tag:theconversation.com,2011:/us/topics/drug-misuse-7710/articlesDrug misuse – The Conversation2023-11-03T02:51:53Ztag:theconversation.com,2011:article/2167362023-11-03T02:51:53Z2023-11-03T02:51:53ZWhen Oregon decriminalised drugs, overdoses went up. Will that happen in the ACT?<figure><img src="https://images.theconversation.com/files/557192/original/file-20231101-27-2zu0r.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5806%2C3687&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>A <a href="https://www.abc.net.au/news/2023-10-28/canberra-drug-decriminalisation-laws-begin-today/103032128">new bill</a> came into effect in the ACT at the weekend decriminalising personal possession of common illegal drugs. </p>
<p>The bill decriminalises the possession of <a href="https://www.health.act.gov.au/about-our-health-system/population-health/drug-law-reform#:%7E:text=The%20reforms%20aim%20to%20divert,of%20paying%20a%20%24100%20fine.">small amounts of illicit drugs</a>, including cocaine, methamphetamine, MDMA, LSD, psilocybin (magic mushrooms) and heroin for personal use.</p>
<p>Critics of the move say when similar laws were brought into effect in the US state of Oregon, overdose deaths went up. However, there was already an upward trend, and Oregon now has lower rates of death from overdose than most other US states. </p>
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<a href="https://theconversation.com/drugs-could-soon-be-decriminalised-in-the-act-heres-why-that-would-be-a-positive-step-157709">Drugs could soon be decriminalised in the ACT. Here's why that would be a positive step</a>
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<h2>Remind me again, what does decriminalisation mean?</h2>
<p>Decriminalisation isn’t legalisation. With decriminalisation, <a href="https://adf.org.au/talking-about-drugs/law/decriminalisation/overview-decriminalisation-legalisation/">drugs are still illegal</a>, but the criminal penalties are removed. Instead, they usually attract a fine, a bit like a speeding fine.</p>
<p>The ACT will be the first Australian jurisdiction to decriminalise common illegal drugs. In this model, people will be diverted from police to <a href="https://www.health.act.gov.au/about-our-health-system/population-health/drug-law-reform#:%7E:text=The%20reforms%20aim%20to%20divert,of%20paying%20a%20%24100%20fine.">attend a one-off health information session</a> where a health worker assesses their wellbeing and the need for support or intervention. They provide education and harm-reduction information and make referrals to other services if needed.</p>
<p>Police will still confiscate illicit drugs they find on people. Drug dealing and trafficking are still criminal offences.</p>
<p>This system means people who are caught with small amounts of some drugs will be diverted away from the criminal justice system. Contact with the criminal justice system is one of the <a href="https://www.smh.com.au/national/nsw/coroner-compares-drug-prohibition-laws-to-racism-20181104-p50dwj.html">biggest harms</a> from illicit drugs. </p>
<p>There’s no evidence enforcement-led solutions to personal drug use reduce use or harms. But having a criminal record can have a long-term impact on getting a job or secure housing, which can then increase the likelihood of further drug use. Current punishments in many states and territories include a possible prison sentence. </p>
<p>Policing of drug laws, and the justice system itself, disproportionately impacts Aboriginal people and other people of colour. Young people have been described as being traumatised and dehumanised by the use of <a href="https://rlc.org.au/news-and-media/rlc-media/abuse-power-needs-stop-why-drug-dogs-and-strip-searches-just-dont-work">drug dogs and strip searches</a> by police.</p>
<p>The change is supported by <a href="https://preventionconversation.org/wp-content/uploads/2018/07/ccsa-decriminalization-controlled-substances-policy-brief-2018-en.pdf">decades of research</a> and backed by major health and human rights organisations, such as the <a href="https://www.theverge.com/2014/7/17/5913057/world-health-organization-drugs-narcotics-legalization">World Health Organization</a>, <a href="https://www.drugpolicy.org.au/un_supports_decriminalisation_of_drugs">the United Nations</a> and the <a href="https://www.unaids.org/en/topic/decriminalization">Joint United Nations Programme on HIV/AIDS</a>.</p>
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Read more:
<a href="https://theconversation.com/our-drugs-policies-have-failed-its-time-to-reinvent-them-based-on-what-actually-works-69984">Our drugs policies have failed. It's time to reinvent them based on what actually works</a>
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<h2>Where else has decriminalised drugs?</h2>
<p>We know from other jurisdictions that decriminalisation reduces harms from drugs and increases seeking help. <a href="https://transformdrugs.org/blog/drug-decriminalisation-in-portugal-setting-the-record-straight">Portugal</a> is the most well-known case. It decriminalised all drugs more than 20 years ago and has seen significant reductions in drug deaths, crime and drug use.</p>
<p>But critics in Australia are concerned about the possible negative outcomes, pointing to problems in Oregon. The federal opposition unsuccessfully introduced a bill to <a href="https://www.abc.net.au/news/2023-10-19/senator-michaelia-cash-fails-to-overthrow-act-drug-laws/102995412#">overturn the ACT legislation</a>.</p>
<p>In November 2020, Oregon passed <a href="https://www.oregon.gov/oha/hsd/amh/pages/measure110.aspx">Measure 110</a>, which decriminalised the possession of small amounts of drugs for personal use. Instead of criminal charges, people are now given a US$100 (A$155) fine for possession, which is waived if they contact a support hotline. </p>
<p>After Portugal decriminalised personal drug use in 2001, there was a <a href="https://transformdrugs.org/blog/drug-decriminalisation-in-portugal-setting-the-record-straight">drop in drug-related deaths</a>.</p>
<p>In the two years after Measure 110 passed, opioid overdose deaths in Oregon <a href="https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/quarterly_opioid_overdose_related_data_report.pdf">more than doubled</a>.</p>
<h2>Why did this happen in Oregon?</h2>
<p>The purpose of decriminalisation is merely to reduce one of the biggest harms from illicit drugs: contact with the criminal justice system. It has certainly <a href="https://www.sciencedirect.com/science/article/pii/S0955395923002025?via%3Dihub">achieved that in Oregon</a>, especially among Black Americans, who are over-represented in the criminal justice system.</p>
<p>In the year before Measure 110 was passed, overdose deaths in Oregon were <a href="https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/quarterly_opioid_overdose_related_data_report.pdf">already on the increase</a>, up 69% on the previous year. Oregon was ranked <a href="https://sos.oregon.gov/audits/Documents/2023-03.pdf">second-highest</a> of all US states for substance use disorders, and ranked <a href="https://sos.oregon.gov/audits/Documents/2023-03.pdf">last</a> of 50 states for access to treatment. </p>
<p>Decriminalisation on its own isn’t intended to directly reduce use or overdoses. Portugal’s success in reducing use and other harms, such as overdoses, is likely more to do with the significant investment in treatment and support. And as Oregon continues the roll-out of treatment program funding, there are indications 2023 overdose death rates have come down, tracking at <a href="https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SUBSTANCEUSE/OPIOIDS/Documents/quarterly_opioid_overdose_related_data_report.pdf">half the rate</a> of the year before.</p>
<p>Oregon’s overdose death rate is now one of <a href="https://drugabusestatistics.org/drug-overdose-deaths/#oregon">the lowest</a> in the <a href="https://www.beckershospitalreview.com/rankings-and-ratings/states-ranked-by-drug-overdose-death-rate.html">United States</a>.</p>
<p>We know treatment is the most effective and cost-effective way to reduce use and harms. A study in California found for every $1 spent on drug treatment, the <a href="https://pubmed.ncbi.nlm.nih.gov/16430607/">community saved</a> $7 in other costs, primarily by reducing crime and increasing employment earnings.</p>
<p>Decriminalisation needs to be supported by treatment, support and evidence-based harm reduction measures, such as access to naloxone and drug checking.</p>
<p>Naloxone has been available for free with no prescription since July 2022 in Australia, and the <a href="https://www.health.gov.au/our-work/take-home-naloxone-program">Take Home Naloxone program</a> will increase the availability of naloxone Australia-wide.</p>
