Drug Policy Expert Committee Stage 2 Report

Drugs: Meeting the Challenge

Victoria: Drug Policy Expert Committee Drugs: Meeting the Challenge Stage Two Report: November 2000 http://www.dhs.vic.gov.au/phd/dpec/index.htm

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Stage 2 Report Drugs: Meeting the Challenge 2

Acknowledgements

The Committee is indebted to many people and organisations for The Committee would like to acknowledge, in particular, the input, their valuable contribution to the work of the Committee advice and support of: throughout Stage Two. Their input has informed the development • The special advisors to the Committee on culturally and of this report. linguistically diverse communities, Mr Hass Dellal, Mr Phong It was clear to the Committee that the community remains rightly Nguyen; all of the Committee’s advisors, who have made an concerned about the level of drug use and its consequences. invaluable contribution to the work of the Committee; the R E The willingness of individuals and organisations to contribute Ross Trust and Professor Roger Wales who supported the time, energy and thinking to the process of consultation impressed international conference on prevention. A full list of special the Committee. advisors to the Committee is at Appendix 16. • Professor Robin Room, Director of the Centre for Social Few of the people who have assisted the Committee in their work Research on Alcohol and Drugs, Stockholm University who believe that there is a simple solution to the current problems contributed to the international conference on prevention and posed by drug use. The advice received reflected the knowledge provided information on other matters to assist the Committee. that current strategies are useful but insufficient. The nature of • The staff of the Australian Drug Foundation, in particular, input received has meant that this report is more broadly framed Janine Kirkbride, Kelvin Frost and Bill Stronach for their than may have otherwise been the case, and for this, the efficiency in fulfilling requests for material from the Secretariat Committee is grateful. and Committee. • Turning Point Alcohol and Drug Centre, and the Victorian Institute for Forensic Medicine for their assistance in compiling data required by the Committee.

The views of local government and their communities have been central to the Committee’s task in preparing its advice. The Committee would therefore like to acknowledge the important role that a number of local government authorities played in hosting consultations. The Councils concerned are listed in Appendix 15. Committee members would also like to acknowledge and thank the Secretariat for the invaluable contribution that they have made to the work of the Committee throughout the development and completion of the Stage Two report. stage 2 report

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 3

Committee Members

Drug Policy Expert Committee Members

Dr David Penington AC (Chair)

Mr Bernie Geary

Cr Dick Gross

Professor Margaret Hamilton

Dr Rob Moodie

Professor Pat O’Malley

Mr Robert Richter QC

Secretariat

Mr Ray Judd - Executive Officer Ms Mel Selvaratnam - Executive Assistant Ms Donna Scott - Manager Ms Jane Alley (part) - Senior Policy Officer Ms Ros Carter - Senior Policy Officer Ms Tanya Sewards (part) - Policy Officer Mr Michael Maher - Senior Policy Officer Dr Caroline Pappas (part) - Project Officer Mr Edmund Misson - Policy Officer Mr John Ryan (part) - Project Officer Ms Anne Mullins - Policy Officer Mr Gary Shaw (part) - Project Officer Ms Liz Sutton - Policy Officer Mr Hakan Yaman (part) - Project Officer Mr Stephen Farrow - Legal Officer Ms Yael Cohn (part) - Administrative Assistant Ms Christine Vincent - Project Officer

