, call the National Alcohol and Other Drug Hotline on 1800 250 015.</em></p><img src="https://counter.theconversation.com/content/224620/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steph Kershaw receives funding from The Australian Government Department of Health and Aged Care and is affiliated with the Cracks in the Ice online toolkit.</span></em></p><p class="fine-print"><em><span>Cath Chapman is Director of Research Development and Strategy at The Matilda Centre, The Universoty of Sydney. She receives funding from the National Health and Medical Research Council, the Australian Government, Paul Ramsay Foundation and other research organisations. She is affiliated with Cracks in the Ice, Positive Choices and OurFutures and is Chair, The Mental Health Services Learning Network (TheMHS).</span></em></p><p class="fine-print"><em><span>Maree Teesson is Chair of Australia's Mental Health Think Tank which is funded by the BHP Foundation. She is Director of The Matilda Centre, The University of Sydney. She receives funding from the National Health and Medical Research Council, Medical Research Future Fund, the Australian Government, BHP Foundation, Paul Ramsay Foundation and other research organisations. She is co-director and co-founder of OurFutures Institute a not-for-profit company established to distribute evidence resources to education organisations.</span></em></p><p class="fine-print"><em><span>Nicole Lee works as a paid consultant in the alcohol and other drug sector. She has previously been awarded grants by state and federal governments, National Health and Medical Research Council and other public funding bodies for alcohol and other drug research. She is a Board member of drug checking organisation The Loop Australia. She is CEO at Hello Sunday Morning, which receives funding from the Australian Government.</span></em></p>Negative attitudes lead to stigma, which sees people who use drugs isolated and marginalised.Steph Kershaw, Research Fellow, Matilda Centre for Research in Mental Health and Substance Use, University of SydneyCath Chapman, Professor, Matilda Centre for Research in Mental Health and Substance Use, University of SydneyMaree Teesson, Professor & Director of The Matilda Centre. Chair, Australia's Mental Health Think Tank, University of SydneyNicole Lee, Adjunct Professor at the National Drug Research Institute (Melbourne based), Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2103162023-07-31T15:26:30Z2023-07-31T15:26:30ZOpioids and cocaine are a deadly combination – and ‘polydrug’ deaths are rising<figure><img src="https://images.theconversation.com/files/540138/original/file-20230731-251277-bhfjl1.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C2987%2C1994&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mans-hand-holding-on-palm-plastic-1056695408">DedMityay/Shutterstock</a></span></figcaption></figure><p>Drug deaths in the US involving both opioids and cocaine have increased dramatically in the past decade, according to a <a href="https://stacks.cdc.gov/view/cdc/129733">new report</a> from the Centers for Disease Control and Prevention (CDC).</p>
<p>Drug-related deaths associated with stimulants, such as cocaine, methamphetamine, amphetamine and methylphenidate, doubled between 2011 and 2021. And deaths associated with using both stimulants and opioids, such as heroin, morphine, fentanyl and methadone, increased by about sevenfold over the same period. The biggest increases have been seen since about 2019. </p>
<p>Cocaine and methamphetamine are stimulant drugs, whereas opioids, such as heroin and methadone, are depressants. This means that cocaine and methamphetamine will, among other things, make you euphoric and more alert with more energy, while heroin has the opposite effect. After an initial rush of euphoria, heroin users report a long period of drowsiness. </p>
<p>It is unclear why people take both types of drugs together. It is not thought that the euphoric effects are changed significantly by taking these drugs together, but cocaine may help with acute withdrawal from heroin. Another explanation is that, by taking both types of drug together, the user balances the stimulant and depressant effects of the drugs. Some medicated opioid abusers take stimulants for an alternative high or to counteract the sedative effects of their medication. </p>
<h2>Different mechanism</h2>
<p>These drugs work via different mechanisms. The stimulants work mostly by activating the brain’s dopamine system. Dopamine is a neurotransmitter, or chemical messenger, important in the brain reward system, so it is critical to both feeling joy and euphoria.</p>
<p>Heroin and similar drugs such as methadone or fentanyl work via the body’s opioid system. The brain and body have various proteins attached to cell surfaces involved in transmitting the opioid signals. The most relevant proteins here are the mu opioid receptors. These receptors are activated by opioid painkillers.</p>
<p>Unfortunately, it is easy to overdose on opioids such as heroin. Overdose can lead to respiratory depression and then respiratory failure. This is when there are long pauses between breaths, which become more like sighs and then a loss of consciousness followed by cessation of breathing. </p>
<figure class="align-center ">
<img alt="Heroin addicts nodding off" src="https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opioids can cause respiratory depression.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/no-drugs-concept-man-woman-aids-533628886">Lipik Stock Media/Shutterstock</a></span>
</figcaption>
</figure>
<p>The exact mechanism whereby opioids cause respiratory depression is unknown but probably involves opioid receptors found in the brainstem.</p>
<p>Cocaine and methamphetamine are less likely to kill you but are still dangerous drugs causing heart palpitations, increased blood pressure and increased risk of stroke. Methamphetamine is especially associated with dangerous <a href="https://www.tandfonline.com/doi/epdf/10.4161/23328940.2014.982049?needAccess=true&role=button">hyperthermia</a> leading to multi-organ toxicity. </p>
<p>Taking stimulants together with an opioid clearly increases your risk of drug-related death.</p>
<p>One reason that we may be seeing more drug-related deaths is due to the increased use of fentanyl. Fentanyl is a synthetic opioid that is <a href="https://www.drugs.com/medical-answers/fentanyl-compare-heroin-opiates-3569710/">50 times</a> more potent than heroin and 100 times more potent than morphine, with a faster onset of action. It is therefore more likely to lead to respiratory depression than other opioids, such as heroin or methadone. </p>
<p>Fentanyl is increasingly being used as an <a href="https://www.clinicaterapeutica.it/2022/173/1/11_DI_TRANA.pdf">adulterant</a> in street drugs, such as heroin. This is because it is cheap and very powerful, so only a small amount is needed to have a large effect.</p>
<h2>Europe’s problem too</h2>
<p>It is not just the US that is seeing a rise in so-called polydrug-related deaths. Data from the <a href="https://www.emcdda.europa.eu/publications/european-drug-report/2023/drug-induced-deaths_en">European Monitoring Centre for Drugs and Drug Abuse</a>) show that deaths from polydrug use, especially those involving opioids, are also increasing in Europe. The European data shows that it is mostly men who are dying and that older age groups are increasingly dying from drug taking. </p>
<p>Taken together, it can be seen that there may be a worldwide increase in polydrug-related deaths and in particular those involving both stimulants and opioids.</p><img src="https://counter.theconversation.com/content/210316/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colin Davidson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The US has seen a huge rise in drug deaths in the past decade involving a stimulant and a depressant.Colin Davidson, Professor of Neuropharmacology and Head of School of Pharmacy & Biomedical Sciences, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1982232023-04-07T12:17:48Z2023-04-07T12:17:48ZMisuse of Adderall promotes stigma and mistrust for patients who need it – a neuroscientist explains the science behind the controversial ADHD drug<figure><img src="https://images.theconversation.com/files/519639/original/file-20230405-28-mn3qts.jpg?ixlib=rb-1.1.0&rect=110%2C100%2C6599%2C4345&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many people with ADHD are finding it difficult to get their Adderall prescriptions filled amid the shortage.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/Adderall%20Shortage/59cf79948b4e43d388ac283673aff1b5?Query=adderall&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=218&currentItemNo=5">AP Photo/Jenny Kane</a></span></figcaption></figure><p>The <a href="https://www.npr.org/sections/health-shots/2023/02/18/1157832613/adderall-shortage-forces-some-patients-to-scramble-ration-or-go-without">nationwide shortages of Adderall</a> <a href="https://www.nytimes.com/2022/10/13/health/adderall-shortage-adhd.html">that began in fall 2022</a> have brought renewed attention to the beleaguered drug, which is used to treat <a href="https://www.cdc.gov/ncbddd/adhd/facts.html#">attention-deficit/hyperactivity disorder</a> and <a href="https://www.ninds.nih.gov/health-information/disorders/narcolepsy#">narcolepsy</a>. </p>
<p>Adderall became a go-to drug for ADHD over the past two decades but quickly came under fire <a href="https://www.advisory.com/daily-briefing/2022/05/05/adderall">because of overprescription</a> and <a href="https://americanaddictioncenters.org/adderall/symptoms-of-abuse">misuse</a>. In some cases, people who do not have <a href="https://publichealth.jhu.edu/2016/adderall-misuse-rising-among-young-adults">a proper ADHD diagnosis</a> are <a href="https://americanaddictioncenters.org/adderall/adderall-abuse-among-college-students">using the drug</a> for its <a href="https://theconversation.com/stimulants-using-them-to-cram-for-exams-ruins-sleep-and-doesnt-help-test-scores-123661">perceived cognitive-enhancing effects</a>, leading to an <a href="https://www.samhsa.gov/data/report/dawn-report-emergency-department-visits-involving-attention-deficithyperactivity-disorder">increase in its abuse rates</a> and drug dependence. </p>
<p>Not only has misuse of Adderall led to its <a href="https://www.buzzfeednews.com/article/kelseyweekman/adderall-shortage-adhd-tiktok-telehealth-stigma">stigmatization as a drug of abuse</a>, it can also lead to <a href="https://doi.org/10.1016/j.drugalcdep.2017.09.033">negative physical side effects</a>, including cardiovascular complications, sleep disturbances and <a href="https://doi.org/10.1097/nmd.0000000000000551">addiction</a>.</p>
<p>I am a <a href="https://neuroscience.ufl.edu/profile/khoshbouei-habibeh/">neuroscientist with a focus on studying the dopamine system</a> in <a href="https://www.semanticscholar.org/author/Habibeh-Khoshbouei/50196943">both the brain and peripheral immune system</a>. My research specifically examines the short- and long-term effects of psychostimulant drugs like methamphetamine on a protein that transports dopamine, a chemical messenger that is not properly regulated in people with ADHD. </p>
<p>Through this work, I aim to better understand the complex interplay between drug use and the dopamine system, which may ultimately lead to new treatments for drug addiction and related disorders. Unfortunately, I’ve seen that the stigma and false narratives surrounding Adderall have made it more difficult for patients who need this medication to access it.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/kWAz1ZHzu2o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A surge in demand for Adderall during the pandemic along with supply chain issues have led to a nationwide shortage.</span></figcaption>
</figure>
<h2>How Adderall treats ADHD</h2>
<p>Adderall is the commercial name of <a href="https://doi.org/10.1177%2F0269881113482532">a mixture of a few types of amphetamines</a>, which are stimulants that increase dopamine levels in the brain to help address deficits in those with ADHD.</p>
<p>The underlying processes that lead to ADHD are poorly understood. The core symptoms include hyperactivity, inattention, mood swings, temper, disorganization, stress sensitivity and impulsivity. </p>
<p>Multiple studies suggest that <a href="https://doi.org/10.1111/j.1749-6632.2001.tb05770.x">these symptoms may be due to</a> the <a href="https://doi.org/10.1523/jneurosci.6033-11.2012">improper regulation of dopamine levels in the brain</a>. </p>
<p>Neurons have a protein called dopamine transporter that normally functions like a vacuum cleaner that sucks the chemical into the neuron. But people with ADHD have a leaky dopamine transporter, meaning that dopamine gets pushed out of the neuron into the surrounding environment of the synapse – the space between neurons where chemical messages are passed back and forth. </p>
<p>Adderall is thought to work by <a href="https://doi.org/10.1523%2FJNEUROSCI.6033-11.2012">blocking this leaky protein</a>, <a href="https://doi.org/10.1523%2FJNEUROSCI.0473-08.2008">preventing dopamine from spewing out</a> of the neuron through the dopamine transporter. This is thought to <a href="https://doi.org/10.1016/j.eclinm.2022.101524">stabilize dopamine levels</a> in the brain of ADHD patients, thus reducing their debilitating symptoms.</p>
<figure>
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<figcaption><span class="caption">Adderall helps stabilize dopamine levels in the brains of people with ADHD.</span></figcaption>
</figure>
<h2>The paradoxical effects of Adderall</h2>
<p>People who don’t have ADHD usually have a functioning dopamine transporter that is able to maintain balanced levels of this chemical inside and outside of the neuron. When they use amphetamines like Adderall, however, the drug can disrupt the transporter’s ability to remove dopamine from the synapse as well as cause it to work backward and push dopamine out of the neuron. This results in <a href="https://doi.org/10.1038%2Fs41531-021-00161-2">too much dopamine in the synapse</a>, which can lead to feelings of euphoria and increased wakefulness. </p>
<p>While these effects might sound good on the surface, misusing the drug is problematic because it can lead to cardiovascular problems. <a href="https://doi.org/10.1001/jamanetworkopen.2022.43597">Current evidence</a> suggests that Adderall doesn’t significantly increase cardiovascular disease risk for people with ADHD. But people without ADHD who misuse Adderall can develop a dependence on the drug and take it at dangerous dosages.</p>
<p>Adderall misuse doesn’t just involve a harmful cycle that reinforces its use because of its rewarding effects. It also reinforces dependence by causing negative emotional states some researchers have dubbed the “<a href="https://doi.org/10.1097%2FNMD.0000000000000551">dark side” of addiction</a>. Excessive activation of the brain’s reward system disrupts how it normally functions, resulting in a decrease in overall sensitivity to reward signals. It also leads to persistent activation of the brain’s stress systems, which results in feelings of anxiety and restlessness in the absence of the drug.</p>
<h2>Adderall works when you need it</h2>
<p>Other drugs like methylphenidate, known by the brand name Ritalin, also treat ADHD by targeting the dopamine transporter.</p>
<p>While Adderall and Ritalin reduce the hyperactive, impulsive and inattentive symptoms in people with ADHD by stabilizing dopamine levels, they do so <a href="https://doi.org/10.1016%2Fj.neubiorev.2018.02.001">using different mechanisms</a>. Ritalin reduces the dopamine transporter’s leakiness by directly blocking entry. Adderall also reduces leakiness, but by competing with dopamine for entry into the transporter.</p>
<p>In people without ADHD, both Ritalin and Adderall significantly increase brain dopamine and induce euphoria, hyperactivity and other symptoms. However, both drugs are equally beneficial to patients with ADHD. </p>
<p>To treat anxiety, depression, narcolepsy and other neuropsychiatric diseases, <a href="https://doi.org/10.1016/s2215-0366(21)00292-3">millions of patients worldwide</a> take <a href="https://www.nimh.nih.gov/health/topics/mental-health-medications">medication that targets the transport</a> of dopamine and other neurotransmitters like norepinephrine and serotonin, but their use is not stigmatized by recreational misuse.</p>
<p>Because of the euphoria-inducing properties and hyperactivity that Adderall can induce for those who do not need the drug, its misuse and abuse have unfortunately promoted false narratives about Adderall for those who do need it. For ADHD patients, however, it can reduce negative symptoms and greatly improve quality of life.</p><img src="https://counter.theconversation.com/content/198223/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Habibeh Khoshbouei does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For those who need it, Adderall and other stimulants can be game-changing medications that help restore the chemical imbalances underlying ADHD. But for those who don’t, these drugs can be harmful.Habibeh Khoshbouei, Professor of Neuroscience, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1992392023-02-06T20:53:55Z2023-02-06T20:53:55ZWhy the drug poisoning crisis in B.C. won’t be addressed by the new decriminalization policy<p>On the same day that British Columbia began a new era in drug policy with the <a href="https://www2.gov.bc.ca/gov/content/overdose/decriminalization">decriminalization of simple possession of some drugs</a>, the province’s chief coroner provided a <a href="https://www2.gov.bc.ca/gov/content/life-events/death/coroners-service/statistical-reports">devastating update</a> about the number of lives lost to illicit drugs during the previous year. </p>
<p>On Jan. 31, 2023, B.C. began a <a href="https://www2.gov.bc.ca/assets/gov/overdose-awareness/decriminalization_factsheet.pdf">three-year pilot project</a> under which simple possession of some drugs (opioids, methamphetamine, cocaine and MDMA) can no longer lead to criminal prosecution or even seizure of the drugs by police. The policy applies to possession of up to 2.5 grams of substance for personal use.</p>
<p>While a major step in the right direction, decriminalization does nothing to tackle what is fuelling the drug-poisoning crisis: the makeup of a toxic and unregulated drug supply. </p>
<p>In fact, imposed carry restrictions of 2.5 grams could theoretically lead to unintended consequences as drugs become more potent to fit within legal limits. </p>
<p>The stated goal of the decriminalization policy change is to <a href="https://theconversation.com/decriminalizing-drug-use-is-a-necessary-step-but-it-wont-end-the-opioid-overdose-crisis-162497">remove the stigma associated with drug use</a> to encourage people to seek help when they need it. </p>
<p>While the effects that decriminalization may have on the stigma of drug use remain to be seen, what it won’t affect is the toxicity of the drug supply that is killing thousands of Canadians each year.</p>
<h2>Inconsistent and unreliable drug supply</h2>
<p>Chemical analysis of drugs (such as from <a href="https://drugcheckingbc.ca/video/">drug checking</a> or police investigations) can tell us what is circulating in the supply, but <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">toxicology results</a> from those who have died from overdoses tell us what is actually causing death. </p>
<p>These data sources describe how increases in adulteration of drugs with fentanyl analogues, <a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">benzodiazepines</a> and animal tranquilizers like <a href="https://substance.uvic.ca/blog/xylazine/">xylazine</a> are driving the drug poisoning crisis. </p>
<p>Fentanyl has been the main opioid sold on the unregulated market for several years. It is typically sold mixed into other powders like caffeine or sugars to make a final product. </p>
<p>Drug supply monitoring has shown that fentanyl concentration in these powders sold on the street can range from zero to nearly 100 per cent, with a standard sample in B.C. being <a href="https://drugcheckingbc.ca/wp-content/uploads/sites/2/2023/01/Drug_Checking_BC_Nov_20224.pdf">around 10–15 per cent</a>. </p>
<p><a href="https://doi.org/10.1093/aje/kwab129">Research conducted in Vancouver</a> has described how fentanyl concentration in these samples was somewhat consistent between 2018 and early 2020, with variability between samples even decreasing over that period. What that may speak to is producers of fentanyl reaching a sort of “sweet spot” that satisfies their customers. People who sell drugs have described how they <a href="https://doi.org/10.1016/j.drugpo.2020.102845">listen to feedback</a> from their regulars and adjust the product to meet their customers’ needs. </p>
<p>However, following the start of the COVID-19 pandemic, <a href="https://epiresearch.org/wp-content/uploads/2022/06/2022-Abstract-Book.pdf#page=77">variation in potency between fentanyl samples rose dramatically</a>, leading to further unpredictability. These changes to the fentanyl supply around the spring of 2020 coincided with rates of drug poisonings previously not seen in the province. </p>
<p>Under B.C.’s decriminalization framework, possession for personal use caps at 2.5 grams of substance. While 2.5 grams may be more than enough MDMA for a night out, it may not be enough heroin to last a single day for someone who has a high opioid tolerance. People who use drugs say that to abide by these limits, they will be forced to make <a href="https://vancouver.citynews.ca/2022/05/31/bc-decriminalization-drugs/">more frequent, smaller purchases.</a> With the drug supply as volatile and unpredictable as it is, every new purchase puts someone at risk. </p>
<h2>Legal limit may affect potency</h2>
<p>Since we know that the drug supply is dynamic, it raises a question: Will the imposed legal carry limit of 2.5 grams result in increased potency of fentanyl to fit within the new 2.5-gram threshold? </p>
<p>Increases in average potency of fentanyl has been <a href="https://www.inhsu.org/resource/fentanyl-concentration-in-drug-checking-samples-and-risk-of-drug-related-mortality-during-an-illicit-drug-toxicity-crisis-in-vancouver-canada-a-time-series-analysis/">shown to be linked to increased drug poisonings</a> in the same geographic area. If the unregulated fentanyl market adjusts to fit more active ingredient into a smaller package, there will be downstream effects on people lives. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cropped image of a person holding a hand-lettered sign reading 'Every death is a drug policy failure'" src="https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An advocate holds a sign at a demonstration in Victoria in April 2022. Decriminalization alone may have little effect on drug deaths without changes to the addiction treatment system.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Chad Hipolito</span></span>
</figcaption>
</figure>
<p>The provincial and federal governments have <a href="https://www.theglobeandmail.com/canada/british-columbia/article-federal-minister-promises-data-on-impact-of-decriminalization/">committed to a data-driven approach</a> to decriminalization. Ongoing drug supply monitoring will help public health professionals characterize what changes occur to the unregulated drug supply as a result of the policy change. Yet the act of decriminalizing drugs for personal use does not have any direct effect on the cause of the ongoing poisoning crisis. </p>
<p>The <a href="https://news.gov.bc.ca/releases/2023PSSG0008-000109">consensus among experts</a> has consistently pointed to unpredictable drugs from an unregulated supply and the absence of a functioning addiction treatment system. For those who want to seek treatment, the lack of available space leaves people waiting, once again left to rely on the toxic drug supply. </p>
<p>If B.C. is serious about confronting the leading cause of unnatural death in the province, it is going to take far more than decriminalizing simple drug possession. People who use drugs require an alternative to the toxic unregulated supply to not be risking their lives every time they use drugs. </p>
<p>Increasing access to a safer supply of drugs through a <a href="https://theconversation.com/safer-supply-of-opioids-saves-lives-providing-alternatives-to-toxic-street-drugs-177925">variety of formats</a> and providing meaningful funding for accessible treatment options are some examples of ways the province can take immediate steps to make an impact. </p>
<p>In the meantime, <a href="https://bc.ctvnews.ca/illicit-drug-death-toll-surpasses-2-000-in-b-c-for-a-2nd-consecutive-year-1.6253605">six more people will die today</a> from a drug poisoning in B.C. And another six will die tomorrow. How many more days can this go on?</p><img src="https://counter.theconversation.com/content/199239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Tobias does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As British Columbia begins a new era in drug policy, the drug poisoning crisis continues without an end in sight.Samuel Tobias, PhD Student, School of Population and Public Health, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1926352022-10-24T00:43:53Z2022-10-24T00:43:53ZDoes methamphetamine use cause Parkinson’s? And what do pizza boxes have to do with it?<figure><img src="https://images.theconversation.com/files/490818/original/file-20221020-21-vvr4vd.jpg?ixlib=rb-1.1.0&rect=66%2C12%2C3881%2C3005&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/sxQz2VfoFBE">Christian Erfurt/Unsplash</a></span></figcaption></figure><p>The South Australian government is planning to roll out a new <a href="https://www.abc.net.au/news/2022-10-17/new-research-links-meth-use-to-parkinsons-disease/101540584">mass media campaign</a> about the impact of using <a href="https://theconversation.com/explainer-methamphetamine-use-and-addiction-in-australia-13280">methamphetamine</a>, including crystal methamphetamine or “ice” and powdered methamphetamine or “speed”.</p>
<p>The campaign includes warning messages on pizza boxes – presumably because young people are the group most likely to try methamphetamine and they also eat lots of pizza.</p>
<p>It’s based on <a href="https://www.unisa.edu.au/media-centre/Releases/2022/dont-let-meth-take-hold-campaign-to-highlight-life-long-impacts-of-minimal-use/">research</a> from a few years ago that <a href="https://people.unisa.edu.au/Gabrielle.Todd#Current-research">links</a> illicit use of methamphetamine and Parkinson’s disease.</p>
<p>The researchers looked at <a href="https://pubmed.ncbi.nlm.nih.gov/26923520/">changes</a> in <a href="https://pubmed.ncbi.nlm.nih.gov/29082542/">parts of the brain</a> after methamphetamine use and say they look similar to those in Parkinson’s patients.</p>
<p>But what does the research really tell us about the link? And will pizza box messages prevent these types of harm? </p>
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<a href="https://theconversation.com/what-is-methamphetamine-or-crystal-meth-140956">What is methamphetamine or 'crystal meth'?</a>
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<h2>Is there a link between methamphetamine use and Parkinson’s?</h2>