<p>The Queensland government has given <a href="https://statements.qld.gov.au/statements/97250">drug checking services</a> the green light to start operating, and Canberra’s fixed-site drug checking service has been <a href="https://www.health.act.gov.au/about-our-health-system/population-health/pill-testing">extended</a> until December 2024. The service checked nearly <a href="https://directionshealth.com/wp-content/uploads/2023/10/CanTEST-Summary_Month-12-2-1.pdf">1,200 samples</a> for their contents and provided more than <a href="https://directionshealth.com/cantest-health-drug-checking-service/">1,500 brief interventions</a> in the first 12 months.</p>
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Read more:
<a href="https://theconversation.com/we-cant-eradicate-drugs-but-we-can-stop-people-dying-from-them-54636">We can't eradicate drugs, but we can stop people dying from them</a>
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<h2>Will drug decriminalisation work in the ACT?</h2>
<p>The ACT is Australia’s most progressive jurisdiction when it comes to drug laws. It <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/Evaluation%20of%20the%20Australian%20Capital%20Territory%20Drug%20Diversion%20Programs.pdf">removed criminal penalties from cannabis</a> possession more than 30 years ago, and in 2019 it introduced a “<a href="https://theconversation.com/home-grown-cannabis-to-be-legal-in-the-act-now-what-124268">home grown</a>” model, removing all penalties for the use and possession of small amounts of homegrown cannabis for personal use. </p>
<p>It has the <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data?&page=1">lowest rate of cannabis use</a> in Australia. There has been no change in rates of cannabis use, drug driving offences or hospital presentations, and there has been a significant reduction in the number of Canberrans being exposed to the police and criminal justice system. </p>
<p>Ultimately, we won’t know the full impact of decriminalisation in the ACT until the bill has been implemented for some time. But evidence from places such as Portugal says it will increase diversion from the criminal justice system, improve access to treatment and harm reduction, and reduce stigma towards people who use drugs. To significantly reduce drug use itself, the ACT also needs to increase investment in drug treatment.</p>
<p><em>If you are worried about your own or someone else’s alcohol or other drug use, you can contact the National Alcohol and other Drug Hotline on 1800 250 015 for free, confidential advice.</em></p>
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Read more:
<a href="https://theconversation.com/as-many-states-weigh-legalising-cannabis-heres-what-they-can-learn-from-the-struggles-of-growers-in-canberra-212009">As many states weigh legalising cannabis, here's what they can learn from the struggles of growers in Canberra</a>
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<img src="https://counter.theconversation.com/content/216736/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee is CEO at Hello Sunday Morning and also 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>Overdose deaths did go up in Oregon after drug decriminalisation, but they were already increasing, as they were in nearby states.Nicole Lee, Professor at the National Drug Research Institute (Melbourne), Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1761832022-02-28T14:00:23Z2022-02-28T14:00:23ZDeath from nitrous oxide and other volatile substances – latest official data<p>Drugs such as cocaine and cannabis are seldom out of the headlines, but it is <a href="https://theconversation.com/volatile-substance-abuse-a-problem-that-never-went-away-101215">rare to read</a> about another class of drugs - volatile substances. Volatile substances <a href="https://www.re-solv.org/volatile-substance-abuse/">cover a range</a> of gases and chemicals that are commonly found in legal household products. Many people will be familiar with nitrous oxide (laughing gas), but these substances also include butane, glue and alkyl nitrites (poppers). </p>
<p>Once inhaled, they are quickly absorbed through the lungs into the bloodstream, passing to the brain. As central nervous system depressants they produce <a href="https://theconversation.com/criminalising-nitrous-oxide-users-is-no-laughing-matter-if-it-distracts-from-more-serious-drug-problems-167297">intoxicating effects</a> that last only a few minutes. This can range from euphoria to less welcome visual or auditory hallucinations.</p>
<p>A <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/deathsrelatedtovolatilesubstancesheliumandnitrogeninenglandandwales/2001to2020registrations">new report</a> from the Office for National Statistics reveals that these substances are not completely benign. Between 2001 and 2020, 716 people in England and Wales died as a result of using volatile substances. </p>
<p>While the annual rate of death has remained stable at 36 people a year, what is striking is the rise in the average age of fatalities, from 28 years old in 2001 to 46 in 2020. The majority (78%) of these are male. </p>
<p>Although we don’t know why there has been a rise in the average age of death, it is possible that, as with drugs like heroin, there is an ageing cohort of users. And like those using heroin, this older group often has complicating physical health problems such as respiratory or heart-related problems that increase their risk of dying.</p>
<p>Although nitrous oxide was recorded in 56 deaths between 2001 and 2020, and is currently subject to government review potentially ahead of <a href="https://theconversation.com/criminalising-nitrous-oxide-users-is-no-laughing-matter-if-it-distracts-from-more-serious-drug-problems-167297">further legal controls</a>, it is gases such as butane and propane that are the most commonly recorded on death certificates, accounting for 324 and 123 deaths respectively during the same period. </p>
<p>Both are found in lighter fuels and some aerosols. The <a href="https://www.re-solv.org/volatile-substance-abuse/butane-and-other-gases/">most common risks</a> from exposure to these gases is from choking or asphyxiation or from heart failure referred to as <a href="https://www.drugrehab.com/addiction/drugs/inhalants/sudden-sniffing-death-syndrome/">sudden sniffing death syndrome</a>.</p>
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<img alt="Discarded nitrous oxide canisters and the balloons used to 'huff' them." src="https://images.theconversation.com/files/448882/original/file-20220228-19-10b7iw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/448882/original/file-20220228-19-10b7iw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/448882/original/file-20220228-19-10b7iw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/448882/original/file-20220228-19-10b7iw3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/448882/original/file-20220228-19-10b7iw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/448882/original/file-20220228-19-10b7iw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/448882/original/file-20220228-19-10b7iw3.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">Laughing gas (nitrous oxide) can kill.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/nitrous-oxide-canisters-cream-puff-chargers-1492734482">Lois GoBe/Shutterstock</a></span>
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<h2>Misperception</h2>
<p>A popular perception is that the use of volatile substances as drugs largely ceased in the 1980s, <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/datasets/drugmisuseinenglandandwalesappendixtable">but surveys</a> of population drug use suggest otherwise. Volatile substances are second only in popularity to cannabis <a href="https://digital.nhs.uk/data-and-information/publications/statistical/smoking-drinking-and-drug-use-among-young-people-in-england/2018#resources">in schoolchildren</a>. They are also more likely to be used at much earlier ages, which is a risk factor for more problematic substance use in later adolescence.</p>
<p>Nearly one in ten people aged 16-24 years old reported using nitrous oxide in the year up to March 2020 – the last year that data is available because of the pandemic. This compares with one in 50 adults aged 16-59. Unfortunately, despite concerns about use in children, data on the use of other volatile substances such as glue and aerosols is not routinely reported in older age groups.</p>
<p>Given how widely available these volatile substances are, and their use in everything from baking equipment to DIY, restricting access to those who might misuse them is difficult. As volatile substances are marked for household or industrial purposes, they are readily available for the adult population. However, the supply for intoxicating purposes (except for alkyl nitrites) is an offence under the <a href="https://www.re-solv.org/wp-content/uploads/2019/06/APPG-Report-on-NPS-VSA.pdf">Psychoactive Substances Act 2016</a>. Likewise, age-restricted sales of butane lighter fuel for any purpose is controlled under the Cigarette Lighter Refill (Safety) Regulations 1999. </p>