Introduction 4

3.2.1 Trade in illegal drugs: A 65 4.4 Public housing 93 5.7 Commitment to prevention - 1 market analysis 4.4.1 Overview The planning process 3.2.2 Production of illegal drugs 4.4.2 Drug pressures 5.7.1 Research clearing 3.2.3 Global demand for illegal 66 4.5 The health system house/forum Introduction drugs 4.5.1 Overview 5.7.2 Whole-of-government/cross- 7 1.1 The context 3.2.4 The international markets for 4.5.2 Drug pressures sectoral prevention 8 1.2 The Stage One individual drugs 68 4.6 Mental health services coordinating committee Recommendations 3.2.5 Australian supply control 4.6.1 Overview 93 5.8 New priority areas for action 9 1.3 The options available 3.2.6 Key issues 4.6.2 Drug pressures 5.8.1 Community mobilisation 10 1.4 Some common myths 35 3.3 Drugs in Victoria 69 4.7 Law enforcement and 5.8.2 Drug communication strategy about drugs and their use 3.3.1 Illegal drug markets in Victoria criminal justice 5.8.3 Supporting parents 13 1.5 The future 3.3.2 Supply of illegal drugs 4.7.1 Overview 5.8.4 Enhancing the school 3.3.3 Measuring prevalence of drug 4.7.2 Drug pressures environment use in Victoria 71 4.8 The way forward 5.8.5 A coordinated approach for 2 3.3.4 Adolescents’ substance use vulnerable young people 3.3.5 Substance use in the general 5.8.6 Reducing harm for current Key Challenges - Drug Strategy population 5 users now and in the future 47 3.4 The impact of drug use on 5.8.7 Prevention resource team 16 2.1 Introduction the Victorian community Prevention 100 5.9 Supporting the framework - 16 2.2 The approach 3.4.1 Ill health and death 75 5.1 Introduction Building capacity 18 2.3 Objectives 3.4.2 Drug-related crime 75 5.2 What is prevention? 5.9.1 ‘The voice of youth’ 20 2.4 The need for a strategic 3.4.3 Street sex work 76 5.3 Types of drug use 5.9.2 Evaluation and monitoring approach 3.4.4 The impact of heroin 77 5.4 Foundations of a 5.9.3 Data collection 23 2.5 Saving lives 3.4.5 Economic costs of drug use framework - The evidence 5.9.4 Coordination and links with 25 2.6 Reintegration - The missing 3.4.6 Other quantifiable impacts base other prevention strategies element of the strategy 3.4.7 Key findings and implications 5.4.1 Risk and Protective Factors 100 5.10 Conclusion 26 2.7 Expenditure on the drug 5.4.2 Genetic predisposition effort 5.4.3 Social exclusion - structural 27 2.8 Responding to different 4 issues 6 cultural needs 82 5.5 Victoria’s prevention 29 2.9 Coroner’s input The social infrastructure framework Treatment and support services 57 4.1 What is the social 5.5.1 Overarching approach 104 6.1 Introduction infrastructure? 5.5.2 Specific issues 105 6.2 Drug treatment - Putting it 3 60 4.2 Education services 86 5.6 Where are we now - Past, into context 4.2.1 Overview current and planned activity 6.2.1 Propositions about drug The problem of drug use in 4.2.2 Drug pressures 5.6.1 Schools treatment Victoria today 62 4.3 State welfare services - 5.6.2 Social marketing 6.2.2 Does drug treatment work? 31 3.1 Introduction supporting children, young 5.6.3 Peer education 6.2.3 When and where do clients 31 3.2 The global market in illegal people and families 5.6.4 Programs to support parents seek treatment? drugs 4.3.1 Overview 5.6.5 Local community involvement 107 6.3 The drug treatment system 4.3.2 Drug pressures in Victoria contents List of Tables List of Figures