<p>Parkinson’s disease is a brain disease that progressively gets worse and has no cure. The key feature is deterioration of neurons that manage the amount of dopamine in a part of the brain, called the <a href="https://www.ncbi.nlm.nih.gov/books/NBK536995/">substantia nigra</a>. Symptoms start to show when <a href="https://pubmed.ncbi.nlm.nih.gov/1933245/">about 50% of the neurons</a> have been damaged. </p>
<p>This part of the brain is responsible for controlling movement as well as the production of the neurotransmitter <a href="https://www.webmd.com/mental-health/what-is-dopamine">dopamine</a>. </p>
<p>Dopamine is the feel good neurochemical and part of the reward pathway in the brain. Every time we do something pleasant – like eating, sex, listening to music – our brain releases a little bit of dopamine to make us feel good and remind us to do it again. Dopamine is also needed for lots of other functions including <a href="https://www.cell.com/trends/cognitive-sciences/fulltext/S1364-6613(19)30013-0#:%7E:text=Dopamine%20enables%20successful%20cognitive%20control,complementary%20roles%20in%20cognitive%20control.">thinking</a> and <a href="https://elifesciences.org/articles/61591">moving</a>.</p>
<p>Methamphetamine triggers the release of much larger amounts of dopamine than most other activities, which is where its intense pleasurable effects come from. But over time, with regular methamphetamine use, the brain’s receptors become less sensitive. <a href="https://adf.org.au/insights/understanding-aod-dependence/">Tolerance</a> results. Then the effects of the drug are not as strong, or you need to use more to get the same effect.</p>
<p>We already know regular methamphetamine use causes changes in brain <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5011179/">structure</a> (what the brain looks like) and <a href="https://www.nature.com/articles/npp2011276">function</a> (how the brain works). And that those changes are similar to those seen in Parkinson’s patients.</p>
<p>But as far as we know, unlike Parkinson’s Disease, the changes after using methamphetamine are temporary and in most cases the brain resets itself back to normal functioning once use stops or becomes less frequent.</p>
<h2>Is the link a causal one?</h2>
<p>A number of animal and human studies have shown <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582059/">a link</a> between people who have a history of methamphetamine use and the later development of Parkinson’s disease in older age.</p>
<p>Studies have shown that people in treatment for methamphetamine problems are up to <a href="https://pubmed.ncbi.nlm.nih.gov/21794992/">two</a> to <a href="https://pubmed.ncbi.nlm.nih.gov/25479916/">three</a> times more likely to develop Parkinson’s disease.</p>
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<img alt="Person looks out of their apartment window" src="https://images.theconversation.com/files/490817/original/file-20221020-11-xx0xn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/490817/original/file-20221020-11-xx0xn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/490817/original/file-20221020-11-xx0xn9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/490817/original/file-20221020-11-xx0xn9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/490817/original/file-20221020-11-xx0xn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/490817/original/file-20221020-11-xx0xn9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/490817/original/file-20221020-11-xx0xn9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">We still don’t know whether methamphetamine causes Parkinson’s.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/zBBlSdn6fVA">Max Harlynking/Unsplash</a></span>
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<p>However, it’s hard to work out whether one causes the other because the numbers of people with both methamphetamine use and Parkinson’s disease are very small.</p>
<p>The estimate of methamphetamine use is around <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">1.3%</a> of Australians), and the number of people who develop Parkinson’s disease (<a href="https://www.parkinson.org/understanding-parkinsons/statistics">around 0.1% worldwide</a>) is relatively small. </p>
<p>The large majority of people who use methamphetamine generally use only <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">a handful of times a year </a> and for a short period in their lifetimes. So even if there is an increased risk of developing Parkinson’s disease, the population risk is quite small.</p>
<p>Studies like those from the <a href="https://pubmed.ncbi.nlm.nih.gov/29082542/">UniSA researchers</a>, that take a snapshot in time and look at the correlation of two events, aren’t able to tell us whether <a href="https://www.jmp.com/en_au/statistics-knowledge-portal/what-is-correlation/correlation-vs-causation.html">one thing causes another</a>, only that they are related in some way.</p>
<p>So we don’t know whether methamphetamine <em>causes</em> Parkinson’s disease.</p>
<p>To really work out whether methamphetamine use causes Parkinson’s disease a <a href="https://en.wikipedia.org/wiki/Longitudinal_study">longitudinal study</a> is needed. A longitudinal study would track people from say childhood to older age and measure their brain structure and function over time to see whether there is higher rate of Parkinson’s disease among people who have used methamphetamine compared to those who haven’t.</p>
<h2>Other potential explanations</h2>
<p>It’s possible that short term brain changes from using methamphetamine have some longer term impact that make someone more vulnerable to developing a range of disorders later in life, including Parkinson’s disease.</p>
<p>But there may also be other explanations for the link.</p>
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Read more:
<a href="https://theconversation.com/why-do-many-people-with-parkinsons-disease-develop-an-addiction-we-built-a-virtual-casino-to-find-out-126019">Why do many people with Parkinson's disease develop an addiction? We built a virtual casino to find out</a>
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<p>For example, people who use methamphetamine regularly are more likely to have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841129/">poor nutrition</a> (because the drug reduces feelings of hunger), more likely to have <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2021.658205/full">experienced trauma</a>, and are at higher risk of <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-3-14">physical injury</a>. These factors might affect the brain in ways that make the development of Parkinson’s disease more likely.</p>
<p><a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/parkinsons-disease/the-genetic-link-to-parkinsons-disease#:%7E:text=About%2015%20percent%20of%20people,SNCA%20gene%20(see%20below).">Genetics</a> plays a major role in Parkinson’s disease and also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506170/">has some role</a> in the development of drug problems. So there might be a common genetic link.</p>
<p>It’s also worth noting that other drugs, <a href="https://bmcneurol.biomedcentral.com/articles/10.1186/1471-2377-13-190">including alcohol</a> and a range of common prescription drugs like medicines for treating psychotic disorders, depression, high blood pressure and epilepsy, also <a href="https://www.tandfonline.com/doi/full/10.1517/14740338.2013.787065">increase the risk</a> of Parkinson’s disease.</p>
<h2>And the pizza boxes?</h2>
<p>We know mass media campaigns for issues that affect a relatively small number of people are <a href="https://pubmed.ncbi.nlm.nih.gov/26338836/">not very effective</a>. Targeted campaigns for people at risk of developing problems <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4248563/">tend to work better</a>.</p>
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<img alt="Peperoni pizza" src="https://images.theconversation.com/files/490819/original/file-20221020-14-u1u4hb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/490819/original/file-20221020-14-u1u4hb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/490819/original/file-20221020-14-u1u4hb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/490819/original/file-20221020-14-u1u4hb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/490819/original/file-20221020-14-u1u4hb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/490819/original/file-20221020-14-u1u4hb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/490819/original/file-20221020-14-u1u4hb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pizza-box messaging is unlikely to work.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/SU1LFoeEUkk">Alan Hardman/Unsplash</a></span>
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<p>Drug use is one of the issues for which public campaigns are largely ineffective. In fact, they can actually increase problems by creating stigma. This makes people <a href="https://theconversation.com/is-there-really-such-a-thing-as-an-addictive-personality-184137">less likely</a> to seek help for their drug problems.</p>
<p>So the pizza box idea is unlikely to have much impact at all. </p>
<p>Money wasted on these types of campaigns would be much better spent on evidence-based interventions. These include addressing the social problems that increase the risk of using methamphetamine such as poverty and childhood trauma, effective <a href="https://www.sydney.edu.au/matilda-centre/news-and-events/2022/02/04/our-futures.html">drug education programs</a> at school, harm reduction programs and <a href="https://ndarc.med.unsw.edu.au/resource/new-horizons-review-alcohol-and-other-drug-treatment-services-australia">treatment</a>.</p>
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Read more:
<a href="https://theconversation.com/parkinsons-disease-bad-dreams-could-be-an-early-warning-sign-new-study-184495">Parkinson’s disease: bad dreams could be an early warning sign – new study</a>
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<p><em>If you are worried about your own or someone else’s drug use you can call the National Alcohol and other Drug Hotline on 1800 250 015 for advice, counselling or help finding a treatment provider.</em></p><img src="https://counter.theconversation.com/content/192635/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee works as a consultant in the alcohol and other drug sector and a psychologist in private practice. She has previously been awarded funding by Australian and state governments, NHMRC and other bodies for evaluation and research into alcohol and other drug prevention and treatment.</span></em></p><p class="fine-print"><em><span>Steven Bothwell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If governments want to tackle drug use, targeting those at most risk is a better strategy than mass campaigns.Nicole Lee, Professor at the National Drug Research Institute (Melbourne), Curtin UniversitySteven Bothwell, Consultant and Adjunct Associate Lecturer, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1671002021-09-16T12:11:03Z2021-09-16T12:11:03ZOxyContin created the opioid crisis, but stigma and prohibition have fueled it<figure><img src="https://images.theconversation.com/files/421389/original/file-20210915-17-1lvjamv.jpg?ixlib=rb-1.1.0&rect=6%2C12%2C997%2C597&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People around the world mourned loved ones on International Overdose Awareness Day on Aug. 31, 2021.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/edmontonians-pose-wooden-crosses-with-roses-on-news-photo/1234986137?adppopup=true"> NurPhoto/Getty Images</a></span></figcaption></figure><p>The <a href="https://theconversation.com/how-the-purdue-opioid-settlement-could-help-the-public-understand-the-roots-of-the-drug-crisis-166701">highly contentious</a> <a href="https://www.npr.org/2021/09/01/1031053251/sackler-family-immunity-purdue-pharma-oxcyontin-opioid-epidemic">Purdue Pharma settlement</a> announced Sept. 1, 2021, comes at a pivotal time for the U.S. overdose crisis: 2020 was the worst year on record, with over <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">93,000 Americans</a> losing their lives to fatal drug overdose. The drug overdose epidemic, now more than two decades long, has claimed the lives of <a href="https://www.cdc.gov/opioids/data/index.html">more than 840,000</a> people since 1999. Current estimates suggest that some <a href="https://www.rand.org/content/dam/rand/pubs/research_reports/RR3100/RR3140/RAND_RR3140.pdf">2.3 million people</a> in the U.S. use heroin and <a href="https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis">1.7 million people</a> use pharmaceutical opioids without a prescription. </p>
<p>Since 2016, I’ve <a href="https://gc-cuny.academia.edu/EmilyCampbell?from_navbar=true">studied the overdose crisis</a> with an eye to understanding its roots as well as its ramifications. As a <a href="https://www.holycross.edu/academics/programs/sociology-and-anthropology/faculty/emily_b_campbell">sociologist</a>, I came to this area of research in my own quest for meaning, as each year brought more funerals of former classmates and friends. What I found was an increasingly dangerous drug environment for people who use drugs, often exacerbated by policies not founded in research and by attitudes that harm those affected.</p>
<h2>How prohibition fuels dangerous markets</h2>
<p>Research shows that <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">the illicit drug market adapts</a> to both demand and drug enforcement efforts. </p>
<p>The first consequence of increased demand is that drugs become <a href="https://doi.org/10.1016/j.drugpo.2007.11.016">cheaper over time</a>. For example, the price of heroin and cocaine have been falling for decades. Political economists explain that demand, coupled with globalization, increases efficiency and competition. The result is that there are more drugs on the illicit market, which in turn lowers prices. </p>
<p>Second, as a response to drug prohibition, <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">drugs become more potent</a>. A stronger product in a smaller package is easier to transport and harder to detect. The American overdose crisis has become <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">a case study</a> in the devastating interplay of demand and prohibition. </p>
<p>OxyContin was released in 1996 and <a href="https://doi.org/10.2105/AJPH.2007.131714">mass-marketed as a revolutionary intervention</a> in the medical treatment of pain. Purdue Pharma, its maker, <a href="https://www.nytimes.com/2007/05/10/business/11drug-web.html?smid=url-share">knowingly downplayed</a> its addictive potential. As an opioid and central nervous depressant, <a href="https://doi.org/10.1300/J069v23n04_01">OxyContin has effects</a> similar to those of morphine or heroin. Not surprisingly, studies show that prescription patterns of opioids from 1999 to 2008 were <a href="https://pubmed.ncbi.nlm.nih.gov/22048730/">directly linked to a surge in overdose deaths</a>.</p>
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<a href="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pill bottle and pills of OxyContin prescription-only pain medication" src="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Oxycontin prescription-only pills were aggressively promoted to primary care physicians as a safe and effective pain control method for patients.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/oxycontin-pills-oxycodone-hydrochloride-prescription-only-news-photo/563590877?adppopup=true">Lawrence K. Ho/Los Angeles Times via Getty Images</a></span>
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<p>As concern over opioid overdose grew, doctors’ prescribing practices <a href="https://doi.org/10.1007/s11013-016-9496-5">came under scrutiny</a>. In 2010, Purdue Pharma replaced the original OxyContin with an <a href="https://doi.org/10.1001/jamapsychiatry.2014.3043">“abuse deterrent” formulation</a> that was more difficult to crush and inhale. As a result, many people who were addicted to OxyContin turned to heroin, which was <a href="https://doi.org/10.1162/rest_a_00755">cheaper and easier to get</a>. This spurred a surge in heroin-related fatal overdoses, which is often termed the <a href="https://doi.org/10.1016/j.drugpo.2019.01.010">second wave of the overdose crisis</a>.</p>
<p>The growing market for heroin paved the way for the <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">introduction of fentanyl</a> into the illicit U.S. drug market. Fentanyl, a drug used in medical settings for severe pain, is <a href="https://www.drugabuse.gov/publications/drugfacts/fentanyl">50 times more potent than heroin</a>. From the standpoint of efficiency for shipping and trafficking, fentanyl is easier to transport and sell than heroin. Fentanyl’s entry into the illicit drug market, in particular in combination with heroin, <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">led to a doubling and tripling </a>of overdose deaths around 2012 to 2013. </p>
<p><a href="https://journals.lww.com/co-psychiatry/fulltext/2021/07000/the_rise_of_illicit_fentanyls,_stimulants_and_the.4.aspx">Since then, fentanyl</a> <a href="https://doi.org/10.1016/j.drugpo.2021.103353">has contaminated</a> the U.S. illicit drug supply: It is often found in not just heroin but cocaine, MDMA – commonly known as Ecstasy – methamphetamine and counterfeit prescription pills. The result is that most people <a href="https://doi.org/10.1016/j.drugpo.2019.07.008">do not know the potency or contents</a> of what they are using. </p>
<p>As the overdose crisis evolves, <a href="https://doi.org/10.1007/s40615-021-01007-6">communities of color</a> in particular have experienced a surge in fatal overdoses – deaths that are often preventable. And most recently, COVID-19 supply chain disruptions led people to use whatever was available, causing <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2021.306256">a surge in overdoses</a> from drug mixing. </p>
<h2>Barriers to treatment</h2>
<p>Too often, people who use drugs are bombarded with messages that are not supported by research and that deepen the harm. </p>
<p>Public health officials and community leaders urge people to seek treatment and highlight that recovery is within reach. Yet, roughly 70% of people who seek treatment are <a href="https://www.rcorp-ta.org/sites/default/files/2020-06/Improving-Access-to-Evidence-Based-Medical-Treatment-for-OUD_FINAL.pdf">unable to access it</a>. <a href="https://doi.org/10.1080/10826084.2017.1363238">Barriers to treatment</a> include health care costs, lack of available treatment options and social stigma. Research also demonstrates that some people are not ready for treatment or <a href="https://doi.org/10.1080/10826084.2017.1310247">do not want to be sober</a>.</p>
<p>Sobriety is touted as the ultimate goal for people who use drugs. Yet research shows that addiction is a <a href="https://doi.org/10.1038/s41386-020-00950-y">recurring brain disease</a>, and relapse is highly likely. Most people who use drugs do so in a <a href="https://www.ucpress.edu/book/9780520293472/hurt">sporadic way</a> that features bouts of controlled and uncontrolled use as well as sobriety. It is also well documented that fear of arrest and shame encourages people to hide their drug use in ways that <a href="https://doi.org/10.1080/10826084.2020.1790008">increase their risk</a> of a fatal overdose. This is because when people use alone, there is no one there to call 911 or perform CPR should an overdose occur. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman holding up phone with image of brother and son who died after taking fentanyl-laced drugs" src="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Laurie Restivo’s brother, David Restivo, 47 (left on phone image), died from fentanyl-laced heroin, and her son, Jason Fisher Jr., 25 (right), died from fentanyl-laced cocaine.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/fentanyl-overdose-restivo-johnson-laurie-restivo-displays-a-news-photo/1315873058?adppopup=true">Reading Eagle/MediaNews Group via Getty Images</a></span>
</figcaption>
</figure>
<p>In terms of effective treatment, <a href="https://doi.org/10.1176/appi.ps.201300256">medically assisted treatments</a> are considered the gold standard for opioid use disorder, yet they are still <a href="https://doi.org/10.1111/jrh.12328">underutilized</a>. <a href="https://doi.org/10.1001/jama.2021.1741">Buprenorphine</a> is an opioid with a “ceiling effect,” meaning it does not intoxicate like morphine or heroin but instead satiates an opioid craving. Buprenorphine assists people in transitioning away from uncontrolled use and mitigates physical cravings. People who are prescribed it are often able to work, attend therapy and regain enjoyment of day-to-day life. </p>
<p>Nonetheless, buprenorphine’s availability <a href="https://doi.org/10.1002/pds.4984">varies widely by state</a>, and people of color are <a href="https://doi.org/10.1377/hlthaff.2020.02261">persistently underprescribed</a> this lifesaving medication. Methadone has been used as a treatment for opioid use disorder since the 1950s, yet it is persistently <a href="https://doi.org/10.1007/s11606-018-4801-3">hard to access</a> long term. Researchers point to the <a href="https://doi.org/10.1080/08897077.2019.1640833">ongoing role of stigma</a> in the underuse of both of these medications. </p>
<h2>Better paths forward</h2>
<p>Public health officials, harm reduction activists and concerned citizens across the U.S. are working to secure <a href="https://doi.org/10.1097/01.NPR.0000534948.52123.fb">safer injection sites</a> where people can use drugs in the presence of medical staff. Such sites facilitate the prevention of fatal overdose by assuring an adequate and timely medical response and open a pathway for further health care and addiction-related treatment. In response to the pandemic’s strains on inpatient care facilities, <a href="https://doi.org/10.1016/j.jsat.2021.108552">take-home methadone</a> availability was expanded in new ways – a change that some treatment experts <a href="https://doi.org/10.1016/j.jsat.2020.108246">hope will be permanent</a>. </p>
<p>For people who use drugs, the <a href="https://doi.org/10.1016/j.jhealeco.2019.01.001">potency and contents of their drugs are often unknown</a>. <a href="https://doi.org/10.1016/j.drugpo.2018.10.001">Drug-checking programs</a> allow people to inspect the <a href="https://doi.org/10.1016/j.drugpo.2018.09.009">contents of their drugs for fentanyl</a> at home with a simple test strip. Such programs have recently gained traction with <a href="https://www.cdc.gov/media/releases/2021/p0407-Fentanyl-Test-Strips.html">federal support</a>. States also continue to expand <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049966/">access to naloxone</a>, an overdose reversal nasal spray that is simple to administer. People who use drugs or have loved ones who use drugs are encouraged to receive training on how to administer naloxone and to carry the nasal spray on them. </p>
<p>Those who argue for a <a href="https://doi.org/10.1503/cmaj.201618">safer supply</a> and <a href="https://doi.org/10.1016/j.socscimed.2021.113986">decriminalization of drugs</a> point to success abroad. <a href="https://www.rand.org/content/dam/rand/pubs/working_papers/WR1200/WR1263/RAND_WR1263.pdf">Heroin-assisted treatment</a> is shown to be effective in keeping people away from an unpredictable drug market, thus lowering the risk of overdose. Germany’s use of <a href="https://doi.org/10.1111/j.1360-0443.2008.02185.x">heroin-assisted treatment</a> improved patients’ physical and mental health while dramatically reducing illicit drug use. In the early 2000s, <a href="https://doi.org/10.1177/2050324516683640">Portugal decriminalized</a> all drugs in response to consistently having the highest fatal overdose rates in Western Europe. With diversion of funds away from prohibition to education and treatment, Portugal saw a drop in overall drug use and now boasts among the lowest fatal overdose rates in Western Europe.</p>
<p>Americans are the world’s <a href="https://doi.org/10.1111/add.14234">largest consumers</a> of drugs and consistently have among the highest rates of opioid and cocaine dependence globally. In <a href="https://gc-cuny.academia.edu/EmilyCampbell?from_navbar=true">my own research</a>, I’ve found that people often describe drug use as a battle between sobriety and death. But the heartbreaking surge in accidental, fatal overdose deaths tells a much more complex story. Ignoring the evidence will surely cost many more lives.</p>
<p><em>If you or someone you care about has a substance use disorder and wants help, you can call SAMHSA’s National Helpline: 1-800-662-HELP (4357). Immediate emotional support is available from the National Suicide Prevention Hotline 800-273-8255.</em> </p>
<p>[<em>Get our best science, health and technology stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-best">Sign up for The Conversation’s science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/167100/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily B. Campbell does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>False narratives about drug addiction and policies that are not supported by research are deepening the overdose epidemic in the US.Emily B. Campbell, Visiting Assistant Professor of Sociology, College of the Holy CrossLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1406062020-06-15T14:14:55Z2020-06-15T14:14:55ZCrystal meth: Europe could now see a surge in supply and use<figure><img src="https://images.theconversation.com/files/341513/original/file-20200612-153812-1hvh1e4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/background-macro-shot-blue-crystals-salt-1175586049">SeventyFour</a></span></figcaption></figure><p>For many people in Europe, the closest they will have got to methamphetamine will be the TV series <a href="https://www.washingtonpost.com/news/wonk/wp/2013/08/15/heres-what-breaking-bad-gets-right-and-wrong-about-the-meth-business/">Breaking Bad</a>. But that could be about to change, as a result of developments in the international supply chain for cocaine and a new potential alliance between Mexican drug cartels and illegal European laboratories. </p>
<p>Other members of the amphetamine family have been used in Europe for years. A number are used in medicine, such as <a href="https://bnf.nice.org.uk/drug/methylphenidate-hydrochloride.html">methylphenidate</a> in the treatment of attention deficit hyperactivity disorder (ADHD); while <a href="https://www.talktofrank.com/drug/speed">“speed” or d-amphetamine</a> has had a steady following among recreational drug users. </p>
<p><a href="https://www.talktofrank.com/drug/methamphetamine">Methamphetamine</a> is more potent than speed, produces more intense effects, has a longer duration of action, and is more likely to be inhaled or injected. Also known as meth, crystal or ice, regular use is <a href="https://www.drugabuse.gov/publications/research-reports/methamphetamine/what-are-long-term-effects-methamphetamine-misuse">more likely</a> to damage users’ brains or affect their mental health. Illicit production of methamphetamine also has a high <a href="https://www.politico.eu/article/brabant-dutch-drug-labs-blight-the-landscape/">environmental cost</a> from things like chemical waste. </p>