<p>But health promotion campaigns offer some hope. Analysis of an earlier UK Department of Health campaign in February 1992, which was aimed at parents warning them of the dangers of misusing volatile substances, appears to have had some <a href="https://www.re-solv.org/wp-content/uploads/2016/02/VSA-annual-report-no22.pdf">effect on fatalities</a>. At the time, there was an estimated 62% fall in deaths related to these substances following the campaign.</p>
<p>However, with new products on the market, and the rise in popularity of nitrous oxide, these campaigns need to be updated. Despite the clear harms, there has been little in the way of official public health activity regarding these substances. </p>
<h2>Up-to-date campaigns are needed</h2>
<p>The recent <a href="https://www.gov.uk/government/publications/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives">UK Drug Strategy</a> makes no specific mention of these compounds, nor does the <a href="https://www.gov.uk/government/publications/misuse-of-illicit-drugs-and-medicines-applying-all-our-health/misuse-of-illicit-drugs-and-medicines-applying-all-our-health#taking-action">updated guidance</a> to health professionals and others who might come into contact with people who use drugs.</p>
<p>Although drugs education forms part of the statutory <a href="https://www.gov.uk/government/publications/relationships-education-relationships-and-sex-education-rse-and-health-education">health education</a> delivered in English schools, there is no mention of volatile substances in the official <a href="https://www.gov.uk/government/publications/teacher-training-drugs-alcohol-and-tobacco">training materials</a> for teachers from the Department for Education. It is left to charities such as the <a href="https://pshe-association.org.uk/drugeducation">PSHE Association</a> and <a href="https://www.re-solv.org/">Re-Solv</a> to provide resources and activities for schools to address these substances.</p>
<p>There is also a concern that not only are deaths from volatile substances under-recorded, but due to the <a href="https://www.emerald.com/insight/content/doi/10.1108/DAT-08-2018-0039/full/html?casa_token=V3sO5yvlTLUAAAAA:6_IxBtBOsuGTznLlGQ-MLMROmYpkAZfPbndaVgKptHmBFFfiAT_gqZEVctbrzGURqH3nrdVm1SYhZfb_6BQujCglnnwZgE2UKIXnaIfT-d0vd7f7okfocQ">stigma associated</a> with using substances like glue and lighter fluid, even within people who take drugs, those that develop problems are not seeking treatment. </p>
<p>These substances are rarely asked about when someone does present to services, and there are workforce issues in drug services generally, with high caseloads, and training that is orientated towards drugs such as heroin and crack cocaine. This means that even if someone does decide to seek support, then workers may not have the necessary skills to support them. There is a risk that none of the <a href="https://www.gov.uk/government/news/largest-ever-increase-in-funding-for-drug-treatment">recently announced</a> increases in funding for drug services will be spent on developing activities to help people experiencing problems with volatile substances. </p>
<p>The most pressing need is for government, education and health agencies to recognise the problem. The average number of deaths related to volatile substances has not decreased over the last 20 years, and, without action, this trend will continue. Unlike other drugs, data on volatile substance deaths, hospitalisations, and treatment episodes are rarely reported, with this new report being something of a rarity. </p>
<p>A renewed public health campaign about the risks of using these substances should be accompanied by advice on how to reduce the potential risks. It may seem counter-intuitive to provide information on how to minimise harm when using these substances, but it could save lives.</p><img src="https://counter.theconversation.com/content/176183/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. He is an unpaid member of the Scientific Advisory Board of the Mind Foundation, and a former unpaid member of the UK Government Advisory Council on the Misuse of Drugs.</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>In 2001, the average age of death from a volatile substance was 28. By 2020, it had risen to 46.Ian Hamilton, Associate Professor of Addiction, University of YorkHarry Sumnall, Professor in Substance Use, Liverpool John Moores UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1242682019-09-26T09:47:35Z2019-09-26T09:47:35ZHome grown cannabis to be legal in the ACT. Now what?<figure><img src="https://images.theconversation.com/files/294268/original/file-20190926-51438-173mape.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C3866%2C2550&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Two cannabis plants per person and four per household will be legal in the ACT from January 31.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/J5UEdHgixEE ">Esteban Lopez/Unsplash</a></span></figcaption></figure><p>The Australian Capital Territory took the next step towards regulation of the illicit drug market yesterday with <a href="https://www.abc.net.au/news/2019-09-25/act-first-jurisdiction-to-legalise-personal-cannabis-use/11530104">new legislation</a> passing through parliament. </p>
<p>The <a href="https://www.legislation.act.gov.au/b/db_59295/">legislation</a>, which won’t come into effect until January 31, 2020, allows cultivation and possession of small amounts of cannabis for personal use for anyone over 18 years.</p>
<p>However, the sale or supply of cannabis is still a criminal offence.</p>
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<a href="https://theconversation.com/legal-highs-arguments-for-and-against-legalising-cannabis-in-australia-95069">Legal highs: arguments for and against legalising cannabis in Australia</a>
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<h2>What happens now?</h2>
<p>The ACT has historically been one of the more liberal jurisdictions when it comes to cannabis.</p>
<p>The territory removed criminal penalties for possessing small quantities of cannabis in <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp0102/02RP06#legislative">1992</a> and broadened this in 2013. Currently, anyone found in possession of less than 50g of dried cannabis receives a “<a href="https://police.act.gov.au/safety-and-security/alcohol-and-drugs/drugs-and-law">simple cannabis offence notice</a>”, essentially a fine.</p>
<h2>What changes next year?</h2>
<p>The new legislation allows adults to grow cannabis plants at home, with limits of two plants per person and four per household, or to possess 50g of dried cannabis.</p>
<p>Cannabis plants can only be cultivated in parts of someone’s home not generally accessible by the public, and only by people who usually live there.</p>
<p>There is a 150g limit for fresh (or “wet”) cannabis to account for cannabis that has been harvested but not yet dried.</p>
<p>The law allows adults to possess cannabis within these limits without the need for a cannabis offence notice to be issued.</p>
<h2>What safeguards are in place?</h2>
<p>The legislation states cannabis must be kept securely when not in someone’s possession to restrict access by children and young people. Smoking cannabis near children is also an offence.</p>
<p>To protect the interests of children and young people, the simple cannabis offence notice still applies for people under 18. This puts it in line with the way possession of tobacco and alcohol by people under the age of 18 is dealt with.</p>
<p>There are still questions about how this law interacts with stricter Commonwealth laws governing banned drugs, with <a href="https://www.theguardian.com/australia-news/2019/sep/26/peter-dutton-cannabis-christian-porter-challenge-act-law-legalise-drugs">some MPs</a> warning about possible conflicts.</p>
<h2>How does this compare with similar regulation overseas?</h2>
<p>Cannabis <a href="https://adf.org.au/insights/cannabis-legalisation/">regulation</a> comes in many forms internationally. The most common model allows the legal sale or supply of cannabis to adults, with further allowances for home grown plants. </p>
<p>The ACT’s allowance of four plants per household is on par with what other jurisdictions allow internationally. However, the ACT’s allowable weight of possessed cannabis is on the lower scale.</p>
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<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>
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<p>Some jurisdictions in Europe allow “<a href="https://transformdrugs.org/cannabis-social-clubs-in-spain-legalisation-without-commercialisation/">cannabis social clubs</a>”, which are a version of a “home grown” model. These are not-for-profit collectives where cannabis is grown and used. Cannabis is not sold. The clubs are only open to members, who own their own plants, and limits to the number of plants per person apply. </p>
<h2>What will the changes achieve?</h2>
<p>Removing offences associated with personal use of cannabis <a href="https://theconversation.com/decriminalisation-or-legalisation-injecting-evidence-in-the-drug-law-reform-debate-6321">reduces the burden on police and the criminal justice system</a>. It also removes the negative consequences associated with criminal convictions for drug use.</p>