17 Table 2.1: Ottawa Charter action 67 Table 4.3: Drug-related ambulance 145 Table 7.1: Bail applications 9 Figure 1.1: US - Deaths from areas for health promotion attendances in Melbourne, June granted and refused in the case drug-related causes, 1990-1997 35 Table 3.1: Illicit Drug Reporting 1998 to December 1999 of drug charges, 1995-96 to 9 Figure 1.2: Deaths in Sweden System - Findings on drug markets 75 Table 5.1: Levels of prevention 1998-99 caused by drug addiction or drug in Melbourne 76 Table 5.2: Programs - Reach and 146 Table 7.2: Sentencing abuse/poisoning, 1969-1997 38 Table 3.2: Adolescent drug use - scope outcomes for drug charges 20 Figure 2.1: Drug Policy and the Key issues 78 Table 5.3: Selected risk and heard in the Magistrates’ Court Social Infrastructure 43 Table 3.3: Adult drug use - Key protective factors 157 Table 7.3: Consumption 27 Figure 2.2: Budget Trends issues 94 Table 5.4: Proposed programs offences: offenders processed 1998/99 - 2002/03 50 Table 3.4: Some impacts of drug use 113 Table 6.1 Estimated costs of by Victoria Police (principal drug 32 Figure 3.1: Global heroin seizurs 61 Table 4.1: Young people in subsiding methadone dispensing offence) and estimated volume remaining Victorian neither in education nor 118 Table 6.2: Comparison of 158 Table 7.4: Canabis offences on the global market, 1988-1999 employment by age estimated number of high- and maximum penalties 32 Figure 3.2: Global seizures of 63 Table 4.2: Community Care risk/drug-dependent users heroin, cocaine, and stimulants, Division Services projected to 2003 with the number 1984-1998 of people attending specialist drug 40 Figure 3.3: Victorian secondary treatment and other health services students, percentage reporting drinking alcohol in the past week, by year level and gender, 1999 Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 5

6.3.1 The primary health care 151 7.4 Corrections 8.4.1 Workforce development 201 Appendix 9: system 7.4.1 Introduction 8.4.2 Monitoring and evaluation Cross-sectoral initiatives 6.3.2 The broader service system 7.4.2 Management of drug and 8.4.3 Research 202 Appendix 10: (supporting the social alcohol affected persons in 8.4.4 Program coordination Pharmacotherapy treatments for infrastructure) police custody 174 8.5 Conclusion heroin dependence 6.3.3 The specialist drug 7.4.3 Community corrections 204 Appendix 11: treatment service system 7.4.4 Prison New pharmacotherapies project 125 6.4 Meeting the needs of 7.4.5 Juvenile Justice 9 205 Appendix 12: special population groups 156 7.5 Law Reform Diversion and Sentencing Options 6.4.1 Youth drug treatment services 7.5.1 Repeal of section 75 of the 176 Recommendations for Drug and Drug-related Offences 6.4.2 Involving the family Drugs Poisons and Controlled 206 Appendix 13: 6.4.3 Women Substances Act 1981 Written submissions received in 6.4.4 Adult offenders 7.5.2 Cannabis law reform 10 relation to both Stage One & Stage 6.4.5 Juvenile Justice population 7.5.3 Alcoholics and Drug- Two terms of reference 6.4.6 Drug treatment service users Dependent Persons Act 1968 Appendices 207 Appendix 14: 6.4.7 Culturally and linguistically 160 7.6 Conclusion 187 Appendix 1: Written submissions received in diverse communities Drug Policy Expert Committee relation to the Drug Policy Expert 6.4.8 Koori communities Stage 2 Terms of Reference Committee’s Prevention Issues 133 6.5 Conclusion 8 188 Appendix 2: paper Drug Policy Expert Committee 208 Appendix 15: Mobilising communities and 189 Appendix 3: List of meetings and consultations 7 supporting the drug strategy Glossary under the Stage Two Terms of 163 8.1 Introduction 191 Appendix 4: Reference. Law enforcement and 163 8.2 Mobilising and Drug Policy Expert Committee 209 Appendix 16: criminal justice Strengthening Communities comment on the report of the Special Advisors to the Drug Policy 138 7.1 Introduction 8.2.1 Clarifying what community Victorian Coroner Expert Committee 139 7.2 Policing strengthening means 196 Appendix 5: 7.2.1 Current initiatives 8.2.2 Clarifying what governments Additional Services Accessed by 7.2.2 Local priority policing can do Clients of Drug Treatment Services 11 7.2.3 Intensive policing activity in 8.2.3 Focusing on drugs - A Sample response to drug problems 8.2.4 Creating an informed 198 Appendix 6: 210 Bibliography 7.2.4 Evaluation community debate Example prevention programs 7.2.5 Training 8.2.5 Sharing and celebrating 199 Appendix 7: 7.2.6 Conclusion success Summary of studies of treatment 143 7.3 Courts and sentencing 165 8.3 Independent Advice to outcomes across modalities 7.3.1 Introduction Government and the 200 Appendix 8: 7.3.2 Bail Community Impact on services of substance use 7.3.3 Sentencing options 166 8.4 Developing the problems within the client group - 7.3.4 Linking defendants to Infrastructure enhancing the capacity to respond services to complex clients