<p>So far, meth use in Europe has been quite <a href="https://www.emcdda.europa.eu/data/stats2019/gps">limited</a>. In England and Wales, for instance, only 15,000 people <a href="https://www.gov.uk/government/statistics/drug-misuse-findings-from-the-2018-to-2019-csew">reported using</a> the drug in 2018-19. This includes some <a href="https://www.vice.com/en_uk/article/n7jdd8/uk-british-dont-use-meth">notable pockets of use</a>, but other drugs are more available, more embedded in leisure and lifestyle, and don’t have the same <a href="https://journals.sagepub.com/doi/10.1177/1741659012443234">negative</a> media <a href="https://www.mirror.co.uk/news/world-news/faces-crystal-meth-shocking-before-7260592">representation</a>. In contrast, 976,000 people reported using cocaine, and around half a million used ecstasy. </p>
<p><strong>Methamphetamine use around the world</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/341515/original/file-20200612-153849-1ftr6bp.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/341515/original/file-20200612-153849-1ftr6bp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/341515/original/file-20200612-153849-1ftr6bp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=312&fit=crop&dpr=1 600w, https://images.theconversation.com/files/341515/original/file-20200612-153849-1ftr6bp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=312&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/341515/original/file-20200612-153849-1ftr6bp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=312&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/341515/original/file-20200612-153849-1ftr6bp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=392&fit=crop&dpr=1 754w, https://images.theconversation.com/files/341515/original/file-20200612-153849-1ftr6bp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=392&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/341515/original/file-20200612-153849-1ftr6bp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=392&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://wdr.unodc.org/wdr2019/prelaunch/WDR19_Booklet_4_STIMULANTS.pdf">Methamphetmine UNODC</a></span>
</figcaption>
</figure>
<p>This is very different to the <a href="https://www.drugabuse.gov/drug-topics/methamphetamine/methamphetamine-trends-statistics">US</a> and also Asia. In east and south-east Asia, for instance, the meth trade is now <a href="https://www.unodc.org/documents/scientific/ATS/2020_ESEA_Regonal_Synthetic_Drug_Report_web.pdf">estimated to be</a> worth around US$61 billion (£48 billion) a year, <a href="https://www.reuters.com/article/us-southeastasia-crime/asia-pacific-meth-drug-trade-worth-up-to-61-billion-un-says-idUSKCN1UD0BO">having quadrupled</a> in five years to become the world’s biggest market. The supply has increased on the back of intense manufacturing in the region, which has improved quality and driven down prices. </p>
<h2>Signs of change</h2>
<p>The gamechanger for Europe could be coming via the cocaine market. <a href="https://www.washingtonpost.com/world/the_americas/coronavirus-coca-crash-bolivia-colombia-peru-latin-america/2020/06/09/8c7da42c-a11f-11ea-be06-af5514ee0385_story.html?mc_cid=5b630ec8fa&mc_eid=%5BUNIQID%5D&utm_campaign=5b630ec8fa-SENSEMAKER_MEMBERS_10_06_20&utm_medium=email&utm_source=Tortoise%20Members">Some reports</a> suggest that the price of coca, the raw ingredient of cocaine, is falling. You might think this would lead to heightened demand, but it could actually threaten future supplies as South American coca farmers switch to alternative crops to put food on the table. </p>
<p>This gap in the market could play into the hands of manufacturers of methamphetamine looking to expand into Europe. Historically, meth production in Europe has been quite localised, serving small domestic markets or exporting to more profitable regions like Asia-Pacific and the Middle East. Now, however, there is <a href="https://www.emcdda.europa.eu/publications/joint-publications/eu-drug-markets-report-2019_en">intelligence that</a> organised crime groups from Mexico might be beginning to take an interest in Europe, potentially sharing manufacturing expertise and supply chains for raw materials. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/341522/original/file-20200612-153849-1f5f4gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/341522/original/file-20200612-153849-1f5f4gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/341522/original/file-20200612-153849-1f5f4gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/341522/original/file-20200612-153849-1f5f4gu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/341522/original/file-20200612-153849-1f5f4gu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/341522/original/file-20200612-153849-1f5f4gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/341522/original/file-20200612-153849-1f5f4gu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/341522/original/file-20200612-153849-1f5f4gu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Breaking borders?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-cooking-meth-538605031">Nomad_Soul</a></span>
</figcaption>
</figure>
<p>A <a href="https://www.telegraaf.nl/nieuws/401784231/mexicanen-aangehouden-bij-vondst-drugslab-in-herwijnen">number of reports</a> from the Netherlands also suggest that well-established laboratories which had been manufacturing large quantities of MDMA (ecstasy) are now <a href="https://www.vice.com/en_uk/article/3azzvj/dutch-and-mexican-gangs-are-teaming-up-to-sell-high-end-meth-to-asia">switching to meth production</a>. One mobile meth laboratory was even found in a boat moored <a href="https://www.theguardian.com/world/2019/may/13/netherlands-police-raid-cargo-ship-crystal-meth-lab-moerdijk">at Rotterdam</a> docks. <a href="https://www.emcdda.europa.eu/">According to</a> the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), reports of police seizures of methamphetamine have also recently increased in Europe.</p>
<h2>Substitution</h2>
<p>Due to the coronavirus, we know that a <a href="https://www.bbc.co.uk/news/business-52557191">European recession</a> is unfolding. It threatens record levels of unemployment, with knock-on effects on consumer spending and people’s choice of leisure activities. Particularly at a time like this, value for money in the drugs market is just as important as with the legitimate economy. This is where methamphetamine may have an advantage over cocaine: its effects last significantly longer, and falling prices and high purity from more European production may make it seriously competitive. </p>
<p>There are several historical examples of how consumers replace one drug with another. When consumers substitute because of government attempts to clamp down on a specific drug, criminologists sometimes call it the <a href="https://www.vox.com/xpress/2014/8/30/6083923/drug-war-on-drugo">“balloon” or “hydra” effect</a>. </p>
<p>One of the reasons for the recent explosion in meth use in Asia, for example, was authorities <a href="https://opendocs.ids.ac.uk/opendocs/bitstream/handle/20.500.12413/14714/655_Drivers_and_Enablers_of_Serious_Organised_Crime_in_Southeast_Asia.pdf?sequence=1">attempting to</a> suppress heroin use and poppy cultivation in the region. This merely increased manufacturing of synthetic drugs like methamphetamine. Not only that, heroin use continued as supply re-routed from Afghanistan to Myanmar. </p>
<p>Shortages of drugs or the arrival of new synthetic drugs have both prompted consumers to substitute one variety for another. And if there is a big rise in methamphetamine use in Europe, drug services in many countries won’t be prepared. </p>
<p>Forseeing what will happen in the drug market is certainly not an exact science. Specialists <a href="https://www.bbc.co.uk/news/magazine-23453028">have predicted</a> a rise in meth use in the UK before and been proven wrong. But this time, along with changes in the global supply chain, we have a pandemic that provides fertile conditions for a stimulant like meth because many people are doing less than usual.</p>
<p>Finally, a thought on how to prepare for this possible surge. In their response to coronavirus, most governments have shown they are willing to “follow the science” to protect the public’s health. As citizens and voters, we can ask them to extend this logic to drugs policy. </p>
<p>The past few decades’ drug policies of control and criminalisation have been costly and have seemingly <a href="https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-and-social-care-committee/news/drugs-policy-report-published-19-20/">failed</a> to achieve their intended objectives. Taking control of production and supply of drugs might seem far-fetched, but there are great potential rewards for thinking outside of the box in this area – both in relation to methamphetamine and other recreational drugs. The pandemic has shown that when there is the incentive and willingness to act, no policies are off the table.</p><img src="https://counter.theconversation.com/content/140606/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives and has received funding from public grant awarding bodies for alcohol and other drugs research.</span></em></p><p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Methamphetamine use has increased dramatically in Asia in the past five years, overtaking even the US. Now cartels spy an opportunities in Europe.Ian Hamilton, Associate Professor, Addiction and Mental Health, University of YorkHarry Sumnall, Professor in Substance Use, Liverpool John Moores UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1325982020-03-02T05:49:07Z2020-03-02T05:49:07ZThe deadly opioid fentanyl is turning up in disguise on Sydney streets, making illicit drug use even riskier<figure><img src="https://images.theconversation.com/files/317934/original/file-20200302-57507-1q4iz80.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C2987%2C1985&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>On February 21 NSW Health <a href="https://www.health.nsw.gov.au/aod/public-drug-alerts/Documents/public-drug-warning-acetyl-fentanyl-21-February-2020.pdf">issued a warning</a> about methamphetamine and cocaine being contaminated with the dangerous opioid fentanyl.</p>
<p>Several people who had taken these illicit stimulant drugs presented to Sydney hospitals with symptoms of opioid overdose, raising the alarm. Drug tests found <a href="https://www.cesphn.org.au/documents/population-health/2955-nsw-health-clinical-alert-acetyl-fentanyl/file">fentanyl and acetyl-fentanyl</a> had caused the overdoses.</p>
<p>It’s believed to be the first time fentanyl has been found in <a href="https://www.abc.net.au/news/2020-02-28/mardi-gras-fentanyl-drug-warning/12010576">stimulant drugs</a> in Australia. </p>
<p>People using stimulants like methamphetamine and cocaine are not looking for the depressant effects of opioids. They would not have expected their drugs to contain fentanyl.</p>
<p>While you never know for sure what you’re getting when you buy illicit drugs, this is an extreme case.</p>
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Read more:
<a href="https://theconversation.com/princes-death-from-fentanyl-is-only-the-tip-of-the-global-overdose-iceberg-60441">Prince's death from fentanyl is only the tip of the global overdose iceberg</a>
</strong>
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<h2>What is fentanyl?</h2>
<p>Fentanyl is a strong synthetic opioid prescribed for severe pain, for example to cancer patients or after surgery. It was <a href="https://theconversation.com/weekly-dose-fentanyl-the-anaesthetic-that-may-have-been-used-as-a-chemical-weapon-on-chechen-rebels-62966">first developed</a> in the 1950s as a fast acting anaesthetic and pain reliever, but its availability has been restricted in recent years because of a high rate of misuse. </p>
<p>Today it’s usually applied in skin patches <a href="https://adf.org.au/drug-facts/fentanyl/">where the pain is</a>. It’s also used in epidurals in combination with other drugs to relieve pain during childbirth.</p>
<p>Fentanyl is much <a href="https://adf.org.au/drug-facts/fentanyl/">stronger</a> than other opioid drugs like heroin, morphine and codeine.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317935/original/file-20200302-57536-1ueb4g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317935/original/file-20200302-57536-1ueb4g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317935/original/file-20200302-57536-1ueb4g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317935/original/file-20200302-57536-1ueb4g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317935/original/file-20200302-57536-1ueb4g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317935/original/file-20200302-57536-1ueb4g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317935/original/file-20200302-57536-1ueb4g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People in the market for methamphetamine or cocaine in NSW may unknowingly be getting drugs laced with fentanyl.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>Opioids are depressants, which means they depress the central nervous system, slowing breathing and heart rate. Other effects include reduced pain, euphoria, constipation, vomiting, slurred speech and loss of appetite.</p>
<p>People who use fentanyl for non-medical reasons inject it. They find a tolerance to the drug builds quickly, the effects diminish quickly and physical dependence is rapid.</p>
<p><a href="https://yourroom.health.nsw.gov.au/a-z-of-drugs/Pages/fentanyl.aspx">Symptoms of fentanyl overdose</a> include difficult or shallow breathing, fainting, cold and clammy skin and blueish lips and skin around the mouth. People can die quickly so seeking emergency help is critical.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-fentanyl-the-anaesthetic-that-may-have-been-used-as-a-chemical-weapon-on-chechen-rebels-62966">Weekly Dose: fentanyl, the anaesthetic that may have been used as a chemical weapon on Chechen rebels</a>
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<p><a href="https://www.deadiversion.usdoj.gov/drug_chem_info/acetylfentanyl.pdf">Acetyl-fentanyl</a> has a slightly different chemical structure to fentanyl but similar effects. It has not been approved for human use.</p>
<h2>A prime culprit in America’s opioid crisis</h2>
<p>Fentanyl has been responsible for many of the overdose deaths reported <a href="http://theconversation.com/princes-death-from-fentanyl-is-only-the-tip-of-the-global-overdose-iceberg-60441">globally</a> in recent years, including in Australia.</p>
<p>Fentanyl and related substances like acetyl-fentanyl are manufactured illegally in some countries. They’re mixed with other drugs to produce powerful effects at a <a href="https://www.ncbi.nlm.nih.gov/pubmed/31465320">lower production cost</a>. Fentanyl may also be found in other drugs because of cross contamination through careless practices in drug labs. </p>
<p>In the United States more than <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">700,000 people</a> died from a drug overdose between 1999 and 2017. Illicit fentanyl caused around half of the overdose deaths <a href="https://www.ncbi.nlm.nih.gov/pubmed/31465320">reported each year since 2013</a>.</p>
<p>While a portion of these people would have knowingly been using fentanyl, many people who overdosed on fentanyl in the US <a href="https://www.ncbi.nlm.nih.gov/pubmed/31712552">had been using stimulants</a> such as methamphetamine and cocaine. </p>
<p>A study in Canada found 73% of people who tested positive for fentanyl <a href="https://pubmed.ncbi.nlm.nih.gov/26577516-why-the-fuss-fentanyl-urine-screen-study-a-cross-sectional-survey-to-characterize-an-emerging-threat-to-people-who-use-drugs-in-british-columbia-canada/">did not know they had taken it</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opioid-dependence-treatment-saves-lives-so-why-dont-more-people-use-it-122537">Opioid dependence treatment saves lives. So why don't more people use it?</a>
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<h2>Risk in Australia</h2>
<p>Illicitly manufactured fentanyl has not been reported in Australia previously. <a href="https://academic.oup.com/jat/article/41/4/318/2967156">Nine overdose deaths</a> that occurred in Melbourne in 2015 were found to include fentanyl and heroin, however the source of the fentanyl was unknown.</p>
<p>An <a href="https://www.abc.net.au/news/2019-04-12/dark-web-fentanyl-sales-spark-fears-of-australian-opioid-crisis/10996602">Australian study</a> published in 2019 found illicitly produced fentanyl was readily available on the dark web and suggested a high risk of the drug being imported to Australia.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317937/original/file-20200302-57517-1827l9v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317937/original/file-20200302-57517-1827l9v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=441&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317937/original/file-20200302-57517-1827l9v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=441&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317937/original/file-20200302-57517-1827l9v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=441&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317937/original/file-20200302-57517-1827l9v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317937/original/file-20200302-57517-1827l9v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317937/original/file-20200302-57517-1827l9v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People who use fentanyl for non-medical reasons typically inject it.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>The <a href="https://www.acic.gov.au/informing-responses-australias-illicit-drug-markets">Australian Crime Commission</a> identified China as a likely source of illicit fentanyl and related substances, highlighting ease of access to Australian markets.</p>
<p>Doctors working in the area of drug dependence have been <a href="https://www.abc.net.au/news/2019-04-12/dark-web-fentanyl-sales-spark-fears-of-australian-opioid-crisis/10996602">expecting to see</a> illicit fentanyl in Australia at some point. The fear is Australia could face an overdose epidemic similar to the US and <a href="https://www.theguardian.com/world/2019/dec/13/canada-opioids-crisis-overdoses-report">Canada</a>.</p>
<h2>How can we reduce harm?</h2>
<p>Harm reduction strategies include training people who take illicit drugs in the use of naloxone, a drug that reverses opioid overdoses, and providing rapid fentanyl test strips so drugs can be tested prior to use.</p>
<p>The test strips are reliable and <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-018-0276-0">easy to use</a>. A small amount of the drug is dissolved in water and the test strip is dipped into the liquid for 15 seconds. </p>
<p>The test strips are highly sensitive and only a tiny amount of fentanyl is needed for it to be detected. It takes five minutes for the test result to appear. </p>
<p>While the strips have been found to be accurate at detecting the presence of fentanyl, they don’t identify the strength or quantity of <a href="https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/Fact_Sheet_Fentanyl_Testing_Approved_ADA.pdf">the drug in the sample</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/testing-festival-goers-pills-isnt-the-only-way-to-reduce-overdoses-heres-what-else-works-118827">Testing festival goers' pills isn't the only way to reduce overdoses. Here's what else works</a>
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<p>Most people who use illicit drugs do so occasionally. It’s likely people using stimulant drugs will not have fentanyl testing kits or naloxone with them. This increases the risk of harm.</p>
<p>Naloxone, testing kits and drug checking availability in general are the best ways to reduce harm from fentanyl. These will need greater promotion if we continue to see cases like we’ve seen in Sydney in the past month.</p><img src="https://counter.theconversation.com/content/132598/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julaine Allan has received funding from NHMRC, ARC, RIRDC and NSW Health to conduct research on substance use. Julaine is currently Director of Research for Western NSW Local Health District.</span></em></p>Fentanyl has been a prime culprit in the opioid crisis in the United States. It’s now turning up in cocaine and methamphetamine in New South Wales.Julaine Allan, Senior research fellow, Charles Sturt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/882482018-01-22T19:07:02Z2018-01-22T19:07:02ZIce psychosis: what is it, and why do only some users get it?<figure><img src="https://images.theconversation.com/files/201268/original/file-20180109-83550-10dw76k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It doesn't matter if you're male, female, young or old, the major risk factor for ice induced psychosis is how much you use it and how addicted you are.</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>There is growing concern about crystal methamphetamine (ice) use in Australia and internationally, in part because of the psychological effects of the drug. Although most people who use ice do not experience psychological problems, <a href="http://journals.lww.com/co-psychiatry/Abstract/2016/07000/Psychosis_induced_by_amphetamines.3.aspx">about one in three people</a> who use it regularly report experiencing psychosis in their lifetime. </p>
<p>Research also suggests that up to <a href="https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-016-0745-5">30%</a> of people who experience ice psychosis go on to develop a long-term psychotic illness such as schizophrenia or bipolar disorder. <a href="http://journals.sagepub.com/doi/abs/10.1177/0004867417748750">Our new study</a> aimed to find out why some ice users are more likely to experience psychosis than others.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ice-causes-death-in-many-ways-overdose-is-just-one-of-them-81752">Ice causes death in many ways, overdose is just one of them</a>
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</em>
</p>
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<h2>So what is ice psychosis?</h2>
<p>Psychosis refers to a range of mental health symptoms, including suspiciousness and paranoia, hallucinations, and unusual or agitated behaviour. Individuals often lose touch with reality, and may not have an understanding of what is happening to them. This can be very distressing for the individual and for their family and friends, and may result in the person having to go to hospital. </p>
<p>Psychosis can occur as part of many different mental health disorders, or be triggered by a range of drugs. Amphetamine-type stimulant drugs, such as ice, are particularly known to potentially trigger psychosis. In the 1970s, amphetamines administered in <a href="https://jamanetwork.com/journals/jamapsychiatry/article-abstract/490932">experimental situations</a> were shown to cause psychotic symptoms in healthy people who had never used the drug before. </p>
<p>In Australia, ice is the drug that most commonly results in <a href="https://www.researchgate.net/publication/276065432_The_role_of_methamphetamines_in_psychosis-related_ambulance_presentations">ambulance attendances</a> for psychosis symptoms. And <a href="http://onlinelibrary.wiley.com/doi/10.1111/dar.12426/full">hospital admissions</a> for ice psychosis have increased steeply in the past ten years. </p>
<p>These patterns of increasing harms have paralleled the increase in the purity of ice and <a href="https://www.mja.com.au/journal/2016/204/4/estimating-number-regular-and-dependent-methamphetamine-users-australia-2002">increasing dependence</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-ice-and-speed-the-drugs-that-kept-soldiers-awake-and-a-president-young-61002">Weekly Dose: ice and speed, the drugs that kept soldiers awake and a president young</a>
</strong>
</em>
</p>
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<h2>What did the study find?</h2>
<p>We know the majority of people who use ice don’t experience psychosis. So we <a href="http://journals.sagepub.com/doi/abs/10.1177/0004867417748750">looked at 20 existing studies</a> examining more than 5,000 regular ice users to try to find out what factors made someone more at risk of psychosis. </p>
<p>We found the frequency and amount of methamphetamine use, and the severity of dependence, were the factors most commonly associated with the risk of psychosis. Unfortunately, the design of the studies, and the different ways in which they measured the frequency and amount of methamphetamine use, mean we can’t estimate exactly how much an increase in use will result in an increase in risk. </p>
<p>Other risk factors included a family history of a psychotic disorder, and current use of other drugs, including cannabis and alcohol. While <a href="http://www.sciencedirect.com/science/article/pii/S0376871614009697">one study</a> found a link between a history of traumatic experiences in childhood and the experience of ice psychosis, more research needs to be done. </p>
<p>Just as important were factors that were <em>not</em> associated with ice psychosis – for example, age, gender, income or employment status. Interestingly, the way in which people used methamphetamine – by smoking versus injecting, for instance – did not appear to affect the likelihood of psychosis.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-methamphetamine-use-and-addiction-in-australia-13280">Explainer: methamphetamine use and addiction in Australia</a>
</strong>
</em>
</p>
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<h2>Better treatment would make the difference</h2>
<p>It’s important to remember almost all of the research on this topic has been cross-sectional. This means measurements of psychotic symptoms and measurements of risk factors have occurred at the same time – so we don’t know which causes the other, only that they’re related. </p>
<p>The best way to study risk factors for ice psychosis would be to follow people from before they start using the drug, to when they develop the problem. But this sort of study is very difficult to conduct when it comes to drug use. Differences in the way researchers measure psychosis, or measure methamphetamine use, also affect how we understand the relationship between the two. </p>
<p>Taken together, the main finding of our study was that people who used the drug more often and were more dependent on it were more likely to experience psychosis. While this might appear obvious, it does help healthcare workers and treatment services identify people who might be at greatest risk. </p>
<p>Similarly, for people who aren’t ready to stop using the drug, changing the frequency or pattern of their use might help them avoid developing psychosis. </p>
<p>More broadly, the key message from our research is better treatment of ice use would translate to a reduction in harms from the drug. The challenge remains making sure effective treatment is available when people are ready and willing to access it.</p><img src="https://counter.theconversation.com/content/88248/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shalini Arunogiri receives funding from the National Health & Medical Research Council (NHMRC), and has received fellowships from the Royal Australian & New Zealand College of Psychiatrists (RANZCP) and the Windermere Foundation.