<p>Most Australians support the <a href="https://theconversation.com/most-australians-support-decriminalising-cannabis-but-our-laws-lag-behind-99285">removal of criminal penalties</a> associated with cannabis use and possession, and a <a href="http://www.roymorgan.com/findings/6026-how-australians-feel-about-marijuana-201501272145">sizeable proportion</a> support legislation.</p>
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Read more:
<a href="https://theconversation.com/most-australians-support-decriminalising-cannabis-but-our-laws-lag-behind-99285">Most Australians support decriminalising cannabis, but our laws lag behind</a>
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<h2>How will it affect people’s interactions with health services?</h2>
<p>Criminalisation of use and possession of drugs reinforces the stigmatisation of people who use them, a <a href="https://pdfs.semanticscholar.org/ed7a/a83d5922415a60bbe1867f3310ace40fecd4.pdf">major barrier</a> to accessing health services. </p>
<p>The further we move away from the <a href="http://www.drugpolicy.org/issues/brief-history-drug-war">war on drugs</a>, the more illicit drug use becomes a health and human rights issue, potentially reducing stigma.</p>
<p>This law is unlikely to have a big impact on the health system. Most people who use cannabis <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/ndshs-2016-detailed/contents/table-of-contents">do so irregularly</a> and acute harms (such as overdoses or severe reactions) are rare.</p>
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Read more:
<a href="https://theconversation.com/men-and-women-use-cannabis-for-different-reasons-46745">Men and women use cannabis for different reasons</a>
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<p>Based on international evidence, full regulation <a href="https://ndarc.med.unsw.edu.au/sites/default/files/Ms%20Vivian%20Chiu%20-%20poster.pdf">does not result</a> in large increases in people using cannabis.</p>
<p>But, with reduced stigma, those who do may be more open to seeking help if their use starts to impact significantly on their day-to-day lives.</p>
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Read more:
<a href="https://theconversation.com/cannabis-and-psychosis-what-is-the-link-and-who-is-at-risk-95368">Cannabis and psychosis: what is the link and who is at risk?</a>
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<h2>Will it affect medical cannabis laws?</h2>
<p>Medical cannabis is treated under a completely <a href="https://www.tga.gov.au/access-medicinal-cannabis-products-1">separate law</a>, in line with other pharmaceutical products. So, the change in recreational cannabis laws do not effect medical cannabis prescribing in the ACT.</p>
<p>However, it is possible that under the new laws people will self-medicate rather than go through medical channels. So they may not have the appropriate medical monitoring of their condition.</p>
<h2>Will other jurisdictions follow?</h2>
<p>Each state and territory determines its own drug laws. Currently there is <a href="https://theconversation.com/australias-recreational-drug-policies-arent-working-so-what-are-the-options-for-reform-55493">significant variation</a> in both legal frameworks and implementation of laws in each jurisdiction. So, it is hard to tell whether other jurisdictions will follow. </p>
<p>Some <a href="https://www.theage.com.au/politics/victoria/fiona-patten-moves-to-legalise-cannabis-predicts-revenue-of-205m-20181219-p50n4t.html">Victorian politicians</a> have been advocating for cannabis legalisation, but this may be some way off. Reason Party leader Fiona Patten has successfully campaigned for a <a href="https://joy.org.au/theinformer/2019/05/30/new-cannabis-parliamentary-inquiry-to-start/">parliamentary inquiry</a> into cannabis to investigate the matter further.</p><img src="https://counter.theconversation.com/content/124268/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, NHMRC and other public funding bodies for alcohol and other drug research</span></em></p><p class="fine-print"><em><span>Jarryd Bartle works as a drug policy consultant for various organisations, which may financially benefit from the legalisation of cannabis.</span></em></p>What will the new legislation mean for cannabis users in the ACT? And will other jurisdictions follow?Nicole Lee, Professor at the National Drug Research Institute, Curtin UniversityJarryd Bartle, Sessional Lecturer in Criminal Law, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1223232019-09-09T04:41:00Z2019-09-09T04:41:00ZNew law gives NZ police discretion not to prosecute drug users, but to offer addiction support instead<figure><img src="https://images.theconversation.com/files/291367/original/file-20190908-175682-1t04qsr.jpg?ixlib=rb-1.1.0&rect=88%2C257%2C4812%2C2997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The new measures that give police discretion not to prosecute are in keeping with Prime Minister Jacinda Ardern's decision not to join US President Donald Trump's "war on drugs". </span> <span class="attribution"><span class="source">from www.shutterstock.com</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>New Zealand passed the <a href="http://www.legislation.govt.nz/bill/government/2019/0119/latest/LMS167550.html">Misuse of Drugs Amendment</a> into law last month, giving police discretion to take a health-centred approach rather than prosecuting those in possession of drugs, including class A drugs like methamphetamine, heroine and cocaine.</p>
<p>The new law also classifies two synthetic cannabinoids as class A drugs and allows for temporary drug class orders to be issued for emerging substances.</p>
<p>The <a href="https://www.drugfoundation.org.nz/policy-and-advocacy/drug-law-reform/?gclid=EAIaIQobChMIl63W2PWV5AIVCSQrCh0OPAPtEAAYASAAEgJn9_D_BwE">New Zealand Drug Foundation</a> hailed the amendment as “<a href="https://www.drugfoundation.org.nz/news-media-and-events/law-change-positive-step-toward-treating-drug-use-as-health-issue/">a massive leap</a>” towards treating drug use as a health issue, while the <a href="https://www.policeassn.org.nz/">New Zealand Police Association</a> argued that it would <a href="https://www.rnz.co.nz/news/national/388222/drug-law-change-goes-too-far-police-association">essentially decriminalise the possession of class A drugs</a>.</p>
<p>Drug use remains a criminal offence in New Zealand – police “discretion” not to prosecute is not tantamount to decriminalisation. I argue that the law change is a positive step towards a health and social response to drug use and misuse, so long as it doesn’t get lost in translation. </p>
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Read more:
<a href="https://theconversation.com/drug-laws-on-possession-several-countries-are-revisiting-them-and-these-are-their-options-121221">Drug laws on possession: several countries are revisiting them and these are their options</a>
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<h2>A ‘health-centred’ approach to drug policy</h2>
<p>The amendment requires police to use their discretion not to prosecute when they find someone in possession of an illicit drug for personal use. Police are directed to consider whether prosecution is required in the public interest or whether a health-centred approach would be more beneficial. </p>
<p>The law change is one of several related government initiatives. The <a href="http://www.legislation.govt.nz/bill/government/2017/0012/latest/DLM7518707.html">previous amendment</a>, passed in December 2018, enabled the development of a medicinal cannabis scheme and legal defence against prosecution for terminally ill patients. And a <a href="https://www.beehive.govt.nz/release/new-zealanders-make-decision-cannabis-referendum">referendum on recreational cannabis legislation</a> will be held in conjunction with the 2020 general election. </p>
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<strong>
Read more:
<a href="https://theconversation.com/potential-cost-to-patient-safety-as-nz-debates-access-to-medicinal-cannabis-120750">Potential cost to patient safety as NZ debates access to medicinal cannabis</a>
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<p>These measures are in keeping with Prime Minister Jacinda Ardern’s decision not to join US President Donald Trump’s “<a href="https://www.rnz.co.nz/news/political/367139/jacinda-ardern-rejects-trump-s-call-for-war-on-drugs">war on drugs</a>”. Instead, Ardern said New Zealand would pursue a “health-based” approach. </p>
<p>While driven in part by a shift in government policy, the amendment was also a response to the <a href="https://coronialservices.justice.govt.nz/assets/Documents/Publications/Chief-Coroner-2017-18-Annual-Report.pdf">chief coroner’s report</a> highlighting that 55 or more people died of synthetic cannabinoid drugs in the past two years. Two of the most dangerous of these, <a href="https://www.drugfoundation.org.nz/info/drug-index/synthetic-cannabinoids/">AMVB-FUBINACA and 5F-ABA</a>, have been reclassified as class A drugs. Provisions have been made for temporary class drug orders to control new and potentially harmful drugs.</p>