40 Figure 3.4: Victorian secondary 49 Figure 3.8: Non-fatal heroin 115 Figure 6.2: Decline in growth in students, percentage reporting overdoses attended by Melbourne numbers of clients on the methadone smoking tobacco in the past ambulances and heroin-related program in Victoria month, by year level and gender, deaths in Victoria, June 1998 to 116 Figure 6.3: Victoria’s specialist drug 1999 April 2000 treatment services - The current 41 Figure 3.5: Victorian secondary 49 Figure 3.9: Heroin-related deaths, framework for service delivery students, reported use of selected Victoria, 1991-1999 and projection to 117 Figure 6.4: Drug treatment services substances ever and in the past 2005 funding 1996-97 to 2002-03 month, all year levels, 1999 58 Figure 4.1: Pressure on selected 119 Figure 6.5: Percentage of clients with 45 Figure 3.6: Use of illegal drugs elements of the social infrastructure - alcohol, opiates and cannabis as the in the past 12 months, Victoria, estimated numbers of people with primary drug problem 1991-1998 substance use problems using services 121 Figure 6.6: Treatment and support 46 Figure 3.7: Use of selected 83 Figure 5.1: Victoria’s prevention services available to each region in the illegal drugs in the past 12 framework specialist drug treatment service system months by age, Victoria, 1998 85 Figure 5.2: Intervention/transition 134 Figure 6.7: A framework for future drug points and who can play a key role in treatment service provision effective prevention 114 Figure 6.1: Methadone prescribers grouped by number of methadone contents clients treated 6

Introduction

The Drug Policy Expert Committee was appointed in November 1999 to provide the State Government with advice on drug policy. Its terms of reference are at appendix 1. Establishment of the Committee was a critical and significant initiative. It reflected the Government’s awareness of the seriousness of the deteriorating situation surrounding increasing use of illegal drugs, rising deaths from drug overdose, increasing community concern over people injecting and suffering drug overdose in public places, littering of syringes and needles and increasing crime associated with drugs. The decision to establish the Committee and to require it to consult extensively recognised the need for both expert and broad community input to drug policy and strategy development.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 1 7