Shalini is also the Chair of the Faculty of Addiction Psychiatry at the Royal Australian & New Zealand College of Psychiatrists (RANZCP). </span></em></p>A new study has looked at why some ice users suffer psychosis and others don’t.Shalini Arunogiri, Addiction Psychiatrist, Lecturer, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/836412017-09-12T19:42:43Z2017-09-12T19:42:43ZIs evidence for or against drug-testing welfare recipients? It depends on the result we’re after<p>The government’s <a href="http://www.abc.net.au/news/story-streams/federal-budget-2017/2017-05-12/federal-budget-2017-pm-says-welfare-drug-test-plan-based-on-love/8520564">announcement in the May 2017 budget</a> of a trial of random drug testing of 5,000 Youth Allowance and Newstart recipients has been almost universally criticised. While the prime minister claimed the program is <a href="https://www.buzzfeed.com/aliceworkman/based-on-love?utm_term=.oxGVVrx480#.cvDaakj6mQ">“based on love”</a>, the CEO of Jobs Australia has warned it will be so demeaning as to <a href="http://www.abc.net.au/news/2017-08-31/welfare-drug-testing-trial-could-lead-to-crime-and-prostitution/8858264">drive young people to sex work</a>. And the government shows no sign of being overwhelmed by the reportedly “<a href="http://www.abc.net.au/news/2017-09-07/labor-greens-warn-against-coalition-drug-testing-welfare-policy/8879968">overwhelming” medical evidence</a> that its policy will not work. </p>
<p>There is a certain amount of hyperbole on both sides of this issue, which is skewing the evidence. This makes it difficult to interpret, largely due to the lack of clarity on what the aims of this program are. Is it to help struggling addicts, reduce the number of drug users, or save money by reducing welfare payments? </p>
<p>Most of the evidence drawn on by critics of the trial comes from places that have implemented such programs. While it has been considered in the UK and Canada, variations on testing welfare recipients for drug use have only previously appeared in the US and New Zealand. So, have they worked? And is there a convincing link between welfare recipients and drug use at all?</p>
<h2>Drug use and welfare</h2>
<p>The most <a href="http://jhppl.dukejournals.org/content/25/4/623.abstract">recent estimates</a> from the US found about one in five people receiving welfare had used illicit drugs in the previous year. That makes <a href="https://scholars.opb.msu.edu/en/publications/drug-use-among-welfare-recipients-in-the-united-states-4">drug use up to 50% more common</a> in welfare households than the general population. </p>
<p>The impact this drug use has on their lives varies widely, however. <a href="https://www.ncbi.nlm.nih.gov/pubmed/11786289">Less than 5% of welfare recipients</a> met the diagnostic criteria for having a substance abuse problem, which would make them eligible for <a href="http://www.journals.uchicago.edu/doi/abs/10.1086/339669">withdrawal treatment</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/185617/original/file-20170912-11525-15odjgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/185617/original/file-20170912-11525-15odjgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/185617/original/file-20170912-11525-15odjgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185617/original/file-20170912-11525-15odjgb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185617/original/file-20170912-11525-15odjgb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185617/original/file-20170912-11525-15odjgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185617/original/file-20170912-11525-15odjgb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185617/original/file-20170912-11525-15odjgb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Less than 5% of welfare recipients have a substance abuse problem.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Closer to home, a <a href="http://igps.victoria.ac.nz/WelfareWorkingGroup/Downloads/Final%20Report/WWG-Final-Recommendations-Report-22-February-2011.pdf">New Zealand government survey</a> found 32% of welfare recipients reported using illicit drugs, in comparison to 18% of the general population. The clandestine nature of drug use, and the reliance on self-reporting in these statistics, make prevalence estimates imperfect. Nevertheless, drug use has been treated as a key driver of welfare dependency in the US, where testing has been implemented intermittently <a href="http://www.newrepublic.com/article/117033/mississippi-drug-testing-welfare-recipients-wont-work">since the turn of the century</a>.</p>
<h2>Drug testing in Florida</h2>
<p>As numbers of such programs grew in the US, <a href="http://www.tandfonline.com/doi/abs/10.1300/J045v17n01_03">one study directly analysed</a> the difference in employment and earnings between welfare recipients who were and were not using drugs in Florida. The study reviewed 6,642 applications as part of drug testing for the <a href="http://www.dhs.state.il.us/page.aspx?item=30358">Temporary Assistance for Needy Families</a> program. This involves the federal government providing financial assistance to pregnant women and families with one or more dependants.</p>
<p>The authors found a small but insignificant difference between groups, which is a difficult result on which to base conclusions. This study also didn’t collect information about the extent of problematic drug use as opposed to recreational use. And it had limited ability to control for related social and demographic factors.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/helping-drug-users-get-back-to-work-not-random-drug-testing-should-be-our-priority-77468">Helping drug users get back to work, not random drug testing, should be our priority</a>
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</em>
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<hr>
<p>The confounding effect of these other factors is often alluded to as <a href="http://www.ijdp.org/article/S0955-3959(14)00035-8/abstract">implied evidence against</a> drug-testing programs. For instance, some <a href="http://jhppl.dukejournals.org/content/25/4/623.abstract">studies have argued</a> depression, physical health problems and limited education are the most common barriers to improving the conditions of <a href="https://www.ncbi.nlm.nih.gov/pubmed/11786289">drug-using welfare recipients</a>. Yet this is not a clear argument against targeting drugs, as there is also evidence <a href="https://www.ncbi.nlm.nih.gov/pubmed/9843121">cannabis</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/18368605">methamphetamine</a> use can exacerbate <a href="https://www.ncbi.nlm.nih.gov/pubmed/19837255">depression and other health</a> conditions. </p>
<h2>Too costly an exercise?</h2>
<p>The other <a href="http://www.huffingtonpost.com.au/2017/05/30/drug-testing-of-welfare-clients-found-only-tiny-number-of-users_a_22118237/?utm_hp_ref=au-homepage">argument against the proposed trial</a>, as put forward by the Australian Greens, is that it’s an ineffective use of money as detection rates of drug users will be minimal. Indeed, in <a href="https://beehive.govt.nz/release/pre-employment-drug-testing-jobseekers">New Zealand</a>, $1 million was spent on a similar scheme, which <a href="http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11184479">detected 22 positive</a> results in a sample of 8,001. </p>
<p><a href="http://www.huffingtonpost.com.au/2017/05/30/drug-testing-of-welfare-clients-found-only-tiny-number-of-users_a_22118237/?utm_hp_ref=au-homepage">Data have also been released</a> for detection rates in a similar program in Arizona, Missouri, Utah and Tennessee over an 18-month period in 2013-14. With a total of just under 200,000 tests at a collective cost of over US$1 million, these states disqualified 14, 780, 29 and 24 people from receiving benefits, respectively.</p>
<p>The Australian government won’t disclose the cost of its current proposal, as it is commercial in confidence. Yet <a href="http://www.news.com.au/national/politics/welfare-drug-tests-for-sydneys-southwest/news-story/d194ac53559b60d7e132c77206e4b337">A$10 million has been set</a> aside to support welfare recipients who test positive, presumably to enter treatment or rehabilitation. In the current system, however, <a href="https://ndarc.med.unsw.edu.au/resource/new-horizons-review-alcohol-and-other-drug-treatment-services-australia">less than half</a> of all people seeking drug treatment are able to get access to it. And the most recent reviews of compulsory drug treatment have reiterated it <a href="https://www.ncbi.nlm.nih.gov/pubmed/26790691">does not improve treatment outcomes</a>.</p>
<p>This A$10 million alone would seem to offset any savings made from withdrawing payments following the very low numbers of positive tests that can be expected. The government has not provided any estimate of potential savings under this policy, so we don’t know if this trial will save money.</p>
<h2>What about drug-related harms?</h2>
<p>No assessment has been made thus far of how drug-related harms – such as emergency department presentations, mental health conditions, or interpersonal violence – changed in response to testing programs. But that doesn’t mean we don’t have reason to think such programs had no effect. </p>
<p>There is <a href="https://academic.oup.com/bjc/article-abstract/50/6/999/404023/What-Can-We-Learn-From-The-Portuguese?redirectedFrom=fulltext">evidence</a>, for example, that <a href="http://journals.sagepub.com/doi/abs/10.1375/acri.36.1.77">prohibition limits</a> drug use. Some studies have found when addicts do enter rehabilitation, they can be <a href="http://www.tandfonline.com/doi/abs/10.1080/09638230126722">motivated by the desire</a> to avoid <a href="http://trove.nla.gov.au/work/6794339?q&sort=holdings+desc&_=1505182991114&versionId=44698886">risk of punishment</a> and frequent interactions with police. This would imply additional hurdles that increase the potential cost of using drugs can effectively reduce levels of use.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/185623/original/file-20170912-11525-11hevrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/185623/original/file-20170912-11525-11hevrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/185623/original/file-20170912-11525-11hevrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185623/original/file-20170912-11525-11hevrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185623/original/file-20170912-11525-11hevrq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185623/original/file-20170912-11525-11hevrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185623/original/file-20170912-11525-11hevrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185623/original/file-20170912-11525-11hevrq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Interactions with police can motivate people to enter rehabilitation.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Some critics argue this program will penalise people with advanced levels of dependence. But to base policy on this is to <a href="http://journal.frontiersin.org/article/10.3389/fpsyt.2013.00031/full">ignore the evidence</a> that addicts can and do <a href="http://www.sciencedirect.com/science/article/pii/S2352853216300530">exercise control</a> over their drug use in response to external factors. The point at which many addicts enter treatment is usually “rock bottom”, when the external motivating factors become <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629650/">sufficient to overpower</a> the persistent desire to use. It’s not clear how removing these factors will encourage addicts to enter treatment.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/viewpoints-is-addiction-a-disease-63113">Viewpoints: is addiction a disease?</a>
</strong>
</em>
</p>
<hr>
<h2>What’s the ultimate goal?</h2>
<p>With regards to the public health argument, the evidence exists but is unsettled and complex. This controversy is not resolved by marginalising the broader picture of relevant research. In terms of the economic argument, there is no reason to expect the costs of this program will be outweighed by the welfare payments that may be cancelled. </p>
<p>It can be said, as some of the architects of this program do say, that the very purpose of this trial is to collect the evidence everyone is clamouring for. The government has committed to ongoing reviews of the program and its outcomes. But this will only be useful if they answer the deeper question of what it is they’re looking for.</p><img src="https://counter.theconversation.com/content/83641/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Brookfield does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most of the evidence drawn on by critics of the trial comes from places that have implemented such programs. So, have they worked?Samuel Brookfield, Emergency Registered Nurse & Public Health PhD Candidate, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817522017-07-30T20:10:42Z2017-07-30T20:10:42ZIce causes death in many ways, overdose is just one of them<figure><img src="https://images.theconversation.com/files/180158/original/file-20170728-23775-1tukwxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most people are unaware of the severe impact ice has on the heart. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Methamphetamine (usually colloquially referred to as “ice”) is a major public health problem in Australia. When we think of methamphetamine-related death, however, we tend to focus on overdose. This is a very real and valid concern. But the extent of the problem extends far beyond drug toxicity. </p>
<p>Methamphetamine dependence is associated with an array of <a href="https://www.ncbi.nlm.nih.gov/pubmed/18368606">serious social</a>, <a href="https://www.mja.com.au/journal/2016/204/4/estimating-number-regular-and-dependent-methamphetamine-users-australia-2002">mental and physical</a> <a href="https://www.semanticscholar.org/paper/Global-burden-of-disease-attributable-to-illicit-d-Degenhardt-Whiteford/1a27d452fa5282dc415e30158d4549684e15e6b2">health problems</a> that include heart disease, stroke, suicide, mood and anxiety disorders, psychosis, and violence. The footprint of methamphetamine is far wider than that of many other drugs. Close to half of deaths occur in rural and regional areas, a great many users are employed, and half have never injected a drug. These are not the “usual suspects” for drug-related death.</p>
<p>In a <a href="https://www.ncbi.nlm.nih.gov/pubmed/28603836">new study</a> we looked at all of the methamphetamine-related deaths that occurred in Australia from 2009 to 2015. There were 1,649 such deaths over that period, and the annual rate doubled from around 150 a year to 300. Of these deaths, 43% were due to drug toxicity. </p>
<p>In the case of methamphetamine, overdose typically results in heart arrhythmias (where the heart isn’t beating properly) and seizures caused by the drug. Importantly, even modest amounts of methamphetamine may cause heart arrhythmia and death. The remainder, however, were due to other causes.</p>
<h2>How methamphetamine affects the heart long-term</h2>
<p>In a fifth of cases, death was due to methamphetamine combined with disease, most commonly heart disease. Methamphetamine is cardiotoxic, meaning it causes damage to our heart muscle, and causes disease in our arteries. </p>
<p>There’s a circular pattern here. Methamphetamine damages the cardiovascular system. The drug also places strain on this system by increasing the force of the blood against the artery walls (it’s a “hypertensive”). Users are then placing strain on damaged hearts. And this damage accumulates and does not reverse. </p>
<p>There’s also a real risk of stroke, and we saw 38 such cases among young people, a demographic not commonly affected by stroke. Importantly, the damage to the cardiovascular system occurs regardless of how the drug is used. Smoked, injected or swallowed – it is the drug that does the damage.</p>
<h2>How methamphetamine fatally reduces inhibition</h2>
<p>Methamphetamine is also associated with traumatic injury and death, as it causes a high degree of disinhibition, impulsivity, aggression and impaired critical judgement. There were 300 completed suicides related to methamphetamine over our study period. </p>
<p>There were around 300 deaths from suicide linked to methamphetamine, and the methods used were more violent, which is linked to the aggression, violence and aggravation caused by the drug. </p>
<p>Some 15% of all methamphetamine-related deaths were due to traumatic accidents, most commonly motor vehicle accidents. Methamphetamine users <a href="https://www.ncbi.nlm.nih.gov/pubmed/14756710">commonly believe the drug improves their driving</a>. It does not. What it does improve is the risk of injury and death. All of these deaths were avoidable.</p>
<h2>What can we do?</h2>
<p>Knowledge of the risks is a start. Many users might assume a racing heart and chest pains are part of the experience of using methamphetamine and not realise these are signs of a system under stress. The heart disease we are seeing in methamphetamine users will be a problem for decades to come, long after they cease use. </p>
<p>In terms of our treatment system, drug treatment centres need to be aware their methamphetamine patients may be at risk of heart disease. Doctors also should ask about methamphetamine involvement if young people are presenting with heart conditions.</p>
<p>Over the past few years there has a been an intense focus on methamphetamine in the wake of evidence of increasing use and harms, including in rural and regional areas. By examining the causes of these deaths we have uncovered that, unlike many other drugs, the harms are very diverse, particularly with regard to the extensive association with heart disease. </p>
<p>This suggests that even if use goes down, we will have a major public health problem for our hospital and community health services for many years to come.</p>
<p>Another striking finding of this research is that very few of those who died were in treatment at the time. Our treatment services are already under intense pressure and this underlines the urgent need for more resources to go into treatment and trials of new medications.</p><img src="https://counter.theconversation.com/content/81752/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shane Darke does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When we think of methamphetamine-related death we tend to focus on overdose. The extent of the problem, however, extends far beyond drug toxicity.Shane Darke, Professor at the National Drug & Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/757722017-04-06T02:07:16Z2017-04-06T02:07:16Z‘Record seizure’ headlines mark another false step in misguided war on drugs<figure><img src="https://images.theconversation.com/files/164020/original/image-20170405-29081-rhxpf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Illicit drugs are priced differently depending upon which stage of the supply chain they are located.</span> <span class="attribution"><span class="source">AAP/Alex Murray</span></span></figcaption></figure><p>The announcement this week of the largest seizure of methamphetamine in Australian history has been accompanied by a familiar chorus of uncritical and often sensationalised <a href="http://www.skynews.com.au/news/top-stories/2017/04/05/police-make--biggest-ever--ice-seizure.html">media reporting</a>.</p>
<p>The “street value” of the 903 kilograms of the seized drug was estimated at nearly A$900 million.</p>
<p>But are the claims government authorities make about drug seizures accurate? And what broader implications do large-scale seizures have for Australia’s drug-control policies?</p>
<p>This record haul, as with countless others preceding it, was a news spectacle. It culminated in a live, nationally broadcast press conference. Later came the wall-to-wall media coverage across TV, print, radio and digital platforms.</p>
<p>Justice Minister Michael Keenan, flanked by Federal Police officers (inexplicably armed and replete with tactical gear), <a href="https://au.news.yahoo.com/a/34914805/900m-ice-drug-seizure-australias-largest-after-afp-and-victoria-police-operation/#page1">declared</a> the seizure’s impact “cannot be underestimated”. He said it represented “a very serious blow to organised crime around the country”. <a href="http://www.huffingtonpost.com.au/2017/04/04/australian-authorities-just-made-the-biggest-ice-bust-ever_a_22026007/">According to Keenan</a>, the money from its sale “hasn’t gone into the pocket of organised criminals”.</p>
<p>These claims don’t stand up well to proper scrutiny.</p>
<h2>How much was it really worth?</h2>
<p>Let’s start with the purported street value of almost $900 million. Illicit drugs are priced differently depending upon which stage of the supply chain they are located. The difference in the price of illicit drugs at the point of production and the point of retail can <a href="http://faculty.publicpolicy.umd.edu/sites/default/files/reuter/files/Drug%20Enforcement%20and%20Drug%20Price.pdf">vary by as much as 100:1</a>. </p>
<p>Law-enforcement agencies often create misleading estimates based on more expensive retail values, rather than on prices higher up the chain of supply. This appears to be the case with this seizure. Authorities have referred to “street” value, rather than the lower prices at the trafficking/domestic wholesale level – where the drugs were intercepted. </p>
<p>However, even going by inflated retail prices, the purported value of this particular haul is massively overestimated. </p>
<p>According to <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/national-idrs_2016_finalwith-customs.pdf">research from 2016</a>, the retail price of 0.1 gram of crystal methamphetamine (the most commonly purchased quantity at “street” level) in Victoria is $50. By these figures, the seizure’s street value comes in at just over $451 million. </p>
<p>While this is a significant sum, it is only half the amount that authorities claimed and which news media reprinted uncritically across Australia. </p>
<h2>What impact will it have on crime?</h2>
<p>Less straightforward, but perhaps more important to assess, is the claimed impact on organised crime. </p>
<p>The seizure of 903 kilograms of methamphetamine may represent a significant loss to the criminal syndicate responsible for this shipment. However, studies conducted both <a href="https://www.researchgate.net/profile/Louisa_Degenhardt/publication/7951194_Evaluating_explanations_of_the_Australian_heroin_drought/links/09e4150cea3c1583f8000000.pdf">in Australia</a> and <a href="http://faculty.publicpolicy.umd.edu/sites/default/files/reuter/files/Drug%20Enforcement%20and%20Drug%20Price.pdf">overseas</a> cast doubt on the notion that effectively tackling organised crime and reducing illicit drug supply can be achieved through border interception alone. </p>
<p>As several decades of failed <a href="https://theconversation.com/the-war-on-drugs-has-failed-now-what-6222">“war on drugs”</a> policing has demonstrated, provided there is strong consumer demand, and the capacity to produce drugs cheaply, reliably and profitably overseas, organised crime groups are likely to continue to fill any gaps in the supply chain that law enforcement interventions create.</p>
<p>Given the manifest inability of law enforcement to control the illicit drugs trade, it is worth questioning why so much emphasis is placed on law enforcement over other, more effective, evidence-based drug policies.</p>
<h2>How does this fit with Australia’s drug policy?</h2>
<p><a href="https://ndarc.med.unsw.edu.au/resource/australian-illicit-drug-policy-timeline-1985-2015">Since 1985</a>, Australia’s approach to illicit drugs has ostensibly been one of <a href="http://nceta.flinders.edu.au/society/harm-minimisation/">harm minimisation</a>. This consists of <a href="http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/DB4076D49F13309FCA257854007BAF30/$File/nds2015.pdf">three pillars</a>: supply reduction, demand reduction, and harm reduction.</p>
<ul>
<li><p>Supply reduction focuses on reducing the supply of illicit drugs through law enforcement (like police and border control). </p></li>
<li><p>Demand reduction involves both treatment services and preventive strategies that aim to reduce drug use.</p></li>
<li><p><a href="http://www.harmreductionaustralia.org.au/what-is-harm-reduction/">Harm reduction</a> accepts some people will continue to use drugs despite the other two pillars, and aims to reduce the harms associated with their drug use.</p></li>
</ul>
<p>The amount of government money spent on these three pillars is far from equitable. <a href="https://theconversation.com/spending-down-on-harm-reduction-for-illicit-drugs-report-15346">Research</a> indicates 66% is spent on law enforcement. Spending on treatment is 21%. Only 9% is spent on prevention, and just 2% spent on harm reduction. </p>