<p>This will mean increased investigative powers for police and heavier sentences for importers, manufacturers and dealers of these substances. It will also enable government to react quickly to emerging high-risk drugs. </p>
<h2>Criminalising drug use doesn’t work</h2>
<p>To support the new legislation, the government has increased <a href="https://www.health.govt.nz/our-work/mental-health-and-addictions/budget-2019-mental-health-wellbeing-and-addiction-initiatives">funding for addiction treatment services</a> and is establishing a <a href="https://www.health.govt.nz/our-work/regulation-health-and-disability-system/psychoactive-substances-regulation/synthetic-cannabis">multi-agency drug early warning system</a>. The amendment emphasises a health response to personal drug use. It applies to all classes of drug. </p>
<p>In practice, police already exercise discretion not to prosecute and have been doing so increasingly in recent years. Police charges for cannabis possession or use have <a href="https://www.justice.govt.nz/justice-sector-policy/research-data/justice-statistics/data-tables/#offence">fallen 70% in the past decade</a>. On the other hand, <a href="https://www.justice.govt.nz/assets/Documents/Publications/Factsheet-People-charged-with-drug-offending.pdf">drug offences</a> for methamphetamine possession or use have risen sharply. Last year, for the first time, they outnumbered cannabis charges.</p>
<p>Overall, thousands of people continue to be convicted each year for minor drug use or possession. These people are <a href="https://www.justice.govt.nz/assets/Documents/Publications/Factsheet-People-charged-with-drug-offending.pdf">disproportionately young and Māori</a>. </p>
<p>There is <a href="https://www.drugfoundation.org.nz/assets/uploads/Cost-benefit-analysis-drug-law-reform.pdf">no evidence that convicting and sentencing drug users reduces drug use</a> overall or benefits them individually. To the contrary, <a href="http://youthlaw.co.nz/rights/young-adults/work/convictions/">criminal convictions</a> often have adverse consequences for career and life opportunities. The <a href="https://www.health.govt.nz/publication/research-report-new-zealand-drug-harm-index-2016">costs</a> to the criminal justice system and taxpayer are considerable.</p>
<h2>Potential outcomes of the law change</h2>
<p>The devil is in the detail. Reduced fear of prosecution will probably lead more people with drug-related problems to seek professional help. Potentially thousands who come to police attention will avoid being prosecuted each year. Instead, many will receive treatment and other forms of support that change their lives in positive ways. </p>
<p>Police and the courts should be freed up to focus on serious drug-related offences and other crime. The proportion of Māori being sentenced and imprisoned should reduce. </p>
<p>But these outcomes depend greatly on how police exercise their discretion not to prosecute. A huge shift in police culture, mindset and professional skill is required. The outcomes presuppose that accessible, specialist addiction and support services are readily available. </p>
<p>The recent government <a href="https://mentalhealth.inquiry.govt.nz/">Inquiry into Mental Health and Addiction</a> noted severe strain on existing services and called for an expanded range of treatment and detox services. This depends not only on additional funding, but requires strong leadership and significant change in the size and composition of New Zealand’s addiction-related workforce. </p>
<p>The amendment’s other provisions should help address the devastating impacts of new substances. The rate of their development will most likely accelerate, and some may be as, or more, dangerous than AMVB-FUBINACA and 5F-ABA. The effectiveness of the multi-agency early warning system will be critical in rapidly identifying these drugs. </p>
<h2>The long road to ‘far-reaching’ drug reform</h2>
<p>While regarded as a significant step in the right direction, many see this and the December 2018 amendment falling far short of being a comprehensive health and social response to drug use and misuse. Both the <a href="https://www.lawcom.govt.nz/sites/default/files/projectAvailableFormats/NZLC%20R122.pdf">Law Commission</a> in 2011 and the <a href="https://mentalhealth.inquiry.govt.nz/">Inquiry into Mental Health and Addiction</a> in 2018 called for a complete rewrite of the <a href="http://www.legislation.govt.nz/act/public/1975/0116/latest/DLM436101.html">Misuse of Drugs Act (1975)</a>. </p>
<p>Drug use remains a criminal offence, even for terminally ill patients. Police discretion means that many people are still being arrested for possession and personal use of cannabis and other drugs. Māori could well continue to be unfairly targeted. </p>
<p>Many drug users are reliant on criminal gangs for supply. This both sustains gangs and other criminal operators, and brings users under the influence of dealers who can encourage progression to more harmful substances and criminal activity to sustain their drug use or addiction. </p>
<p>The upcoming referendum may in part address this in relation to cannabis. But more far-reaching reform will be required across the full spectrum of substances. In the interim, new measures will need to be carefully monitored and adapted to ensure that they conform with their intent.</p><img src="https://counter.theconversation.com/content/122323/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Max Abbott 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>A change to drug laws in New Zealand has been hailed as a leap towards treating drug addiction as a heath issue. But it has also been criticised for essentially decriminalising class A drugs.Max Abbott, Professor of Psychology and Public Health, AUT, Auckland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/562052016-03-25T09:40:38Z2016-03-25T09:40:38ZThe other opioid crisis – people in poor countries can’t get the pain medication they need<figure><img src="https://images.theconversation.com/files/116393/original/image-20160324-17840-1018h1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hard to get. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-244226398/stock-photo-morphine-sulfate-pills-with-bottle-and-prescription.html?src=6k1Q_GIQBxQ8258IRKLelw-1-3">Morphine pills image via www.shutterstock.com.</a></span></figcaption></figure><p>There are two opioid crises in the world today. One is the epidemic of abuse and misuse, present in many countries but rising at an <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">alarming rate in the United States</a>. The other crisis is older and affects many more people around the world each year: too few opioids. </p>
<p>Hospitals in the U.S. and Europe routinely prescribe opioids for chronic cancer pain, end-of-life palliative care and some forms of acute pain, like bone fractures, sickle cell crises and burns. But patients with these conditions in much of Asia, Africa and Latin America often receive painkillers <a href="http://www.nytimes.com/2007/09/09/world/africa/09iht-pain.4.7440327.html?_r=0">no stronger than acetaminophen</a>.</p>
<p>Many factors play into this crisis, but I would argue that the International Narcotics Control Board (<a href="https://www.incb.org/">INCB</a>), an independent monitoring agency established by the U.N., <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=10232633&fulltextType=RA&fileId=S089803061600004X">is a fundamental cause</a> of untreated pain in Asia, Africa and Latin America.</p>
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<img alt="" src="https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&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">A worker handles medicine in the Pharmacie de la Sante Publique warehouse in Abidjan, Ivory Coast. Opioid painkillers can be difficult to access in many parts of Africa.</span>
<span class="attribution"><span class="source">Thierry Gouegnon/Reuters</span></span>
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<h2>Just how vast is the gap in pain relief?</h2>
<p>In 2009, the U.S., Canada and Europe accounted for 18 percent of global population, but <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">90 percent</a> of global morphine consumption.</p>
<p><a href="https://ppsg.medicine.wisc.edu/">The global gap in access to opioids has been growing</a> for a long time. In the U.S., consumption of morphine in 2013 was 32 times higher than in 1964 (increasing from 2.3 mg per person to 79.9 mg per person). In the same time period, morphine consumption in Tanzania only doubled to 0.15 mg person. In India in 2013, this figure was only 0.11 mg per person.</p>