<p>This distorted allocation of scarce taxpayer dollars is not evidence-based. Harm-reduction strategies provide an outstanding return of investment. Needle exchange programs, for example, return <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/A407CF4FECBDC715CA257BF0001F98B2/$File/return2.pdf">$27 for every $1 spent</a>.</p>
<p>Meanwhile, there is little evidence supporting any reliable return on investment from efforts to control supply. An increasing number of studies suggest these are <a href="http://heinonline.org/HOL/LandingPage?handle=hein.journals/cicj13&div=5&id=&page=">counter-productive</a> – they actually <a href="https://www.opensocietyfoundations.org/sites/default/files/kerr-enforcement-english-20100615.pdf">exacerbate drug-related harms</a>. </p>
<p>Australia was prompted to implement harm-reduction interventions by a looming HIV epidemic in 1985 and led the world in doing so. Consequently, Australia has some of the lowest rates of HIV incidence <a href="http://www.abc.net.au/news/2016-07-10/the-ends-of-aids-as-a-public-health-issue-in-australia/7580852">in the world</a>. However, in recent decades, Australia has lagged behind the rest of the Western world in <a href="https://www.hri.global/contents/1739">implementing harm-reduction initiatives</a>.</p>
<p>A <a href="http://australia21.org.au/wp-content/uploads/2017/03/Can-Australia-respond-to-drugs-more-effectively-and-safely-Roundtable-report-Final.pdf">recent report</a> highlights that the current imbalance in drug policy is not working. There are no reductions in the demand for illegal drugs or in their availability, and prices are continuing to fall. </p>
<p>For policing agencies, and politicians committed to populist law-and-order policies, drug busts of the size witnessed this week are highly choreographed media events. They represent major PR opportunities to justify the enormous and disproportionate sums of taxpayer dollars spent each year on ineffective, costly and counter-productive enforcement-led supply reduction. </p>
<p>Pursuing these same, tired war-on-drugs strategies might seem like a show of strength. But it will take real courage for politicians to acknowledge the need for a new approach.</p>
<p>In the meantime, let’s take claims about the value of drug seizures with a grain of salt.</p><img src="https://counter.theconversation.com/content/75772/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr James Martin receives funding from the Australian Institute of Criminology and the National Health and Medical Research Council. He is a founding member of the Alcohol and Other Drugs Media Watch, an independent organisation of researchers and drug professionals intended to highlight media misreporting of drug issues. </span></em></p><p class="fine-print"><em><span>Stephen Bright is is a founding member of the Alcohol and Other Drugs Media Watch project, an independent organisation of researchers and drug professionals intended to highlight media misreporting of drug issues. </span></em></p>Let’s take claims about the value of drug seizures with a grain of salt.James Martin, Senior Lecturer in Criminology, Macquarie UniversityStephen Bright, Senior Lecturer of Addiction, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/732702017-03-09T02:56:24Z2017-03-09T02:56:24ZWeekly Dose: while the media panic about ice, we should worry about carfentanil<figure><img src="https://images.theconversation.com/files/158652/original/image-20170228-29942-5zatbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most people who take carfentanil think they're taking something else, usually heroin. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>While the <a href="https://theconversation.com/ice-wars-message-is-overblown-and-unhelpful-72719">media seem embroiled</a> in a <a href="http://www.huffingtonpost.com/christopher-j-ferguson/how-journalists-contribut_b_6213190.html">moral panic</a> about methamphetamine or “ice”, those of us who actually work with overdose patients are nervously watching out for a far more dangerous drug: carfentanil.</p>
<p>You may have heard of <a href="https://theconversation.com/weekly-dose-fentanyl-the-anaesthetic-that-may-have-been-used-as-a-chemical-weapon-on-chechen-rebels-62966">fentanyl</a>, a synthetic opioid similar to morphine, the drug derived from the opium poppy. Fentanyl is 50 to 100 times more potent than morphine, but there wouldn’t be a day that goes by where we don’t use it in the emergency department, mostly for pain relief. </p>
<p>Carfentanil is an ultra-potent synthetic version of this. Its only legitimate use is in veterinary practice for large animals such as elephants. Its distribution is restricted to veterinarians engaged in zoo and exotic animal practice, wildlife management programs, and researchers.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=599&fit=crop&dpr=1 600w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=599&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=599&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=753&fit=crop&dpr=1 754w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=753&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=753&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
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<h2>How does it work?</h2>
<p>The human body manufactures neuropeptides called endorphins. Opioids work by binding to endorphin receptors in the body, namely opioid receptors. </p>
<p>There are several types of receptors, all which, when activated, create slightly different effects - some make you feel good, or sleepy, or less anxious. </p>
<p>One, called the μ-receptor, is very good at mediating respiratory depression. And carfentanil can activate this receptor better than almost any other opiate.</p>
<h2>How was it developed?</h2>
<p>Developed in the mid-1970s as a large animal sedative (Wildnil), carfentanil is 10,000 times more potent than morphine. A lethal dose in humans is only 20 micrograms. That is the weight of ten snowflakes, or a single grain of pollen.</p>
<p>It is so potent that lab technicians require special protective equipment to analyse it, and have to have the antidote at the lab bench. It <a href="http://www.elephantcare.org/Drugs/carfenta.htm">takes only 10mg</a> to knock down a wild African elephant. An <a href="http://www.ajemjournal.com/article/S0735-6757(10)00117-8/abstract">unfortunate veterinarian</a> who merely splashed some on his eye while trying to sedate an elk required resuscitation.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-fentanyl-the-anaesthetic-that-may-have-been-used-as-a-chemical-weapon-on-chechen-rebels-62966">Weekly Dose: fentanyl, the anaesthetic that may have been used as a chemical weapon on Chechen rebels</a>
</strong>
</em>
</p>
<hr>
<h2>What are its uses?</h2>
<p>Carfentanil has no therapeutic human application. And for most consumers who have ingested it, they have done so involuntarily, thinking it was another drug, usually heroin.</p>
<p>So why is it available? In the world of heroin, “quality” is frequently conflated with potency. A product that may be significantly “cut” can be dosed with minute quantities of fentanyl-like products to give the impression of enhanced value. By increasing the perceived “purity” of a shipment, you can increase its apparent value. </p>
<p>It’s particularly useful that the manufacture of carfentanil is entirely synthetic, and not reliant on the vagaries of crops in Afghanistan’s Helmand province, or border patrols in Herat Province. It’s far easier to smuggle a suitcase of an ultra-potent product globally than a shipping container of something more “dilute” and organic.</p>
<h2>Why should we be so concerned about it?</h2>
<p>The first epidemic of fentanyls and fentanyl-related compounds <a href="https://en.wikipedia.org/wiki/%CE%91-Methylfentanyl">dates back to the 1970s</a>. Between 2005 and 2007, another product, this time from Mexico, <a href="https://www.justice.gov/archive/ndic/pubs11/20469/index.htm">killed hundreds of Americans</a>. </p>
<p>Globally, we are now seeing a third wave of fentanyl-related deaths, dating from perhaps late 2013, far more serious than any that preceded it. There were over <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a2.htm">5,000 deaths in the US alone in 2014</a>. Ohio state had <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a3.htm">over 1,100 deaths in 2015 alone</a>. The figures for 2016 could be far greater still.</p>
<p>Those of us in the business of tracking down new illicit drugs in Australia have felt the malign presence of the fentanyls for a while now. We have been forewarned by our overseas colleagues - equally aghast at their escape into the open market. <a href="https://www.eventbrite.com.au/e/new-and-novel-psychoactive-substances-challenges-for-healthcare-workers-tickets-22756633704#">We predicted</a> the synthetic fentanyls would be a major issue for Australia in April 2016. </p>
<p>For about a year, we’ve been hearing reports of “heroin” overdoses that are no longer responding to standard doses of our normal opiate antidote, <a href="https://theconversation.com/weekly-dose-naloxone-how-to-save-a-life-from-opioid-overdose-63459">naloxone</a>. That is usually about 2mg, but in cases we suspect involved carfentanil and its close cousins, it can take ten times more to make someone breathe again.</p>
<p>In December, a carfentanil seizure was <a href="http://www.couriermail.com.au/news/carfentanil-deadly-tranquilliser-found-for-the-first-time-in-australia/news-story/21cf74b4e9d2fe46ec8263e60aee343a">reported in Sydney</a> - last month <a href="http://www.dailymail.co.uk/news/article-4233436/Queensland-Police-issue-warning-carfentanil-drug.html">another in Brisbane</a>. Like a lethal strain of flu, now it’s here, and all we can do is work furiously to prevent it becoming established. This involves engagement with the consumer community, an approach which doesn’t appear to be viewed favourably by Australian policy makers.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-naloxone-how-to-save-a-life-from-opioid-overdose-63459">Weekly Dose: Naloxone, how to save a life from opioid overdose</a>
</strong>
</em>
</p>
<hr>
<p>In many ways, the fentanyl-related compounds connect many of the problems and solutions of modern drugs policy in Australia. Many are novel products, manufactured to pharmaceutical purity, as the global drug market mutates into something darker and less tangible. Their emergence has been catalysed by a Big Pharma peddled epidemic of opiates, <a href="https://www.theguardian.com/science/2016/may/25/opioid-epidemic-prescription-painkillers-heroin-addiction">coupled with a subsequent crackdown in availability</a>.</p>
<p>We have no meaningful toxicological early warning system that widely shares data in Australia - we rely on whispers. Consumers who overdose are unlikely to survive outside of a medically-supervised injecting centre, providing yet more pressure for the <a href="https://theconversation.com/why-australia-needs-drug-consumption-rooms-53215">expansion of those services in Australia</a> - and yet still, they are opposed.</p>
<p>The tabloid press would have us believe the drug “ice” is currently the biggest threat to Australian society. But doctors and drug professionals alike will tell you that potentially, the unfettered spread of carfentanil and the illicit synthetic fentanyls is much worthier of your fear.</p><img src="https://counter.theconversation.com/content/73270/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Caldicott is a recipient of an NH&NMRC Partnership Grant. He is affiliated with ATODA, and provides bipartisan medical advice on illicit drugs to state and federal agencies. He is the Clinical Lead of the Australian Drug Observatory (ANU)</span></em></p>Carfentanil is an ultra-potent synthetic opioid. Its only legitimate use is in veterinary practice for large animals such as elephants, but it sneaks into heroin shipments to increase its potency.David Caldicott, Emergency Medicine Consultant, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/727232017-02-15T20:49:53Z2017-02-15T20:49:53ZFull response from Mark McGowan on methamphetamine use in Western Australia<p>In relation to <a href="http://theconversation.com/factcheck-its-true-western-australia-has-the-highest-rate-of-methamphetamine-use-in-the-country-72506">this FactCheck</a> on the rates of methamphetamine use in Western Australia, The Conversation requested sources and comment from West Australian Labor leader Mark McGowan.</p>
<p>In response, a spokesperson for Mark McGowan said (questions from The Conversation in bold):</p>
<p><strong>When Mark McGowan used the term “we”, was he was referring to Western Australia?</strong> </p>
<blockquote>
<p>Yes.</p>
</blockquote>
<p><strong>Could you please provide a source, or sources, to support the assertion that Western Australia (if that is confirmed as the reference point) has the worst rate of methamphetamine usage in the country?</strong></p>
<blockquote>
<p>Sources:</p>
<p><a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549848">National Drug Strategy Household Survey</a> detailed report 2013 (the 2016 report is not out yet - so this is the latest). Quote from Page 11 of the report ‘Meth/amphetamine use was higher in Western Australia (3.8%) than any other jurisdiction.’ </p>
<p>Also media citing WA Police Commissioner in November 2016 (PerthNow report) - ‘[Police Commissioner] Karl O'Callaghan said our findings reflected the fact WA continued to have the highest meth use per capita in Australia.’</p>
<p>Liberal National Government also acknowledges that WA has the highest rate (WA Government “<a href="https://www.mediastatements.wa.gov.au/MediaDocuments/WA%20Meth%20Strategy%202016.pdf">Western Australian Meth Strategy</a>”) Page 7.</p>
</blockquote>
<p><strong>Could you confirm that when Mr McGowan used the term “worst”, he was indicating the highest rates?</strong></p>
<blockquote>
<p>Yes.</p>
</blockquote>
<p><strong>Is there any other comment you’d like us to include?</strong></p>
<blockquote>
<p>A McGowan Labor Government will implement a State-wide, coordinated and targeted Methamphetamine Action Plan (MAP) focussed on three key areas to reduce demand, reduce harm and reduce supply. This is the most comprehensive plan to tackle methamphetamine use ever released in WA. </p>
<p>WA Labor will work with experts and stakeholders on early targeted prevention, better treatment services and effective withdrawal services. The MAP will build on what is currently seen as best practice, providing education, training, rehabilitation, coordination and research. There will be more focus on breaking the cycle of drug related crime in our community by ensuring that there is a focus on rehabilitation in prisons with a specialised treatment and withdrawal services. </p>
<p>WA Labor also announced that meth traffickers will face a maximum life sentence in prison in a plan to cut the supply in WA.</p>
<p>The flow on effects of methamphetamine use are devastating and will not be solved by prosecution alone. We need to ensure that equal emphasis is given to reducing both the demand and the harm caused by methamphetamines.</p>
</blockquote><img src="https://counter.theconversation.com/content/72723/count.gif" alt="The Conversation" width="1" height="1" />
West Australian Labor leader Mark McGowan’s responded to The Conversation’s request for sources and comment regarding our FactCheck on methamphetamine usage rates in Western Australia.Madeleine De Gabriele, Deputy Editor: Energy + EnvironmentLucinda Beaman, FactCheck EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/725062017-02-14T05:38:41Z2017-02-14T05:38:41ZFactCheck: it’s true – Western Australia has the nation’s highest rate of methamphetamine use<blockquote>
<p>We have the worst rate of methamphetamine usage in the country. – <strong>West Australian Labor leader Mark McGowan, <a href="https://thewest.com.au/politics/state-election-2017/crime-spike-gave-labor-weapon-hurt-liberals-ng-b88371752z">quoted</a> in The West Australian, February 6, 2017.</strong></p>
</blockquote>
<p>The illicit drug methamphetamine, commonly known as “speed”, “crystal meth” and “ice”, continues to <a href="http://www.abc.net.au/news/2017-01-25/adelaides-methamphetamine-use-climbs-sewage-analysis-shows/8210188">make</a> <a href="http://www.smh.com.au/entertainment/tv-and-radio/tom-carroll-on-his-recovery-from-addiction-and-taking-part-in-the-new-abc-doco-ice-wars-20170202-gu4n35.html">headlines</a> in Australia as communities grapple with its <a href="https://theconversation.com/are-we-in-the-midst-of-an-ice-epidemic-a-snapshot-of-meth-use-in-australia-39697">destructive effects</a>. </p>
<p>In a <a href="https://thewest.com.au/politics/state-election-2017/crime-spike-gave-labor-weapon-hurt-liberals-ng-b88371752z">news report</a> outlining the Liberal and Labor party’s strategies for tackling drug-related crime in Western Australia, state Labor leader Mark McGowan was quoted as saying “we have the worst rate of methamphetamine usage in the country”.</p>
<p>Is that right?</p>
<h2>Checking the source</h2>
<p>When asked for sources to support his statement, a spokesperson for Mark McGowan referred The Conversation to the <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549848">2013 National Drug Strategy Household Survey</a>, particularly page 11 of the report, which says:</p>
<blockquote>
<p>Meth/amphetamine use was higher in Western Australia (3.8%) than any other jurisdiction. </p>
</blockquote>
<p>The spokesperson also referred The Conversation to the state government’s <a href="https://www.mediastatements.wa.gov.au/MediaDocuments/WA%20Meth%20Strategy%202016.pdf">Western Australian Meth Strategy 2016</a> report, which states on page seven that meth use in Western Australia is higher than the national average.</p>
<p>And the spokesperson cited Western Australia’s Police Commissioner Karl O'Callaghan, who was <a href="http://www.perthnow.com.au/news/western-australia/wa-speaks-meth-drug-issue-voted-states-top-crime-problem/news-story/8274d9ef179070d27a93818c0c39b1eb">reported</a> as saying the state continues to have the highest methamphetamine use per capita in Australia. </p>
<p>You can read the full response from McGowan’s office <a href="http://theconversation.com/full-response-from-mark-mcgowan-72723">here</a>.</p>
<h2>Does Western Australia have the highest rate of methamphetamine use?</h2>
<p>Yes. The latest available Australian data, published in the <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/ndshs-2013/">2013 National Drug Strategy Household Survey</a>, show that 3.8% of the West Australian population had used methamphetamine in the 12 months prior to the survey. That’s nearly double the Australian average of 2.1%.</p>
<p>This isn’t a recent phenomenon. The rate of methamphetamine use in Western Australia has been higher than the rest of the nation since at least the 1990s.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/156711/original/image-20170214-25962-1msla1b.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/156711/original/image-20170214-25962-1msla1b.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=754&fit=crop&dpr=1 600w, https://images.theconversation.com/files/156711/original/image-20170214-25962-1msla1b.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=754&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/156711/original/image-20170214-25962-1msla1b.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=754&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/156711/original/image-20170214-25962-1msla1b.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=948&fit=crop&dpr=1 754w, https://images.theconversation.com/files/156711/original/image-20170214-25962-1msla1b.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=948&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/156711/original/image-20170214-25962-1msla1b.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=948&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/156688/original/image-20170213-25987-1vk4i6c.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/156688/original/image-20170213-25987-1vk4i6c.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=545&fit=crop&dpr=1 600w, https://images.theconversation.com/files/156688/original/image-20170213-25987-1vk4i6c.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=545&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/156688/original/image-20170213-25987-1vk4i6c.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=545&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/156688/original/image-20170213-25987-1vk4i6c.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=685&fit=crop&dpr=1 754w, https://images.theconversation.com/files/156688/original/image-20170213-25987-1vk4i6c.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=685&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/156688/original/image-20170213-25987-1vk4i6c.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=685&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The rate of methamphetamine use across Australia has been declining since 1998 – including in Western Australia. But over that time, the rate of use in the state has remained consistently higher than the Australian average.</p>
<p>The rate of use of many other drugs, including binge drinking, cannabis and pharmaceuticals for non-medical purposes, is also <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/ndshs-2013/ch7/">higher in Western Australia</a> than the Australian average. </p>
<h2>How do we know?</h2>
<p>The data in the charts above come from the <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/about-ndshs/">National Drug Strategy Household Survey</a>. It’s a reliable data set that’s been collected every three years since the 1990s.</p>
<p>It’s the only population level data we have that shows drug use trends. That means it collects data from the general population, including people who don’t use drugs at all, not just among specific groups of people who use drugs.</p>
<p>It’s not perfect; no dataset is. The survey has been criticised because it’s likely to underestimate drug use. But it is likely to underestimate usage of all drug types in all locations and relatively consistently over time, so it can give us a good sense of trends over time and differences between states.</p>
<p>All the other reliable data available is collected among people in <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/aodts-nmds-2014-15/aodts-nmds/">treatment</a>, people in the <a href="http://aic.gov.au/about_aic/research_programs/nmp/duma.html">justice system</a>, or populations of people who <a href="https://ndarc.med.unsw.edu.au/project/illicit-drug-reporting-system-idrs-d1">regularly use</a> drugs. The rates of use among these groups is much higher than the general population, so the data doesn’t reflect drug use in the general community.</p>
<p>The <a href="http://www.aihw.gov.au/2016-national-drug-strategy-household-survey/">2016 National Drug Strategy Household Survey</a> is due to be released shortly. In general, drug use shows relatively small increases and decreases over time (typically less than half to one percentage point change between years), so it’s unlikely that the 2016 data will buck the long term trend too much.</p>
<h2>People are using more potent forms of methamphetamine</h2>
<p>Although the rate of methamphetamine use across Australia has stabilised at <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549848">2.1%</a> of the population between 2010 and 2013, we have seen a major shift in the <em>type</em> of methamphetamine people are using. Western Australia has seen the <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549643">same shift</a> as the rest of the country.</p>
<p>In 2010, most people who used methamphetamine preferred to use the less potent powder form, known as “speed”. But by 2013 around half the people surveyed preferred to use the stronger crystal form, known as “ice”. Speed and ice have the same chemical makeup, but ice is a lot stronger.</p>
<p><strong>Changes in methamphetamine use among Australian users aged 14 or older, 2007 to 2013</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/156305/original/image-20170210-8655-1hmoiv7.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/156305/original/image-20170210-8655-1hmoiv7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/156305/original/image-20170210-8655-1hmoiv7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=390&fit=crop&dpr=1 600w, https://images.theconversation.com/files/156305/original/image-20170210-8655-1hmoiv7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=390&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/156305/original/image-20170210-8655-1hmoiv7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=390&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/156305/original/image-20170210-8655-1hmoiv7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=490&fit=crop&dpr=1 754w, https://images.theconversation.com/files/156305/original/image-20170210-8655-1hmoiv7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=490&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/156305/original/image-20170210-8655-1hmoiv7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=490&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This shows the main forms of methamphetamine used by recent users (meaning within the last 12 months) aged 14 or older, 2007 to 2013.</span>