<p>Per capita medicinal opioid consumption in Asia, Central America, the Caribbean and Africa <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">is far below</a> the INCB’s own minimum global standard. In countries and regions below this benchmark (set at 200 daily doses per million inhabitants per day), we can be certain that patients who need opioids for legitimate medical reasons do not receive them.</p>
<p>The INCB argues that poor countries have too few opioids because they <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">cannot afford them</a>. While there is a correlation between national income and national consumption of opioids, cost isn’t the principal issue. </p>
<p>Generic opioids are cheap. A generic 10mg immediate-release morphine sulfate tablet costs roughly <a href="http://journals.lww.com/anesthesia-analgesia/Abstract/2007/07000/Pain_Management__A_Fundamental_Human_Right.37.aspx">US$0.01 to produce</a>.</p>
<p>The main problem, <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=10232633&fulltextType=RA&fileId=S089803061600004X">I would argue</a>, is a policy based on the fear that increased use of opioids will inevitably lead to abuse and trafficking. Palliative care physician and ethicist Eric Krakauer calls this fear “<a href="https://dx.doi.org/10.3109/15360288.2010.501852">opiophobia</a>.” </p>
<p>The work of the INCB has been crucial in increasing this fear of opioids and promoting restrictive policies that continue to keep millions of patients in unnecessary pain.</p>
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<img alt="" src="https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.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">
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<span class="caption">Morphine has legitimate medical uses.</span>
<span class="attribution"><span class="source">Vaprotan, via Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<h2>Fear of abuse drives ‘opiophobic’ policies</h2>
<p>The International Narcotics Control Board has two purposes: to prevent addiction and to ensure the availability of opioids for legitimate medical use. But since its founding in 1968, the INCB has focused almost entirely on combating drug abuse, while ignoring access to pain relief.</p>
<p>One way the INCB tried to prevent addiction was by writing so-called “model laws” that it encouraged countries to enact. One such <a href="https://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1969-01-01_2_page002.html">law</a>, written in 1969, set controls on opioid prescription and distribution that were manageable for wealthier countries, but that would prove onerous in poor countries, particularly those with few doctors.</p>
<p>The Model Law stated, for instance, that opioids could be supplied only by doctors. This provision did not affect access to opioids in the United States or in other wealthy nations with many physicians. But many poorer countries, where doctors were scarce, relied on nurses and other kinds of practitioners to prescribe drugs. The model law made no allowance for this.</p>
<p>In addition, the Model Law stated that physicians who prescribed opioids inappropriately or who failed to keep full records should be subject to “the same prison sentences and fines as are inflicted under the Penal Code for housebreaking.”</p>
<p>INCB laws were promoted by the United Nations Fund for Drug Abuse Control (<a href="https://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1971-01-01_2_page002.html">UNFDAC</a>), which was founded in 1970. The UNFDAC conducted training sessions for national drug-control administrators and law enforcement to stress the dangers of abuse. But, as I found in my research, the sessions rarely mentioned the importance of access to pain relief.</p>
<p>The model laws and training sessions helped inspire countries in Latin America, Asia and Africa to pass <a href="http://dx.doi.org/10.1017/S089803061600004X">new, more restrictive laws</a> during the 1970s and ‘80s. </p>
<p>For instance, in India, a 1985 law required hospitals to obtain so many licenses before each shipment of morphine that many stopped using the drug at all. Medicinal morphine consumption in India fell by 97 percent between 1985 and 1997. </p>
<p>In Panama, nurses were barred from prescribing opioids. Paraguay and Guinea-Bissau mandated long prison sentences for any doctor who could not produce documentation justifying every single pill prescribed over years of practice. Fearing these punishments, doctors avoided prescribing opioids, even when they were medically necessary.</p>
<h2>Countries underestimate opioid needs in response to INCB pressure</h2>
<p>The INCB also tried to prevent opioids prescribed to treat pain from being diverted into illegal markets by requiring every country to provide annual estimates of projected opioid needs for medical and scientific purposes. The INCB was responsible for approving these annual estimates, and tried to ensure that countries imported no more than the approved quantities. </p>
<p>Between the 1960s and the 1980s, <a href="https://books.google.com/books/about/Estimated_World_Requirements_of_Narcotic.html?id=O_8tAQAAIAAJ">INCB reports</a> chastised many nations in Africa, Asia and Latin America for making estimates that it considered too high.</p>
<p>A country that imported more opioids than the INCB had approved risked a costly stain on its international reputation. The INCB could even <a href="http://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1962-01-01_1_page007.html">recommend that countries impose trade embargoes</a> on nations that produced or imported more opioids than it had deemed necessary. As a result, countries low-balled their estimates of future medicinal opioid requirements.</p>
<p>But the INCB didn’t judge these estimates based on actual medical need. Rather, <a href="https://books.google.com/books/about/Estimated_World_Requirements_of_Narcotic.html?id=O_8tAQAAIAAJ">it insisted</a> estimates should be based on the number of physicians in a country, a potentially misleading piece of data in parts of the world were doctors are in short supply, and nurses and other health care professionals fill the gaps and prescribe medicine. </p>
<p>The INCB worried that too many opioid prescriptions could lead to abuse. Indeed, this is a major cause of the current addiction crisis in the United States. But, in the countries where the INCB exerted the greatest influence, the bigger problem was that too few (rather than too many) opioids were being prescribed.</p>
<p>A 1989 report from the INCB and World Health Organization revealed that national estimates of future opioid need were often calculated based <a href="https://www.ncjrs.gov/pdffiles1/Digitization/141719NCJRS.pdf">on nothing more than previous years’ imports</a>. That report also quantified the extent of untreated cancer pain, estimating that “at least 3.5 million cancer patients” worldwide “suffer needlessly from pain.” </p>
<h2>The INCB is starting to change, slowly</h2>
<p>For many years, the only thing most countries heard from the INCB was that their estimates were too high. But in 1999, <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">the INCB announced</a> it would begin to contact governments that submitted “particularly low estimates” to encourage them to increase their imports.</p>
<p>And in 2010, the INCB agreed that countries with few doctors should <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">allow nurses to prescribe morphine</a>, a reversal from previous policy recommendations. </p>
<p>But these small steps have not been enough to overcome the fear of opioids spread by decades of model laws and training sessions. The INCB’s recommendations continue to focus almost entirely on abuse.</p>
<p>For instance, a 2012 INCB <a href="https://www.incb.org/documents/Narcotic-Drugs/Guidelines/estimating_requirements/NAR_Guide_on_Estimating_EN_Ebook.pdf">report</a> stated that national requests to import opioids sufficient to address existing need might be denied if such imports might raise “the possibility of diversion or abuse.” </p>
<p>International meetings, especially the <a href="http://www.unodc.org/ungass2016/">United Nations Special Session on the World Drug Problem</a> in April 2016, should pay far more attention to untreated pain than they have in the past. </p>
<p>More recent estimates from the World Health Organization suggest that each year <a href="http://www.who.int/medicines/areas/quality_safety/ACMP_BrNote_Genrl_EN_Apr2012.pdf">5.5 million terminal cancer patients</a> and 1 million end-stage HIV/AIDS patients around the globe don’t get enough treatment, or any treatment at all, for their moderate to severe pain. The WHO estimates that tens of millions of people are denied medically necessary pain treatment every year.</p>