<span class="attribution"><a class="source" href="http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/ndshs-2013/ch5/#t5_4">Australian Institute of Health and Welfare, 2013 National Drug Strategy Household Survey</a></span>
</figcaption>
</figure>
<p>The majority of people who use methamphetamine use a small amount, very occasionally, for a short period in their life, and never experience any major problems with it. Around 70% of people who used a methamphetamine in the last year used it <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549848">fewer than 12 times</a>, and many of those used it only once or twice.</p>
<p>But for the small percentage who do experience problems, it is a drug that can cause significant <a href="https://theconversation.com/crystal-meth-harms-on-the-rise-in-australia-18190">harm</a>.</p>
<p>Even though there hasn’t been a significant increase in the number of people using methamphetamine, the shift to the stronger form means that the risks – which include <a href="https://www.mja.com.au/journal/2016/204/4/estimating-number-regular-and-dependent-methamphetamine-users-australia-2002-2014">drug dependence</a>, <a href="https://ndarc.med.unsw.edu.au/news/methamphetamine-deaths-increase-across-australia-and-ice-use-jumps-52-cent-among-people-who">overdose</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.12474/abstract">aggression</a> and <a href="https://www.promises.com/articles/abused-drugs/meth-causes-psychosis-study-finds/">mental health</a> problems – are amplified. As a result, we have seen a big increase in people who use methamphetamine regularly coming to <a href="https://www.mja.com.au/journal/2007/186/7/hospital-separations-cannabis-and-methamphetamine-related-psychotic-episodes?inline=true">hospital</a>, needing an <a href="http://apo.org.au/node/56610">ambulance</a>, seeking <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/data-sources/aodts-nmds-2014-15/clients/age-profile/">drug treatment</a> and being <a href="http://www.abc.net.au/news/2015-05-15/drug-data-shows-ice-arrests-nearly-double-in-five-years/6471024">arrested</a>.</p>
<h2>Verdict</h2>
<p>Mark McGowan’s statement is correct. Western Australia has the highest rate of methamphetamine use in Australia – and has since records of the use of this drug began. Western Australia has a higher rate of other drug use as well. <strong>– Nicole Lee</strong></p>
<hr>
<h2>Review</h2>
<p>This is appears to be a fair representation of the available population data. As the author notes, no data set is perfect. When you look at groups of people who regularly use drugs, the jurisdictional trends differ from general population trends.</p>
<p>In addition we’d note the heading would more accurately read “It’s true – Western Australia has the nation’s highest rate of methamphetamine use according to available population data”. <strong>– Courtney Breen and Amanda Roxburgh</strong></p>
<hr>
<p><div class="callout"> Have you ever seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at checkit@theconversation.edu.au. Please include the statement you would like us to check, the date it was made, and a link if possible.</div></p><img src="https://counter.theconversation.com/content/72506/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee works as a paid consultant to public, private and not for profit services to support treatment and policy implementation. She has previously been awarded grants by the state and federal government, NHMRC and other public funding bodies for alcohol and other drug research. She is a member of AOD Media Watch, a site that monitors reporting on alcohol and other drug issues in the media. Nicole was interviewed for the program.</span></em></p><p class="fine-print"><em><span>Amanda Roxburgh receives funding from the federal government.</span></em></p><p class="fine-print"><em><span>Courtney Breen receives funding from the federal government. </span></em></p>West Australian Labor leader Mark McGowan said his state has the “worst rate of methamphetamine usage in the country”. We asked the experts to check the evidence.Nicole Lee, Professor at the National Drug Research Institute, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/697802016-12-06T07:13:50Z2016-12-06T07:13:50ZAsia is in the grip of a transnational crime crisis – but governments look away<p>The immense demand for methamphetamine (ice), ecstasy and new psychoactive substances <a href="https://ssrn.com/abstract=2842099">among the wealthy urban residents of East Asia and beyond</a> has <a href="http://www.unodc.org/toc/en/reports/TOCTA-EA-Pacific.html">revitalised organised crime in the region</a>. </p>
<p>The <a href="http://www.latimes.com/world/asia/la-fg-drugs-china-meth-ice-20160218-story.html">scale of recent drug seizures in underground laboratories</a> in China’s Guangdong province alone is staggering – and it’s jumped by 50% in the last year. In January 2015, for instance, 2.2 tonnes of solid and liquid <a href="http://www.latimes.com/world/asia/la-fg-drugs-china-meth-ice-20160218-story.html">methamphetamine destined for Shanghai</a> were uncovered in the coastal county of Lufeng. In May that year, 1.3 tonnes of ketamine and 2.7 tonnes of its precursors were <a href="http://www.latimes.com/world/asia/la-fg-drugs-china-meth-ice-20160218-story.html">found in the city of Yangjiang</a>, disguised as black tea bound for Southeast Asia.</p>
<p>Responding to the challenges posed by organised crime groups are a handful of capable law enforcement agencies; a patchwork of cross-border mutual legal assistance agreements; and a fledgling regional security response from ASEAN. These agencies struggle to have an impact on the scale of criminal enterprise in the region. They are also constrained by concerns about sharing intelligence with potentially compromised police, customs and military services.</p>
<h2>Crime and connectivity</h2>
<p>In 2013, the United Nations Office of Drugs and Crime (UNODC) <a href="http://www.unodc.org/toc/en/reports/TOCTA-EA-Pacific.html">estimated that crime groups earned</a> about US$90–$100 billion a year from illicit sources. Narcotic production and trafficking in drug precursors were the most lucrative, followed by illegal wildlife and timber trading. UNODC found human trafficking, illegal e-waste disposal, maritime crimes ranging from piracy to illegal fishing, counterfeiting of medicines and “high street” products and underground gambling were the most damaging crimes.</p>
<p>It’s easy, then, to see why the burden of transnational crime is often borne by the poor people of Southeast Asia. A growing demand for timber and wildlife products <a href="https://www.unodc.org/southeastasiaandpacific/en/2016/02/organized-crime-southeast-asia/story.html">puts pressure on cash-strapped communities</a> to collude with criminal groups in extracting and marketing these resources. And the Japanese yakuza and triads or “black societies” in Taiwan, Hong Kong and South Korea also seek opportunities to dump e-waste in under-regulated jurisdictions. </p>
<p>Southeast Asia’s lucrative markets, combined with the availability of and demand for consumer and medicinal products, have proved irresistible to criminal enterprises.</p>
<iframe src="https://datawrapper.dwcdn.net/qWbnn/1/" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="620"></iframe>
<p>This is illustrated by the fact that cross-border <a href="https://www.unodc.org/documents/southeastasiaandpacific/Publications/2015/d_rugs/ATS_2015_Report_web.pdf">movement of illicit products</a> into and out of Southeast Asia, often via India and China, has intensified in recent years. This is <a href="https://www.unodc.org/southeastasiaandpacific/en/2016/02/organized-crime-southeast-asia/story.html">due, in part,</a> to free-trade agreements between ASEAN and these countries, as well as the massive upgrade of the region’s infrastructure and connectivity now under way. </p>
<p>China’s One Belt, One Road initiative, the India–Myanmar–Thailand Trilateral Highway and the Trans-Asian Railway are all speeding up change and development in transport and commerce in the region. Yet <a href="https://www.unodc.org/southeastasiaandpacific/en/2016/02/organized-crime-southeast-asia/story.html">a 2016 UNODC assessment</a> noted that, despite the existence of “thriving networks of cross-border criminals”, a “fully operational framework on tackling cross-border crime does not exist”.</p>
<h2>Organised crime in East Asia</h2>
<p>Organised crime groups in East and Southeast Asia are diverse and often ephemeral. Some, such as <a href="http://www.regionalsecurity.org.au/Resources/Files/vol5no4BroadhurstandLee.pdf">the triads of southern China</a>, have survived since the 19th century. Others form and disband in a generation or less. </p>
<p>The defining feature of organised crime is that <a href="http://www.hup.harvard.edu/catalog.php?isbn=9780674807426&content=reviews">it offers protection services</a> – the enforcement of contracts – for illicit markets. In circumstances where state-led conflict-resolution is weak, <a href="http://www.hurstpublishers.com/book/hidden-power/">it can provide similar services</a> as legal institutions.</p>
<p>Law-enforcement agencies now <a href="http://www.regionalsecurity.org.au/Resources/Files/vol5no4BroadhurstandLee.pdf">routinely observe convergence and connectivity</a> among different Asian crime groups. Former ethnic or linguistic distinctions once associated with traditional organised crime groups, for instance, are now blurred. And major Chinese and Japanese crime groups are increasingly connected with Mexican, West African, Iranian and South Asian crime groups. </p>
<p>This reflects the impact of the <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2115290">globalisation of trade and the increasing wealth</a> of China, India and the region. Opportunities abound for <a href="https://www.interpol.int/en/Crime-areas/Organized-crime/Organized-crime">expanding into industries or locations</a> unhampered by existing protection providers.</p>
<p>Strategic violence still <a href="http://bjc.oxfordjournals.org/content/50/5/851.short">plays a crucial role in enforcing contracts</a> in illicit markets and establishing distribution markets. Hong Kong triads, such as the Sun Yee On, merged with or rented local protection services in China and Southeast Asia as China opened up its economy.</p>
<p>These looser macro-criminal networks are <a href="http://www.tandfonline.com/doi/full/10.1080/00396338.2014.920148">often referred to as “red-black”</a> in Chinese, a euphemism for collaboration between the criminal world and corrupt elements of the state. This occurs at the county level in <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2115290">China or at the sub-state level in the Golden Triangle</a>, as the tri-state confluence of Myanmar, Laos and China is known. </p>
<p>The Triangle is now also known for the mass production of amphetamine-type stimulants, such as ecstasy, built on the older tradition of opium production and heroin refinement. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/148380/original/image-20161202-25674-1acpqcy.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/148380/original/image-20161202-25674-1acpqcy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/148380/original/image-20161202-25674-1acpqcy.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/148380/original/image-20161202-25674-1acpqcy.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/148380/original/image-20161202-25674-1acpqcy.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/148380/original/image-20161202-25674-1acpqcy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=571&fit=crop&dpr=1 754w, https://images.theconversation.com/files/148380/original/image-20161202-25674-1acpqcy.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=571&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/148380/original/image-20161202-25674-1acpqcy.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=571&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>Along with amphetamine-type stimulants, ice pills and heroin are transported from production areas in northeast Myanmar in modest quantities of a kilogram or less — below the prevailing legal threshold for trafficking — to markets in Bangkok, Yangon or Kunming. This method, known as “<a href="http://citation.allacademic.com/meta/p_mla_apa_research_citation/1/2/7/2/1/p127219_index.html?phpsessid=bh8ci6kbkg4gga6k1qrhd2b0t5">ants moving house</a>”, earns the successful smuggler US$2000 per run. </p>
<p>Larger amounts may be diverted via Cambodia for tran-shipment to highly profitable markets <a href="https://www.acic.gov.au/publications/intelligence-products/organised-crime-australia">such as Australia</a> and <a href="https://www.acic.gov.au/publications/intelligence-products/illicit-drug-data-report">Japan, where premium wholesale prices beckon</a>.</p>
<h2>Ineffective law enforcement</h2>
<p>The lack of effective action to suppress problems such as illegal drugs, counterfeiting and wildlife extraction reflects <a href="https://www.unodc.org/southeastasiaandpacific/en/2016/02/organized-crime-southeast-asia/story.html">ASEAN’s relatively weak integration with regard to security problems</a>. Until there’s a sense that ASEAN is a community with a shared fate, effective co-ordination to combat organised crime is likely to be little more than window dressing. </p>
<p>Most Asian governments have given economic development priority over concerns about illicit trade and organised crime. Progress against organised crime will remain ad hoc unless this changes.</p>
<p>Worthy but nonsensical aspirations to be a “drug-free” region by 2015, set out at the <a href="http://asean.org/joint-statement-of-the-tenth-asean-ministerial-meeting-on-transnational-crime-10th-ammtc-consultation/">2010 ASEAN Ministerial Meeting on Transnational Crime</a>, and the Work Plan on Combating Illicit Drug Production, Trafficking and Use <a href="https://ssrn.com/abstract=2115290">adopted in 2010 by the seventh ASEAN Ministerial Meeting</a> on Transnational Crime, signal this weakness.</p>
<p>Alternative policies that seek to regulate recreational drugs and the pursuit of harm-reduction strategies would help undercut the profits of criminal groups. Policies that reorient consumer choices to undercut the goods and services organised crime provides would also help. </p>
<p>The key to effective suppression of organised crime will be the action of the ASEAN+3 group (the three being China, Japan and South Korea). </p>
<p>China’s awakening to the high cost of fake and often dangerous products, as well as the perils of using “ice” for the young, should help reduce the scale of organised crime activities in the region. Chinese-led <a href="http://origin.www.uscc.gov/sites/default/files/Research/Staff%20Report_PrecursorChemicalReport%20071816_0.pdf">restrictions on the export of precursor chemicals</a> – effective from late 2015 – could be significant if followed by India and ASEAN. </p>
<p>Harsh alternatives are brutal and undermine the rule of law. Attempts to curtail demand by resorting to extrajudicial police killings may have popular appeal, but as with former Thai prime minister <a href="https://www.hrw.org/news/2008/03/12/thailands-war-drugs">Thaskin Shinawatra’s controversial 2003 war on drugs</a>, Philippine President Rodrigo Duterte’s campaign against drug pushers may ultimately serve to <a href="http://theconversation.com/dutertes-war-on-drugs-bitter-lessons-from-thailands-failed-campaign-66096">consolidate crime groups, raise protection costs and temporarily displace activities</a> to less hostile locations.</p>
<p>By December 3, Duterte’s “war on drugs” had seen <a href="http://www.rappler.com/newsbreak/iq/145814-numbers-statistics-philippines-war-drugs">2,028 drug crime suspects killed</a> during police operations while <a href="http://www.rappler.com/newsbreak/iq/145814-numbers-statistics-philippines-war-drugs">3,841 deaths had been attributed</a> to vigilantes. The high risk of homicides involving vigilantism shows the campaign is out of control and corrosive of the independence of courts. </p>
<p>Any hope of reducing the impact of transnational crime will depend on reducing the demand for illicit products as well as enhancing the legitimacy and effectiveness of law enforcement.</p><img src="https://counter.theconversation.com/content/69780/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Roderic Broadhurst does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Organised crime groups are profiting from the fruits of globalisation such as free-trade agreements as well as the massive upgrade of the region’s infrastructure and connectivity now underway.Roderic Broadhurst, Chair professor, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/666402016-10-13T06:11:15Z2016-10-13T06:11:15ZJust how big is the drug problem in the Philippines anyway?<p><em>“Hitler massacred three million Jews … there’s three million drug addicts. There are. I’d be happy to slaughter them.”</em> </p>
<p>These words, <a href="http://www.nytimes.com/2016/10/01/world/asia/philippines-rodrigo-duterte-hitler-drugs.html">spoken</a> by Filipino President Rodrigo Duterte in September, have become notorious worldwide. </p>
<p>Duterte has since <a href="http://www.reuters.com/article/us-philippines-duterte-hitler-idUSKCN1220H9">apologised</a> for the reference to the Holocaust. But alongside continued <a href="https://www.hrw.org/news/2016/09/16/philippines-independent-investigation-duterte-needed">concern about the extrajudicial killings</a> in the Philippines drug war, questions remain about whether there are actually three million drug users in the country – and whether they are addicts. </p>
<p>If true, drug users would represent 3% of the nation’s population – even higher than <a href="http://www.nationmultimedia.com/national/1-2-million-thais-are-addicted-to-drugs-30174048.html">Thailand’s 1.8%</a> (based on a recent estimate of 1.2 million), or Indonesia’s 1.8% based on an official (but questionable) <a href="https://theconversation.com/indonesia-uses-faulty-stats-on-drug-crisis-to-justify-death-penalty-36512">estimate of 4.5 million</a>. </p>
<p>Are there really three million “drug addicts” in the Philippines?</p>
<p>The official statistics show a much lower figure. In 2015, the Philippine Dangerous Drugs Board estimated a total of <a href="http://www.rappler.com/nation/146654-drug-use-survey-results-dangerous-drugs-board-philippines-2015">1.8 million drug users</a>. Of this number, 859,150 were thought to be users of <em>shabu</em> or crystal methamphetamine – the drug of particular concern in the country. </p>
<p>The term “user” was defined in the report as someone who had used drugs at least once in the past year. Of all drug users, 85% reported using at least once monthly and 50% cited weekly use. Thus the number of drug “abusers” or “addicts” is necessarily lower than that. </p>
<p>Still, we can’t dismiss Duterte’s claims on the sole basis of the 2015 survey or previous ones, given the variability of their results. </p>
<p>In 2005, the drugs board reported <a href="http://www.ddb.gov.ph/research-statistics/research/45-research-and-statistics/100-2005-researches#a">five million regular users of methamphetamine alone</a> - amounting to a prevalence of 6% of the country. This prompted <a href="https://www.unodc.org/pdf/research/wdr07/WDR_2007.pdf">the UN Office on Drugs and Crime to suggest</a> that the Philippines has the “the world’s highest methamphetamine prevalence rate” at the time.</p>
<p>But just three years later, the <a href="http://www.ddb.gov.ph/images/psrsd_report/2008%20National%20Household%20Survey.pdf">prevalence was reported to be only 1.9%</a>. </p>
<p>Given the poor quality of the reports themselves (the 2008 report cites Wikipedia as reference), it’s unclear whether they reflect actual changes, or merely methodological flaws. </p>
<h2>Duterte’s philosophy of drug use</h2>
<p>While Duterte’s figures cannot be definitively dismissed, his view of drug users can be. His use of the term <em>adik</em> (addict) - a word that has very negative connotations in the Philippines - is in line with his conviction that users of illicit drugs, particularly methamphetamines, are beyond redemption.</p>
<p>He has claimed, for instance, that the continuous use of <em>shabu</em> would “<a href="http://newsinfo.inquirer.net/797735/shabu-addicts-beyond-redemption">shrink the brain</a>”, making users “<a href="http://news.abs-cbn.com/news/08/17/16/duterte-blasts-un-for-interference">no longer viable as human beings in this planet</a>”. Based on these statements, and contrary to his own government’s <a href="http://newsinfo.inquirer.net/810545/drug-war-enters-phase-2">official stance and efforts</a>, Duterte seems to think rehabilitation is not an option. </p>
<p>Numerous studies present a far more complex picture. While methamphetamine has indeed been demonstrated to cause damage to <a href="http://www.jneurosci.org/content/24/26/6028.short">neurons and the brain’s white matter</a>, various therapies, such as <a href="http://www.tandfonline.com/doi/abs/10.1080/09595230801919494">cognitive-behavioural therapy</a> and to a lesser extent, <a href="http://www.tandfonline.com/doi/abs/10.1080/08897070802218554">pharmacotherapy</a>, have shown promise as forms of rehabilitation. </p>
<p>What’s more, alternative models of dealing with substance abuse, including those that employ <a href="http://www.globalcommissionondrugs.org/wp-content/themes/gcdp_v1/pdf/Global_Com_Alex_Wodak.pdf">demand-reduction and harm-reduction frameworks</a>, strongly suggest that drug use is embedded in, and in part determined by, users’ <a href="http://www.sciencedirect.com/science/article/pii/S0955395902000075">social and physical environment</a>. </p>
<p>My <a href="http://www.ijdp.org/article/S0955-3959(14)00162-5/abstract">own ethnographic research among young drug users</a> in a poor urban community in the Philippines resonates with these perspectives. Caught in an informal economy where income opportunities are scarce and living conditions are harsh, <em>shabu</em> allows the youths to stay awake and work at night, gives them energy, alleviates their hunger, and provides them with moments of euphoria amid their difficult lives. </p>
<p>While some of them exhibit signs of addiction (they have gaunt, hollowed-out faces, for instance), most remain functional. And while some of them admit to resorting to crime (such as stealing mobile phones), the only crime most commit is taking drugs. </p>
<p>Educational and economic opportunities, I found, can help them move away from drug use – and prevent many others from using drugs in the first place. </p>
<h2>A widely held view</h2>
<p>Duterte’s philosophy of drug use is shared by many Filipinos, and has common since the very beginning of the “war on drugs” in the early 1970s. In 1972, Filipino bishops <a href="http://cbcponline.net/v2/?p=175">described</a> drug users as “mental and physical wrecks”, calling them “worst saboteurs” who were “worthy of the highest punishments”.</p>
<p>In 1988, the Philippine Supreme Court, foreshadowing Duterte’s assertions, wrote in <a href="http://www.lawphil.net/judjuris/juri1988/feb1988/gr_l_69844_1988.html">one of its decisions</a> that it was:</p>
<blockquote>
<p>Common knowledge that drug addicts become useless if not dangerous members of society and in some instances turn up to be among the living dead. </p>
</blockquote>
<p>In many towns and cities in the Philippines, anti-drug posters (with messages like “Get high on God, not on drugs”) are displayed prominently, as if to demonstrate public’s resolve to get rid of what they see as society’s great menace. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/141455/original/image-20161012-13467-1v6v514.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/141455/original/image-20161012-13467-1v6v514.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/141455/original/image-20161012-13467-1v6v514.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/141455/original/image-20161012-13467-1v6v514.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/141455/original/image-20161012-13467-1v6v514.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/141455/original/image-20161012-13467-1v6v514.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/141455/original/image-20161012-13467-1v6v514.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/141455/original/image-20161012-13467-1v6v514.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In a village center in Zamboanga City, posters call on drug users to surrender or face the consequences.</span>