<p>Pain is universal, but its relief is still a function of geography.</p><img src="https://counter.theconversation.com/content/56205/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luke Messac 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>Why are so many people in dire need of pain relief unable to access the powerful painkillers that are so commonly prescribed in the United States?Luke Messac, M.D./Ph.D. student in History, University of PennsylvaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/500752015-11-12T19:20:32Z2015-11-12T19:20:32ZYou don’t have to go off the grid to get treatment for drug dependence<figure><img src="https://images.theconversation.com/files/101652/original/image-20151112-9374-zpl23l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Evidence-based drug treatments are relatively successful at reducing use and improving quality of life.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-329595416/stock-photo-mature-woman-discussing-problems-with-counselor.html?src=pp-same_model-329595437-9CTx2p4rAJ1fyYCwfk1MMA-2&ws=1">SpeedKingz/Shutterstock</a></span></figcaption></figure><p>Every other week stories appear online and in the media about alternative “treatments” for drug dependence. <a href="http://www.smh.com.au/world/rock-im-a-drug-addict-and-other-cracking-rehab-admissions-in-kyrgyzstan-20151031-gkepee.html?skin=text-only">Rock therapy</a> in Kyrgyzstan and <a href="http://www.sbs.com.au/news/dateline/story/last-resort-rehab">vomit therapy</a> in Thailand are two recent examples. </p>
<p>Long <a href="http://nationaldrugstrategy.gov.au/internet/main/publishing.nsf/Content/699E0778E3450B0ACA257BF0001B7540/$File/Patient%20Pathways%20National%20Project.pdf">waiting lists</a> for drug treatment in Australia and a perception that drug treatments are ineffective may be driving people to seek solutions elsewhere. But these untested interventions are expensive at best and potentially dangerous at worst. </p>
<p>So what treatments <em>do</em> work for ice and other drug users?</p>
<h2>Not all drug users need treatment</h2>
<p>Different drugs have different dependence thresholds. For most drugs, infrequent, short-term users make up the larger group of people. They eventually stop without experiencing any significant problems.</p>
<p>For <a href="http://www.ncbi.nlm.nih.gov/pubmed/16723192">methamphetamine</a> (which includes ice and speed), using more than weekly is associated with dependence. Around <a href="http://www.aihw.gov.au/alcohol-and-other-drugs/ndshs-2013/">15% of people</a> who used methamphetamine in the past year fall into this category. </p>
<p>For <a href="http://onlinelibrary.wiley.com/doi/10.1046/j.1360-0443.2001.9657379.x/abstract">cannabis</a>, around 20% of people who have used in the past year are likely to be dependent. Around 4% of <a href="http://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/TR.097.pdf">drinkers</a> are dependent. </p>
<p>This means that 85% of methamphetamine users, 80% of cannabis users and 96% of drinkers are probably not dependent and are unlikely to need treatment. </p>
<p>Those who are not dependent are still at risk of unwanted side effects and overdose. Harm-minimisation strategies are designed to keep this group, and the community, as safe as possible while they continue to use. Measures include police random breath testing, drug checking (testing the content of drugs) and needle and syringe programs.</p>
<p>Methamphetamine users also commonly experience mental health problems such as transient psychosis (25%) or symptoms of depression (80%). </p>
<p>This group may not be willing, or need, to access drug treatment but may seek help for their mental health symptoms through their GP or other health service. Addressing mental health symptoms can encourage users to <a href="http://www.emeraldinsight.com/doi/abs/10.1108/17570971211225145">seek help</a> for their drug use earlier.</p>
<h2>What works for those who need treatment?</h2>
<p>The goal of treatment for alcohol or other drug dependence is to reduce use and to improve quality of life. According to the National Institute of Drug Abuse (NIDA) in the United States, people who enter and remain in treatment reduce their use of alcohol or other drugs, are less involved in criminal activity and have better general functioning. </p>
<p>There are also <a href="http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/how-effective-drug-addiction-treatment">cost savings</a> to the community through better health and reduced crime.</p>
<p>For those people who use alcohol or other drugs and need treatment there are a number of effective options. The <a href="http://psychology.org.au/Assets/Files/Evidence-Based-Psychological-Interventions.pdf">Australian Psychological Society</a> has undertaken a review of psychological interventions for mental health conditions and found that <a href="http://www.aacbt.org/viewStory/WHAT+IS+CBT%3F">cognitive behaviour therapy</a> (CBT) has the best evidence for its effectiveness. </p>
<p>NIDA endorses a number of <a href="https://www.drugabuse.gov/publications/principles-drug-addiction-treatment/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies">treatments</a> as effective. Most fit within the group of behavioural and cognitive therapies.</p>
<p>For dependent heroin users and cigarette smokers, and to some extent dependent drinkers, <a href="http://www.drugabuse.gov/publications/principles-drug-addiction-treatment/evidence-based-approaches-to-drug-addiction-treatment/pharmacotherapies">drug therapies</a> are also effective. But for other drugs, medical treatments are generally limited to medicines to relieve symptoms of withdrawal or use such as mental health symptoms.</p>
<p>Drug dependence is a chronic health condition and relapse is likely along the road to recovery. The <a href="http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/how-effective-drug-addiction-treatment">overall relapse rate</a> is around 50% after one year. This is similar to relapse rates after treatment for other chronic health conditions, such as diabetes, hypertension and asthma. It is also similar to other mental health conditions such as <a href="http://www.australianprescriber.com/magazine/30/2/44/6">psychosis</a>, which has a reoccurrence rate of 70%, and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2169519/">depression</a> (50%).</p>
<p>The <a href="http://nationaldrugstrategy.gov.au/internet/main/publishing.nsf/Content/699E0778E3450B0ACA257BF0001B7540/$File/Patient%20Pathways%20National%20Project.pdf">Patient Pathways</a> study in Australia found that one year after treatment, about 40% of dependent users in treatment were abstinent, ranging from 60% (methamphetamine) to 28% (alcohol). However, continuous abstinence was harder to achieve, with only around 30% of people remaining abstinent for an entire year. </p>
<p>But not everyone who goes through drug treatment aims to be abstinent from drugs. Around 55% of people in treatment succeeded in making significant changes to their use.</p>
<p>A <a href="http://www.odysseyhouse.com.au/uploads/70255/ufiles/ATOS_11_year_bulletin_FINAL.pdf">follow-up of heroin users</a> who entered treatment found substantial reductions in heroin and other drug use, crime and injecting-related health problems. Reductions were still evident after two years and maintained after 11 years.</p>
<h2>When is treatment most effective?</h2>
<p>The idea that drug users need to hit “rock bottom” before recovery is possible is not supported by evidence. Many people make significant changes to their use well before they reach crisis point.</p>
<p><a href="http://pubs.niaaa.nih.gov/publications/arh23-2/086-92.pdf">Motivation</a> is important in the success of drug treatment, but part of the core skills expected of alcohol and other drug treatment professionals is the ability to increase motivation for engaging in treatment and reducing drug use. </p>
<p>In <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2005.01002.x/abstract">a study</a> of an intervention for methamphetamine users, which included a motivational component, more than a third of people entering the study were not interested in changing their drug use. But their outcomes were similar to those who were motivated at the beginning of treatment and both groups showed increased abstinence.</p>
<p>Mandated treatment programs, such as court diversion or <a href="http://www.aic.gov.au/criminal_justice_system/courts/specialist/drugcourts.html">drug court</a> programs, also show that people who are ordered to treatment through the justice system do well once they get there.</p>
<h2>What treatments are available in Australia?</h2>
<p>Specialist alcohol and other drug treatment services vary between states. </p>
<p>Publicly funded services are run by government and non-government organisations. These services are generally free or low cost to the consumer. They offer a range of options including outpatient counselling, group programs, rehabilitation day programs (typically six to 12 weeks), inpatient rehabilitation programs of typically between two and 12 months, and inpatient and outpatient detoxification. </p>
<p>The different treatment options show similar outcomes.</p>
<p>In the public sector, most people needing drug treatment choose <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551454">outpatient counselling</a>, which is the <a href="http://nationaldrugstrategy.gov.au/internet/main/publishing.nsf/Content/699E0778E3450B0ACA257BF0001B7540/$File/Patient%20Pathways%20National%20Project.pdf">least expensive</a> option. </p>