<span class="attribution"><span class="source">Gideon Lasco</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>These sentiments underwrite the widespread support that Duterte’s war on drugs enjoys. And although a majority of Filipinos think <a href="http://cnnphilippines.com/news/2016/10/07/SWS-Duterte-war-on-drugs-survey.html">drug suspects should not be killed</a>, many see the extrajudicial killings as a necessary evil to get rid of the far worse menace of drug addicts and the criminality associated with them.</p>
<p>In light of this attitude, what must be most urgently addressed is the lack of understanding about drug use and the dearth of information about the true extent and nature of drug use in the country. That means scholarly and journalistic investigations that fill these gaps must be communicated effectively to the public. </p>
<p>Otherwise, the official discourse and popular understandings of drug use will remain unchallenged - and the “three million addicts” in the Philippines will all be deserving of the “highest punishment” in the eyes of their fellow Filipinos.</p><img src="https://counter.theconversation.com/content/66640/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>For his research on drug use in the Philippines, Gideon Lasco received funding from the University of Amsterdam's Global Health Research Priority Area.</span></em></p>Duterte says there are three million drug users in the Philippines. There are almost certainly many fewer than that.Gideon Lasco, PhD candidate in Medical Anthropology, Amsterdam Institute for Social Science Research (AISSR), University of AmsterdamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/660962016-09-29T06:35:22Z2016-09-29T06:35:22ZDuterte’s war on drugs: bitter lessons from Thailand’s failed campaign<p>The body count from Philippine President Rodrigo Duterte’s “war on drugs” is growing by the day. While he’s not the first national leader to condone violence and extrajudicial killings in the name of controlling illicit drug use, Duterte would be wise to learn from Southeast Asian history on what works, and what doesn’t.</p>
<p>Duterte’s policy has already resulted in <a href="http://www.abc.net.au/news/2016-09-16/duterte-drug-war-overkill-creating-crisis-in-philippines/7850424">more than 3,000 casualties</a>, leading to broad international condemnation. </p>
<p>The deaths have resulted in either police operations where suspects have resisted arrest or summary executions by unknown perpetrators. Drug pushers and users are voluntarily surrendering to the police in <a href="http://news.abs-cbn.com/news/07/14/16/60000-drug-users-pushers-have-surrendered-palace">huge numbers</a>, exacting a toll in the country’s already <a href="http://edition.cnn.com/2016/08/21/asia/philippines-overcrowded-jail-quezon-city/">overcrowded jail system</a>. Nor are there enough <a href="http://cnnphilippines.com/news/2016/07/26/drug-rehab-program.html">drug rehabilitation centres</a> to absorb many of them.</p>
<p>Other countries have adopted similar policies in the past - only to see them <a href="http://www.globalcommissionondrugs.org/reports/war-on-drugs/">fail</a>. </p>
<p>Colombia’s drug war resulted in the deaths of powerful members of drug cartels, for instance, but also in skyrocketing levels of violence, marginalisation, and human rights violations.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/139337/original/image-20160926-31837-537wn5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/139337/original/image-20160926-31837-537wn5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/139337/original/image-20160926-31837-537wn5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/139337/original/image-20160926-31837-537wn5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/139337/original/image-20160926-31837-537wn5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/139337/original/image-20160926-31837-537wn5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/139337/original/image-20160926-31837-537wn5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Duterte wants to keep on his ‘bloody war’ against the drug dealers and takers.</span>
<span class="attribution"><span class="source">Jorge Silva/Reuters</span></span>
</figcaption>
</figure>
<h2>Thailand’s drug war</h2>
<p>The most salutary tale for Duterte comes from Thailand. The drug war waged in the early 2000s by former Thai prime minister Thaksin Shinawatra could hold important lessons for the Filipino government about the unforeseen political consequences of condoning violence in the name of controlling crime.</p>
<p>Launched in 2003, Thaksin’s war on drugs bears significant similarities to what’s happening in the Philippines. Like Duterte, Shinawatra was very popular, managing to lead a one-party administration in a country used to government by coalition. This strong electoral mandate allowed him to take on his country’s gargantuan and systemic drug problem.</p>
<p>As one of the world’s <a href="https://www.brookings.edu/wp-content/uploads/2016/07/WindleThailand-final.pdf">major transit points</a> for narcotics, drug-use had been common in Thailand since the 1950s. But in the 1990s, the use of methamphetamines (known in Thai as <a href="http://www.cesar.umd.edu/cesar/drugs/yaba.asp"><em>ya ba</em></a>) started to cause concern among Thai political elites. </p>
<p>Most methamphetamines were produced on the <a href="http://www.nytimes.com/2009/11/07/world/asia/07thai.html?_r=0">Thailand-Myanmar border</a> by ethnic Burmese rebels, who used sales to finance their armed struggle. But the drug was largely consumed by the rural working class Thais, due to its affordable price.</p>
<p>When the media began reporting rising methamphetamine use among young people, <a href="http://www.globalsecurity.org/military/world/war/thai-drug-war.htm">key political figures</a>, particularly <a href="https://www.hrw.org/reports/2004/thailand0704/4.htm">King Bhumibol Adulyadej</a> and his privy council, expressed grave concern. </p>
<p>A former police lieutenant colonel himself, Thaksin declared an all-out war against <em>ya ba</em>. Drug dealers were labelled enemies of the state, and after <a href="http://news.bbc.co.uk/2/hi/asia-pacific/7260127.stm">three months and 2,500 deaths</a>, the prime minister proclaimed victory.</p>
<p>Thailand’s war on drugs was carried out through collaboration between local governors and police officers. Government officials compiled “<a href="https://www.hrw.org/legacy/english/docs/2008/02/07/thaila17993.htm">blacklists</a>” which led to arrests and, in many cases, extrajudicial killings. As the bodies piled up, the police claimed that most deaths resulted from rival drug cartels killing each other to avoid betrayal by their <a href="http://edition.cnn.com/2003/WORLD/asiapcf/southeast/02/21/thailand.drugs/">accomplices</a>.</p>
<p>The pressure on the police to measure their success was paramount, and it was defined by the body count. This metric reinforced the existing hierarchy, already prone to abuse, corruption and even complicity in the drug trade. </p>
<p>Police targets normally consisted of the “small fish” within the drug network (low-level dealers, for instance, and hill tribe villagers). Rarely did the lists contain drug lords themselves but every death in the war counted as a step toward success. </p>
<p>According to an <a href="http://www.nationmultimedia.com/homeMost-of-those-killed-in-war-on-drug-not-involved-i-30057578.html">official investigation</a> launched after <a href="https://www.theguardian.com/world/2006/sep/19/thailand">the 2006 military coup</a> that wrenched power from Thaksin, 1,400 people out of the 2,500 killed as part of the war on drugs had nothing to do with drugs. And profitable drug routes from Myanmar reportedly remained intact, protected by the Myanmar and Thai government bureaucracy and business <a href="https://news.vice.com/article/drug-trafficking-meth-cocaine-heroin-global-drug-smuggling">elites</a>.</p>
<p>Despite the violent and bloody crackdown, the Thai population <a href="https://www.wsws.org/en/articles/2003/05/thai-m09.html">largely endorsed Thaksin’s war</a>. Prior to his downfall in 2006, the prime minister was admired by both his supporters and critics for his business-oriented efficiency, policy decisiveness and resilience in the face of harsh criticism. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/139338/original/image-20160926-31853-qoppod.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/139338/original/image-20160926-31853-qoppod.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/139338/original/image-20160926-31853-qoppod.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/139338/original/image-20160926-31853-qoppod.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/139338/original/image-20160926-31853-qoppod.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/139338/original/image-20160926-31853-qoppod.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/139338/original/image-20160926-31853-qoppod.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Thailand’s former premier Thaksin Shinawatra launched a failed campaign against drugs.</span>
<span class="attribution"><span class="source">Yuriko Nakao/Reuters</span></span>
</figcaption>
</figure>
<p>The former prime minister successfully controlled the discourse of the war, even in the face of reports of human rights violations. He claimed the drug war was necessary, and that Thais should turn a blind eye to the inevitable “collateral damage” of his campaign. <a href="https://www.hrw.org/reports/2004/thailand0704/4.htm#_ftnref8">Public opinion</a> supported the campaign; some surveys showed support of 97.4%. </p>
<h2>Lessons for Duterte</h2>
<p>Thailand’s experience shows that the real culprits at the top of the drug pyramid often escape extralegal approaches to eradicating drug problems with impunity. After thousands of deaths, Colombia and Mexico discovered the same truth decades ago. </p>
<p>Networks of illegal drug supply go beyond any one country’s sovereign borders. The Philippines is a producer, a transit point, and a consumer of <a href="http://www.pctc.gov.ph/illicit-drug-trafficking.html">narcotics</a>. Each role requires specific policies that involve the entire state apparatus, as well as civil society. </p>
<p>The drug trade is a transnational threat; this means neighbouring states have to work together to fight. In this sense, Duterte’s plea for <a href="http://www.philstar.com/headlines/2016/09/06/1620914/duterte-laos-seeks-asean-unity-vs-terror-drugs">regional cooperation</a> on illegal drugs is a step in the right direction and should be supported by other ASEAN countries.</p>
<h2>Drugs and democracy</h2>
<p>Political leaders who want to wage wars against illegal drugs also open the possibility of power abuse from the security sector. In places with rampant corruption, lack of police professionalism, a culture of impunity, and links between drug lords and political elites, governments are susceptible to declare “regimes of exception” where security forces are given extra-legal powers in order to succeed in their mission. </p>
<p>Duterte has already hinted at <a href="http://www.rappler.com/nation/146824-duterte-revive-philippine-constabulary">militarising the police</a> to combat illegal drugs, a move that will erode the gains made from security sector reform and democratisation in the Philippines after 1986.</p>
<p>Duterte still has the chance to turn away from his current approach and form a more sensible policy that uses less force, involves the participation of local communities, and looks at the issue of illicit drugs in all its dimensions. </p>
<p>Illicit drug use is a health issue that requires targeted, non-criminal, interventions starting with the individual. It’s also a systemic problem that requires sociopolitical measures that address poverty, corruption and social exclusion. </p>
<p>Unlike Thaksin, Duterte can pivot away from his current approach toward a more comprehensive anti-drug framework. Thaksin’s drug war dealt a double whammy to Thailand’s democracy – the scorched earth policy not only undermined state accountability, but it was also used as <a href="http://www.aljazeera.com/news/asia-pacific/2008/09/2008935491945127.html">ammunition</a> by the elite opposition in the military coup that toppled him in 2006.</p>
<p>Critics of Duterte should not merely provide strong condemnation. Instead, they should understand the underlying political context of human rights in the Philippines and constructively argue for policy to turn away from lethal strategies. Stubborn opposition with the goal of <a href="http://newsinfo.inquirer.net/817072/duterte-ouster-plots-wont-be-taken-lightly-palace">destabilising</a> a popular government will be met with an equally bitter reaction from the state. </p>
<p>The Philippines can avoid being dragged into a downward spiral of political polarisation, something Thailand is currently experiencing. If not, then the Philippines might also end up with a tragic democracy just like its neighbour to the west.</p><img src="https://counter.theconversation.com/content/66096/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janjira Sombatpoonsiri is co-Secretary General of the Asia Pacific Peace Research Association.</span></em></p><p class="fine-print"><em><span>Aries Arugay is also Executive Director of the Institute for Strategic and Development Studies, Inc. a Manila-based policy think tank.</span></em></p>Can Philippine president Rodrigo Duterte learn anything from Thailand’s failed campaign against drugs in the early 2000s? Maybe to adopt a less bloody and more comprehensive approach.Janjira Sombatpoonsiri, Assistant Professor, Thammasat UniversityAries Arugay, Associate Professor of Political Science, University of the PhilippinesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/411862016-09-11T20:09:17Z2016-09-11T20:09:17ZHow does ice use affect families and what can they do?<figure><img src="https://images.theconversation.com/files/137130/original/image-20160909-13345-w0v9ca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">US TV-style 'interventions' aren't the answer. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-210886186/stock-photo-teenager-problems-teenage-girl-cries-while-her-mother-looks-at-her-on-the-background.html?src=5UtKCi4Tk9jhy81jHfcEMw-1-15">Kamira/Shutterstock</a></span></figcaption></figure><p>Some of the <a href="https://www.youtube.com/watch?v=aVA3Pj6gBGk">greatest impacts</a> of drug use are on families, but families sometimes feel in a position of little control when it comes to responding. Often they receive mixed messages about what they should do.</p>
<p>Ice or crystal meth, the strongest form of methamphetamine, has arguably the biggest impact on families of all drugs. It increases the <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.12474/abstract">risks</a> of psychosis, violence and impulsivity and decreases emotional control. This can create a volatile and chaotic environment for people living with a person with an ice problem.</p>
<p>So, what can families really do?</p>
<h2>The good news</h2>
<p>The good news is fewer teenagers and young people are drinking and <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/ndshs-2013/">trying drugs</a> than in the past. Those who are drinking and taking drugs do so less often than in previous years. Most young people who are offered drugs don’t try them.</p>
<p>Drug <em>use</em> does not necessarily mean drug <em>dependence</em>. So parents shouldn’t panic if they discover their son or daughter has tried drugs. Most people who use drugs do so very occasionally, for a short period and then stop.</p>
<p>Most people who use drugs don’t need treatment. Specialist treatment in a drug and alcohol centre is designed for people who are experiencing moderate to severe harms, such as addiction or dependence (which is the clinical term). </p>
<p>For crystal meth, more than <a href="http://www.sciencedirect.com/science/article/pii/S0376871606001475">weekly use</a> is associated with dependence. Around 15% of people who have used methamphetamine in the last year use once a week. A further 15% use more than once a month but less than once a week. These groups are at higher risk of other harms such as overdose. </p>
<p>That means 70% of people who use methamphetamine do so irregularly and won’t be dependent or experiencing the harms of long-term use.</p>
<h2>Prevention is better than cure</h2>
<p>The best protection for kids is prevention. Children are strongly influenced by their <a href="http://dera.ioe.ac.uk/6903/1/rdsolr0507.pdf">parents’ attitudes</a> – sometimes more so than by their peers. Parents influence when and how their kids use drugs and alcohol through timing, supervision, modelling, attitudes and communication.</p>
<h3>Timing</h3>
<p>There’s a popular myth that introducing kids to small amounts of alcohol early has a protective effect. The argument is that they can learn to drink safely when supervised by parents. </p>
<p>But there’s no evidence that early sips of alcohol are protective, and lots of evidence that delayed drinking reduces risk. </p>
<p>Early supply of alcohol from years 7 to 9 is the single biggest <a href="http://connections.edu.au/publicationhighlight/parents-who-supply-sips-alcohol-early-adolescence-prospective-study-risk">predictor</a> of drinking in year 10. </p>
<p>So delay the introduction of alcohol as long as possible.</p>
<h3>Supervision</h3>
<p>Parents who establish clear and understandable rules and then supervise their children to ensure those rules are followed tend to have children <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084357/">with lower rates of alcohol and drug use</a>.</p>
<p>Low parental supervision is associated with <a href="http://www.sciencedirect.com/science/article/pii/S0890856709634092">earlier</a> drinking and drug use.</p>
<h3>Modelling</h3>
<p>Parents have an important influence on whether kids drink and use drugs through their own <a href="http://scholar.google.com.au/scholar_url?url=https://www.researchgate.net/profile/Judy_Andrews2/publication/14839250_The_Influence_of_Parent_Sibling_and_Peer_Modeling_and_Attitudes_on_Adolescent_Use_of_Alcohol/links/55c1280908aed621de154156.pdf&hl=en&sa=X&scisig=AAGBfm118HWb8-pU_V2x8wRUmrno4bCoTA&nossl=1&oi=scholarr&ved=0ahUKEwir1ZyyvO_OAhUEJJQKHbAUDPcQgAMIHCgAMAA">behaviour</a>. Not getting drunk or using drugs in front of your kids – or not reaching for a medicine for every minor ailment – are the kinds of strategies parents can use to reduce early exposure to alcohol and other drugs.</p>
<p>Kids who learn effective coping and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518980/">social skills</a> and good emotion regulation are also less likely to use drugs. These skills are typically learnt through parental modelling.</p>
<h3>Attitudes</h3>
<p>Clear and early communication of values and <a href="http://www.ncbi.nlm.nih.gov/pubmed/16228115">attitudes</a> to drugs heavily influences children’s attitudes to drug use and the likelihood they will try drugs.</p>
<p>Talk to pre-school kids about safe use of medicines when they are sick. Talk to them about the effects of smoking and alcohol in primary school, especially if you notice smoking and drinking in movies or on TV. Communicate family rules about drinking and drugs in high school, including drinking and driving.</p>
<p>Make not using alcohol and other drugs “normal”. Only a small proportion of teenagers drink and a very small proportion try drugs. Those who do generally drink or take drugs only very occasionally. If teenagers think everyone is doing it, they are more likely to do it themselves.</p>
<h3>Communication</h3>
<p>Keep an open dialogue with young people about alcohol and drugs. Particularly talk to high school students about what is happening in their year level. </p>
<p>Young people are more likely to discuss difficult issues, including drugs and alcohol, when they believe their parents will not be reactive. Using the <a href="http://friendlyschools.com.au/cyberstrong/5-teaching-and-learning/5.4">LATE Model</a> has been shown to increase help-seeking: <strong>l</strong>isten, <strong>a</strong>cknowledge issues, <strong>t</strong>alk about options, and then end with <strong>e</strong>ncouragement.</p>
<h2>What about when there is a problem?</h2>
<p>When someone in the family has a problem with alcohol or other drugs, family members cope in a number of ways, with both positive and negative impacts on the family. <a href="http://opus.bath.ac.uk/21589/1/paper4jo.pdf">Some</a> will tolerate substance use and its impact; some will attempt to change the drug use; and some will withdraw by reducing interaction.</p>
<p>There’s no right or wrong way of responding. But when family members have vastly different coping styles or change the way they cope in unpredictable ways, conflict in the family can result. Agree on boundaries and responses, and stick to these as much as possible.</p>
<p>It can help family members to get support from a family therapist who specialises in alcohol or other drug problems in the family, or from one of the many support groups available. These include <a href="http://sharc.org.au/program/family-drug-help/support-group">Family Drug Help</a> and <a href="http://www.fds.org.au/meetings-and-events/family-support-meetings">Family Drug Support</a>.</p>
<h2>What works?</h2>
<p>Families can encourage the person who uses drugs to seek help from a number of <a href="http://theconversation.com/you-dont-have-to-go-off-the-grid-to-get-treatment-for-drug-dependence-50075">sources</a> if they’re ready. When families are involved in an effective way, the person using drugs is <a href="https://www.researchgate.net/publication/8228917_Family-based_therapies_for_adolescent_alcohol_and_drug_use_Research_contributions_and_future_research_needs">more likely to engage</a> in treatment and outcomes are better.</p>
<p>If the person isn’t ready to seek treatment, talk to a family specialist who can explore options for encouraging someone into treatment.</p>
<h2>What doesn’t work</h2>
<h3>Fat camp</h3>
<p>American TV-style “family interventions” or Southpark “fat camp”-style interventions aren’t generally effective.</p>
<p>The premise behind them is that the person using is in “denial” about their drug use and how it affects others. They are designed to force the person to see those connections. However, confrontation is rarely helpful and it’s often distressing for all involved.</p>
<p><a href="http://www.researchgate.net/publication/14475502_A_Comparison_of_the_Johnson_Intervention_with_Four_Other_Methods_of_Referral_to_Outpatient_Treatment">Research</a> suggests those who enter treatment as a result of a family intervention are less likely to stay in treatment and more likely to relapse.</p>
<h3>Forced treatment</h3>
<p>Last year, Tasmanian MP Jacqui Lambie <a href="http://www.news.com.au/national/politics/senator-jacqui-lambie-reveals-her-son-is-addicted-to-the-drug-ice/news-story/d6804a56adc30cf7d7a8e680c44c2641">voiced</a> many families’ frustration, proposing forced treatment for people who use ice. Lambie eventually admitted, though, that this type of strategy would not have helped her son.</p>
<p>Her assessment was correct. There is <a href="http://www.ncbi.nlm.nih.gov/pubmed/26790691">no evidence</a> that forcing people into treatment has any long-term benefits in reducing drug use. In some cases it can actually backfire, making it less likely a person will seek treatment in future.</p>
<p>While forced treatment is an <a href="https://www2.health.vic.gov.au/alcohol-and-drugs/aod-policy-research-legislation/aod-legislation/severe-substance-treatment-act-ssdta">option</a> in some states in Australia, there are many more palatable options available for people who use ice and their families if treatment is required.</p>
<hr>
<p><em>The <a href="http://abc.net.au/4corners">Four Corners</a> report <a href="http://www.abc.net.au/4corners/stories/2016/09/08/4535254.htm">Rehab Inc, The high price parents pay to get their kids off ice</a> goes to air on Monday, September 12, at 8.30pm on ABC television & iView.</em></p><img src="https://counter.theconversation.com/content/41186/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee provides alcohol and other drug policy development and training to schools and other workplaces as a private consultant. She has previously been awarded funding by Australian and state governments, NHMRC and other bodies for evaluation and research into drug prevention and treatment.</span></em></p><p class="fine-print"><em><span>Paula Ross consults to 360edge which provides alcohol and other drug policy development and training to schools and other workplaces and conducts evaluations of drug treatment programs.