<p>Although self-help groups are considered peer support rather than treatment services per se, programs such as <a href="http://smartrecoveryaustralia.com.au/">SMART Recovery</a> and a range of 12-Step programs are widely available. These are usually run by consumers and peers at low or no cost.</p>
<p>Private services are also available in all states, both through hospitals – usually offering inpatient detoxification, inpatient stays of typically up to three months that include individual and group attendance – and private individuals, such as psychologists, psychiatrists and addiction medicine specialists. These services vary in cost, some of which may be claimable through Medicare and/or private insurance.</p>
<p>In Australia, government-funded services are expected to meet minimum standards of accreditation for health providers, and some states require minimum qualifications for practitioners. Private providers, such as hospitals, psychologists, nurses and medical professionals, may be required to meet certain professional standards for registration and accreditation. </p>
<p>However, many providers that offer drug and alcohol treatment, such as “counsellors” and “psychotherapists”, are unregulated. There are also no specific minimum requirements for establishing a private drug rehabilitation program. </p>
<p>Some use frameworks that are not consistent with the evidence. Very few have been independently evaluated. If considering treatment, it is important to check into any potential program to ensure it meets best practice standards.</p>
<p>Evidence-based treatments for drug use problems are available in Australia at low or no cost to consumers, but waiting lists can be long. Public investment in these treatment options for drug users is essential if we’re serious about improving access to and outcomes of treatment. </p>
<p>Innovation is important, but new and untested treatment programs should be subjected to well-conducted evaluation of outcomes to ensure they’re not only doing good but are also doing no harm.</p><img src="https://counter.theconversation.com/content/50075/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee works as a private consultant to health services and is the President and Board Chair of the Australian Association for Cognitive and Behaviour Therapy</span></em></p>Many untested drug therapies are expensive at best and potentially dangerous at worst. So what treatments do work for ice and other drug users?Nicole Lee, Associate Professor at the National Centre for Education and Training on Addiction, Flinders UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/188232013-11-05T01:48:49Z2013-11-05T01:48:49ZSome ways to balance the benefits and harms of opioids<figure><img src="https://images.theconversation.com/files/34219/original/x9tp7b3n-1383281846.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are some effective ways to balance the harms of opioids with its benefits.</span> <span class="attribution"><span class="source">strollerdos/Flickr</span></span></figcaption></figure><p>The use of opioid medication in Australia has grown considerably in the past 20 years, and so have related harms. This increase in use is <a href="https://www.mja.com.au/journal/2012/196/6/opioid-prescribing-australian-general-practice">primarily for chronic pain conditions</a>, now the most common reason for opioid prescription.</p>
<p>The use of the prescription opioid oxycodone <a href="http://www.ncbi.nlm.nih.gov/pubmed/21164159">has risen</a> by 152% in Victoria in the last decade, while hospitals attendances have doubled and <a href="http://injuryprevention.bmj.com/content/17/4/254.short">deaths have increased</a> 21-fold.</p>
<p>New South Wales hospital data suggests over half the opioid-related deaths in that state were among people who had chronic medical conditions and <a href="https://www.mja.com.au/journal/2011/195/5/prescription-opioid-analgesics-and-related-harms-australia?0=ip_login_no_cache%3D4c01b0ccfe4c7127e30259c52106a614">had been prescribed opioids</a> by their doctor. Under a third (27%) of these deaths were intentional overdoses. </p>
<p>People who suffer the harms of opioid medications come from a wide range of the population; from the troubled and dependant, to the elderly, who are at greater risk of mistakenly overusing medication.</p>
<p>While it’s important that we address people getting opioids from doctor-shopping or illegal sources, we also need to reduce harms in those who are prescribed opioids; to prevent misuse, monitor them for signs of psychological distress, and minimise medication errors.</p>
<h2>Opioids and chronic pain</h2>
<p>Opioids come in variety of forms, and can be used for a large number of medical issues. The most common reasons for use are acute injuries and chronic non-cancer pain conditions, which is the main reason for long-term use.</p>
<p>There are a number of problems with opioid use for chronic pain, the foremost of which is that we have scant evidence to support their <a href="http://www.ncbi.nlm.nih.gov/pubmed/19460051">long-term use</a>, even though we are well aware of their harms.</p>
<p>Chronic pain conditions are very complex; there’s no blood test or other kind of investigation to determine their existence. </p>
<p>Pain is a physical, psychological, and social illness, and other issues such as depression, substance dependence, and other chronic medical conditions are <a href="http://www.psychosomaticmedicine.org/content/68/2/262.short">more likely in people</a> who suffer from it. Chronic pain conditions often coexist with drug dependency, as a result of the constant physical and psychological suffering. </p>
<p>It would be inhumane to not give people with chronic pain an opportunity to trial medication that may help them feel and function better, but we need to be careful about managing harms. How then do we manage people with chronic pain effectively while limiting overuse?</p>
<h2>Shared responsibility</h2>
<p>Doctors need to ensure that patients benefit from opioid use. People at risk of forming a dependency or having an overdose shouldn’t be excluded from use but need to be monitored. A good way to do this is by providing a short-term trial while looking out for signs of risky behaviour. </p>
<p>There’s currently a permit system for opioids that places accountability solely on doctors for their supply. </p>
<p>Greater patient responsibility is important for providing people with a sense of control of their pain and the condition causing it. Having a contract between doctor and patient is important to establishing responsibility for the pain and treatment.</p>
<h2>Continuity of care</h2>
<p>The permit system also does little to enforce continuity of care, and is only required after eight weeks of use. Having a permit system that encompasses a trial phase and requires constant review by the same doctor can potentially foster this occurrence.</p>
<p>Continuity of care is vital. Right now, people are able to alternate between doctors, especially if they’re at the same clinic. Many people start off on what may initially be a trial of opioid medications, end up with an endless supply as they float between doctors. </p>
<p>Having a regular doctor allows insight into the story behind the pain, allows monitoring for signs of dependence or overuse, or to realise the treatment isn’t helping and cease its use.</p>
<p>Alcohol intake, use of other medications, and social problems may also not be known to a new doctor, even though these are significant factors in overdose.</p>
<h2>Monitoring and education</h2>
<p>Adverse events are not just the result of misuse, they can happen because of drug interactions and medication errors as well, especially in the elderly. </p>
<p>It’s vital that people getting a prescription for opioids have information about the drugs explained to them. And that doctors are aware of any difficulties with information uptake or other related issues, such as the inability to read dosing on the pack. </p>
<p>Education and continuity of care are strongly linked, and allow medication use to be monitored and reinforced.</p>
<p>It’s impossible to negate all the risks of opioid use, and misuse and addiction will continue to occur. But good management can both limit the need for these medications and prevent their misuse. </p>
<p>These are not just exercises in risk minimisation, but positive acts to treat chronic pain conditions more effectively. </p><img src="https://counter.theconversation.com/content/18823/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Grant was previously was employed as a Pharmacovigillance Physician at MSD, but has no ongoing relationship.</span></em></p>The use of opioid medication in Australia has grown considerably in the past 20 years, and so have related harms. This increase in use is primarily for chronic pain conditions, now the most common reason…Matthew Grant, Academic Registrar - Faculty of Medicine, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.