She is affiliated with Family Drug Help@SHARC by her position on the advisory committee. She conducts a private practice in which she sees family and individuals with problems associated with substance use.</span></em></p>Ice increases the risks of psychosis, violence and impulsivity, and decreases emotional control. So what can families really do?Nicole Lee, Associate Professor at the National Drug Research Institute, Curtin UniversityPaula Ross, Sessional psychology lecturer, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/647532016-09-08T20:04:35Z2016-09-08T20:04:35ZEx-ice users lecturing school kids isn’t the answer to preventing drug use<figure><img src="https://images.theconversation.com/files/136990/original/image-20160908-25279-1up6cua.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Programs like the Meth Project are unlikely to have any significant impact on drug use.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-193838348/stock-photo-woman-slumped-on-sofa-with-drug-paraphernalia-in-foreground.html?src=fdo1X81kzDyRj6h8BGl82A-1-32">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>Australia is following the lead of the United States and sending ex-ice users into schools in the hope they can have an impact on kids’ attitudes towards drug use and prevent use. </p>
<p>The <a href="http://australianantiicecampaign.org.au/">Australian Anti Ice Campaign</a> has recently rolled out a program based on the Montana <a href="http://www.news.com.au/lifestyle/real-life/news-life/the-meth-project-exice-addicts-teaching-kids-of-seven-how-to-dodge-drugs/news-story/505ecb6082da56aa9370d2c883e97cff">Meth Project</a>. Former users show confronting images of some of the negative effects of ice use and share personal stories of suicide attempts, mental health problems and deaths from ice.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/zd712j3kavE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">One of the many Montana Meth Project advertisements.</span></figcaption>
</figure>
<p>But, although well-intentioned, there’s little evidence this type of program is effective. It may even serve to normalise, and therefore <a href="http://www.ncbi.nlm.nih.gov/pubmed/12380855">increase</a>, drug use.</p>
<p>So what works in school-based drug education and how should schools implement drug policy?</p>
<h2>What works for school drug ed?</h2>
<p>According to the United Nations Office on Drugs and Crime (<a href="https://www.unodc.org/documents/prevention/UNODC_2013_2015_international_standards_on_drug_use_prevention_E.pdf">UNODC</a>), programs are more likely to be effective if they:</p>
<ul>
<li>use interactive methods</li>
<li>are delivered by trained facilitators</li>
<li>are delivered through a series of structured sessions, often with refreshers</li>
<li>normalise the non-use of alcohol and other drugs</li>
<li>impact perceptions of risk associated with substance use</li>
<li>provide opportunities to practise and learn personal and social skills.</li>
</ul>
<p>Programs are more likely to be ineffective if they:</p>
<ul>
<li>use non-interactive methods like lecturing</li>
<li>are information-only, particularly if they are based on fear</li>
<li>are based on unstructured chat sessions</li>
<li>focus only on building self-esteem and emotional education</li>
<li>address only ethical or moral decision-making or values</li>
<li>use ex-drug users as testimonials</li>
<li>use police officers to deliver the program.</li>
</ul>
<p>Australia’s broader drug policy is based on “harm minimisation”. This acknowledges it’s impossible to eliminate drugs from society and that most people will use drugs only occasionally and for a short period in their lives. So reducing harms associated with drug use is the priority.</p>
<p>The Australian government’s <a href="http://apo.org.au/resource/principles-school-drug-education">Principles for School Drug Education</a> state that drug-education outcomes should contribute to the overall goal of minimising drug-related harm.</p>
<p>In Australia, school programs that adopt a <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1465-3362.2012.00420.x/abstract">harm-minimisation</a> goal have been shown to prevent and reduce alcohol and other drug use.</p>
<h2>Who should drug ed programs target and how?</h2>
<h3><em>Universal programs</em></h3>
<p>Universal school-based alcohol and other drug-education programs are delivered to all students, regardless of level of risk. They have the advantage of reaching large audiences at relatively low costs. </p>
<p>Many of the available universal programs are ineffective at best. Some have even been shown to increase risk of <a href="nceta.flinders.edu.au/download_file/-/view/834">alcohol</a> or <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1465-3362.2012.00420.x/abstract">other drug</a> use.</p>
<p>Most school-based programs have had very little evaluation, but among those that have been evaluated with Australian students, <a href="https://www.climateschools.com.au/">Climate Schools</a> has the best <a href="http://hej.sagepub.com/content/early/2016/01/27/0017896915612227.abstract">evidence</a>. A number of other <a href="https://positivechoices.org.au/resources/recommended-programs/">evidence-based</a> universal programs are available.</p>
<h3><em>Selective programs</em></h3>
<p>Selective programs are designed for adolescents and young people who are at greater risk for developing substance-use problems.</p>
<p>They often show bigger impacts on drug use than universal programs, but are often not used in schools because of practical limitations and risk of stigmatisation.</p>
<p>Only one selective program has been evaluated in Australia. “<a href="http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12558/full">Preventure</a>” has been shown to reduce drinking and problematic drinking among high-risk youth.</p>
<h3><em>Online programs</em></h3>
<p>Some 87% of all households and 97% of households with 15- to 17-year-olds in Australia have <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/8146.0">access</a> to the internet. Most children also have internet access at <a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features60Jun+2011">school</a>. This makes online programs increasingly important for alcohol and other drug education, and a number do appear to be <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1465-3362.2012.00517.x/full">effective</a>.</p>
<p>The online programs <a href="http://www.ncbi.nlm.nih.gov/pubmed/17114331">Consider This</a> and <a href="https://www.climateschools.com.au/">Climate Schools</a> have the most evidence for reducing alcohol and drug use.</p>
<h2>What should schools do?</h2>
<p>Based on what we know about programs that are and aren’t effective, programs like the Meth Project are unlikely to have any significant impact on drug use. But they may increase acceptability of drug use among students.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/136988/original/image-20160908-25237-1v38imk.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/136988/original/image-20160908-25237-1v38imk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/136988/original/image-20160908-25237-1v38imk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=340&fit=crop&dpr=1 600w, https://images.theconversation.com/files/136988/original/image-20160908-25237-1v38imk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=340&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/136988/original/image-20160908-25237-1v38imk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=340&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/136988/original/image-20160908-25237-1v38imk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=427&fit=crop&dpr=1 754w, https://images.theconversation.com/files/136988/original/image-20160908-25237-1v38imk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=427&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/136988/original/image-20160908-25237-1v38imk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=427&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Fear-based programs are more likely to be ineffective.</span>
<span class="attribution"><a class="source" href="https://montanameth.org/">Screenshot of montanameth.org</a></span>
</figcaption>
</figure>
<p>An <a href="http://link.springer.com/article/10.1007/s11121-008-0098-5">evaluation</a> of the US program, on which the Australian program is based, showed no evidence of positive outcomes. It found an increase in the acceptability of methamphetamine and a decrease in the perceived danger of using drugs among school students exposed to the program.</p>
<p>Schools should ensure their school drug policy is comprehensive and includes only elements we know to be effective, meaning they have been shown to reduce alcohol and other drug use.</p>
<p>In December 2015, the Commonwealth government launched the <a href="http://www.positivechoices.org.au">Positive Choices</a> portal as part of the government’s drug and alcohol prevention strategy for schools. This provides evidence-based drug prevention resources for teachers, students and parents to support positive choices about drug and alcohol education for young people.</p><img src="https://counter.theconversation.com/content/64753/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee provides alcohol and other drug policy development and training to schools and other workplaces as a private consultant. She has previously been awarded funding by Australian and state governments, NHMRC and other bodies for evaluation and research into drug prevention and treatment.</span></em></p><p class="fine-print"><em><span>Nicola Newton currently holds a research fellowship from the Society for Mental Health Research and her research into drug prevention has been funded from the Australian Government Department of Health and the National Health and Medical Research Council. She is co-director of Climate Schools Pty Ltd. </span></em></p>Australia is following the lead of the United States and sending ex-ice users into schools in the hope they can impact kids’ attitudes towards drug use and prevent use.Nicole Lee, Associate Professor at the National Drug Research Institute, Curtin UniversityProfessor Nicola Newton, Senior Research Fellow, National Drug and Alcohol Research Centre; Director, Prevention Stream, NHMRC Centre for Research Excellence in Mental Health and Substance Use, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/642442016-08-22T19:17:28Z2016-08-22T19:17:28ZJump or die. How a silver medallist leapt over the odds that marginalise drug users<figure><img src="https://images.theconversation.com/files/134938/original/image-20160822-18722-1jgycm6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Luvo Manyonga after winning the silver medal in the men's long jump at the Rio 2016 Olympics</span> <span class="attribution"><span class="source">Dylan Martinez/Reuters</span></span></figcaption></figure><p>Since winning the silver at the Rio Olympics, everybody loves South African long-jumper Luvo Manyonga. That wasn’t always the case, as pointed out by journalist Luke Alfred in his poignant 2014 piece “<a href="http://mg.co.za/article/2015-09-17-luvo-manyonga-jumps-or-dies">Luvo Manyonga jumps or dies</a>”.</p>
<p>Manyonga, it appeared after <a href="http://www.sport24.co.za/OtherSport/Athletics/Luvo-Manyonga-banned-for-tik-20120611">testing positive</a> for recreational methamphetamine use in 2012, was destined to become another promising young person lost to –- and I paraphrase – “the demon scourge of drugs”. Instead, the <a href="http://www.dailymaverick.co.za/article/2016-08-14-luvo-manyonga-broke-a-deal-with-the-devil-and-decided-to-jump-rather-than-die/?utm_medium=Social&utm_campaign=Echobox&utm_source=Twitter&utm_term=Autofeed#link_time=1471138130">prodigal son</a> returned, with a silver medal in hand. His is an example for other young people. If we are to believe the popular press and social media commentators, drugs can ruin your life and hard work and abstinence will be rewarded.</p>
<p>Without doubt this young man has achieved something remarkable, but we need to be careful as to how we frame this narrative. There is a mantra that originated in <a href="http://www.theatlantic.com/health/archive/2014/03/the-surprising-failures-of-12-steps/284616/">12 step programmes</a> that drug use leads to jails, institutions or death.</p>
<p>Like many of his peers, Manyonga could easily have ended up in jail. In reality jails are largely the consequence of policy and stigma. They are a consequence because we have criminalised drug use. And institutions because <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361129/">unmet treatment needs</a> mean that people with psychiatric disorders may end up using drugs in an attempt to <a href="http://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.142.11.1259">self-medicate</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/134949/original/image-20160822-18702-id0fou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/134949/original/image-20160822-18702-id0fou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=392&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134949/original/image-20160822-18702-id0fou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=392&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134949/original/image-20160822-18702-id0fou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=392&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134949/original/image-20160822-18702-id0fou.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134949/original/image-20160822-18702-id0fou.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134949/original/image-20160822-18702-id0fou.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Luvo Manyonga competing in the Rio Olympics.</span>
<span class="attribution"><span class="source">Kai Pfaffenbach/Reuters</span></span>
</figcaption>
</figure>
<p>The third consequence is death because drug users are stigmatised and do not have equal access to health services, increasing their risk for infectious diseases. They are marginalised, often live in squalid conditions, or suffer the consequences of impure or variable doses of drugs. All are consequences of prohibition.</p>
<p>Apparently Manyonga was, by his own interpretation, “<a href="http://www.sport24.co.za/OtherSport/Olympics2016/manyonga-i-was-so-close-to-death-20160815">near death</a>”. </p>
<p>The fact is that the data from population studies shows that the vast majority of drug users (<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3227547/">99,2%</a> in the case of cocaine for example) will <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-clinpsy-032511-143041">resolve</a> their drug use issues. Death from drugs is the exception.</p>
<p>This doesn’t mean that a literal or metaphorical death was not awaiting Manyonga, or others like him. The prospects for any young person in a South African township are severely limited. There are few employment opportunities, especially for someone who has not completed high school. The impact of apartheid cannot be understated: communities were displaced and dispossessed, narrative histories destroyed and families split. All of this has led to high levels of psychosocial dislocation, which, as renowned psychology professor <a href="http://www.brucekalexander.com/">Bruce Alexander</a> has convincingly argued, leads to higher levels of drug use and addiction.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2pCuKhELUMo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Luvo Manyonga in action during the Rio Olympics.</span></figcaption>
</figure>
<h2>Drugs the saviour for many</h2>
<p>Many of the headlines and articles refer to Manyonga’s drug of choice (“tik” or methamphetamine) as a “<a href="http://www.okayafrica.com/in-brief/rio2016-olympics-luvo-manyonga-south-africa-mens-long-jump-silver/">demon</a>”. Well, for many it is a saviour. A lifetime of uncertainty, instability and little hope for the future makes drug use a very attractive option. The instant short-term gains far outweigh the long-term consequences – this is normal human behaviour heightened by circumstance – of <a href="http://www.picoeconomics.org/">picoeconomics</a>, or micro-micro-economics, which explores the implications of an experimental discovery. </p>
<p>American psychiatrist, psychologist and behavioural economist George Ainslie explains it in “<a href="http://www.ncbi.nlm.nih.gov/pubmed/16262913">Breakdown of Will</a>”. In a world of uncertainty and unemployment, drug use provides <a href="http://collections.crest.ac.uk/94/">consistency and vocation</a>. We know that social status influences <a href="http://www.ncbi.nlm.nih.gov/pubmed/19811777">D2/3 receptor availability in primates and humans</a>, making drug use and the artificial increases in dopamine all the more attractive. </p>
<p>The increased salience of drug use is not a function of pharmacology, but a function of circumstance, as drug policy specialist Professor Paul Hayes has previously <a href="https://theconversation.com/many-people-use-drugs-but-heres-why-most-dont-become-addicts-35504">discussed</a>. The point is that drugs (tik or otherwise) are not the “demon”. If there is a demon, it is inequality and lack of opportunity.</p>
<p>Not only does inequality lead to increased levels of drug use, but it also significantly increases the consequences. Drug users from the privileged (usually white) communities around the globe suffer far fewer consequences related to drug use than the economically marginalised (usually black or other-than-white) communities. Michelle Alexander describes the “war on drugs” as a form of racial control in her <a href="http://newjimcrow.com/">book</a> “The new Jim Crow: Mass incarceration in the age of colorblindness”.</p>
<h2>Apartheid-style policing</h2>
<p>In South Africa the “war on drugs” is still used to justify continued <a href="https://www.opensocietyfoundations.org/voices/south-africa-still-fighting-apartheid-drug-war">apartheid-style policing</a>. In many township schools pupils who test positive for cannabis are immediately suspended, increasing their risk. Police <a href="http://www.news24.com/SouthAfrica/News/disorganised-police-search-at-gugulethu-school-leaves-mec-disillusioned-20160512">conduct raids</a> with <a href="http://www.dailysun.co.za/News/National/Police-didnt-find-drugs-20150824">sniffer dogs</a>. Random searches are common, and the <a href="http://www.groundup.org.za/article/police-clampdown-gangs-gets-mixed-reactions/">approach</a> to complex social issues is primarily a criminal justice one. When caught, people from these communities are arrested and criminalised. They are not sent to R1000-a-day (approximately $75) rehabs like many of the more privileged drug users.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/134946/original/image-20160822-18737-1685qmr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/134946/original/image-20160822-18737-1685qmr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134946/original/image-20160822-18737-1685qmr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134946/original/image-20160822-18737-1685qmr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134946/original/image-20160822-18737-1685qmr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134946/original/image-20160822-18737-1685qmr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134946/original/image-20160822-18737-1685qmr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Luvo Manyonga competes in the men’s long jump final at the IAAF World Championships in 2011.</span>
<span class="attribution"><span class="source">Pawel Kopczynski/Reuters</span></span>
</figcaption>
</figure>
<p>If, like many of his peers, Manyonga had been caught by police it is doubtful he would have competed again. People would have dismissed him as a victim of “addiction”. But that would not be true. As the <a href="http://www.drugfreesport.org.za/wp-content/uploads/2012/12/Manyonga.pdf">ruling</a> made after his failed 2012 drug test by the South African Institute for Drug Free Sport notes: “He is a product of an impoverished background.” It goes on to say: “ASA (<a href="http://www.athletics.org.za/">Athletics South Africa</a>) and <a href="http://www.sascoc.co.za/">Sascoc</a> (South African Sports Confederation and Olympic Committee) have failed in their duty to support the athlete.” It continues:</p>
<blockquote>
<p>Although funds have been made available to the athlete for purposes of participation, this in itself is not sufficient to provide a sound basis for a young athlete to manage a lifestyle that he is not accustomed to. He is young and immature and whilst he has needed professional guidance, these institutions have failed him. </p>
</blockquote>
<p>In a similar way society has failed the majority of the people who live in the same circumstances.</p>
<p>But Manyonga was fortunate. He overcame his circumstances because he had a talent and that <a href="http://mg.co.za/article/2014-07-31-the-impossibility-of-loving-luvo">motivated some people</a> to invest time and money in him. First Mario Smith, an athletics coach from Stellenbosch, spotted him and nurtured his talent. Then, even though things were not going well, John McGrath, a former Irish rower-turned conditioning coach, took “a punt”, and kept going even after Smith was killed in a car accident and Manyonga couldn’t even find a sponsor for spikes. Eventually Sascoc president Gideon Sam stepped in to right some of the previous wrongs and helped Manyonga secure a place at the <a href="http://www.up.ac.za/high-performance-centre">High Performance Centre</a> in Pretoria, far from the chaos of his home of Mbekweni township.</p>
<p>Neuroscientist <a href="http://www.memoirsofanaddictedbrain.com/books/#bod">Marc Lewis</a>, writing in his book “The Biology of Desire”, describes how we should approach helping people resolve their habitual drug use: “What they need is sensitive, intelligent social scaffolding to hold the pieces of their imagined future in place – while they reach toward it.” </p>
<p>This is exactly what Smith and McGrath did. They gave a future champion the image of himself as a future champion. And they nurtured him through good and bad. And now it has paid dividends. From this we could learn a lot about how our current policies and structures contribute to the burden of drug use in our communities.</p>
<p>But that is not the real story. To reduce Manyonga’s achievements to a victory over the imagined demon of drugs is to devalue his immense talent and the vital role that those who have helped him played. </p>
<p>More importantly it is to fail to appreciate a set of broader policies and structural barriers that marginalise so many people to the extent that many people have, as McGrath noted, only two choices: Jump or die. And we know that very few have the talent to jump like Manyonga.</p><img src="https://counter.theconversation.com/content/64244/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shaun Shelly receives funding from Open Society Foundations, AmfAR, INPUD and Mainline. He is affiliated with the Addictions Division at the Department of Psychiatry and Mental Health at the University of Cape Town and is the Projects, Policy, Advocacy and Human Rights Manager at TB/HIV Care Association.</span></em></p>A South African Olympic silver medallist achieved something remarkable, especially after testing positive for methamphetamine use in 2012. But care needs to be taken in how this narrative is framed.Shaun Shelly, Addiction Division, Department of Psychiatry and Mental Health, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.