The Committee has sought, through discussions with the 1.1 The context community, local government, professional groups interacting with drug users, and business and provider organisations, to engage Most of the drugs now defined as illegal in Australia have only in open debate about the problem. As at the time of the Premier’s been made so in relatively recent years. Cannabis was banned in Drug Advisory Council report in 1996, the challenge has been to 1926, following an international treaty decision, when it was almost get the community to face and understand the facts, so as to unknown in Australia. Heroin was widely used in pain relief in achieve policies based on evidence. The Committee has terminal cancer and in childbirth until its importation was experienced considerable difficulty in having the evidence prohibited in 1953 after pressure from the United States and the discussed publicly in a dispassionate manner. United Nations regulatory body. Both drugs were brought once Issues surrounding drugs commonly evoke strong emotional more to Australia by US troops coming on leave from Vietnam in responses, given the impact that drug use and associated crime the mid-1960s. The traffickers accompanied them. In 1964, there have on individuals, families and the community. That there are were six overdose deaths in Australia due to heroin. They have moral issues entailed in drug use is not denied, but many in the increased year by year since that time, reaching 737 in 1998. community are driven by strong and often unexplained feelings, Cannabis has always been primarily a drug used by young rather than by views that have any rational basis. We face a people, and its use spread rapidly across Australia at a time of serious situation in public health terms, with steadily rising protest against the Vietnam War and against authority on numbers of deaths, and a progressive rise in drug related crime, university campuses in the early 1970s. Many of the attitudes in despite the best efforts of law enforcement authorities. The first the community towards cannabis use stem from its association obligation must be careful re-examination of all the available with the rejection of authority or ‘conventional’ cultural mores. evidence to see what options are available to improve the Cannabis has been produced primarily from Australian sources to situation. meet a steadily growing demand, although some importation of Moral judgements are made on a variety of bases. Some assert the highly potent cannabis resin and other products has that use of substances that alter the mind is itself immoral. continued. The growing heroin problem has had its origin in However, it must be acknowledged that use of substances which burgeoning world production of opium. The United Nations alter the mind goes back, in various sections of human society, for estimates that there has been a 32 per cent increase in illegal 1 thousands of years, whether we are talking of alcohol, cannabis opium production since 1995. The Australian Customs Service (marijuana), opium, coca leaves and many other natural has confirmed this and also noted that there has been a derivatives. In our own community, use of tobacco and alcohol is significant recent increase in production of high-quality widespread, as is the use of Valium (or other benzodiazepines) in amphetamines in Asia. Australia is an convenient, affluent market the relief of anxiety. These are not generally seen as raising moral that is easily penetrated, with so many goods reaching the issues. For some, injecting is seen as the immoral act, but many country in sealed containers every day and a wide-open coastline. illegal drugs, such as cannabis products, are not injected. Efforts to stop illegal drugs coming into the country have been That drug addiction is a serious problem is not disputed, but the redoubled in recent years, largely as a result of the great majority of users of cannabis are not addicted. In our Commonwealth Government’s Tough on Drugs strategy. The community, initiation into use of potentially addictive drugs most Commonwealth currently invests $188 million annually in Customs commonly occurs when people are young. If the need is to and Federal Police strategies for interdiction and law enforcement 2 educate and to alter attitudes, and so reduce peer pressure to related to drugs. It is still estimated that these efforts only stop 3 use drugs, then this must start with recognising that the current some 10 per cent of the supply. Major enforcement efforts have illegal status of drugs has not proved to be an effective barrier to had little impact on street availability in the major cities of 4 their use. New approaches are essential to reduce initiation into Australia. The same is the case in the US, despite its huge 5 use of drugs. There must be new approaches to work with drug expenditure on law enforcement against drugs. As Milton users if many more are to be effectively drawn into treatment, Friedman has pointed out, ‘market forces will inevitably overcome rehabilitation and, eventually, true reintegration into the community, prohibition when dealing with substances for which there is a 6 so as to lessen the problems which currently cause such disquiet plentiful supply and a willing market.’ and suffering. Understanding the context of current arrangements, their origins and evidence as to their effectiveness or otherwise, and a willingness to learn from experience in other countries, are fundamental to providing the best options for our community at a time when the status quo is clearly not an answer.

Introduction 8

The age at which young people commence illegal drug use is 1.2 The Stage One recommendations declining. There are now 13, 14 and 15 year olds using heroin.7 The proportion of heroin users who are under 16 years increased Changing a deteriorating situation with increasing use of drugs, from less than 1 per cent in 1993 to 7 per cent in 1998.8 As the steadily rising overdose deaths and crime associated with the age of initiation is falling, the amount of illegal drug use is drug trade, presents formidable problems. To recommend increasing. Nearly 1 per cent of Victorians admitted to having continuing with current strategies without substantial change, is to used heroin in the last 12 months in 1998, up from 0.2 per cent in accept many more deaths and further deterioration in our 1995.9 Deaths in Victoria alone reached 359 in 1999, and unless community, which both the Government and the Committee find there is a major change in the way we handle the issue, the unacceptable. The Committee’s Stage One report included Victorian Coroner estimates that deaths will reach close to 500 by particular strategies for handling the escalating street based drug the year 2005.10 These deaths occur among people from every scene in five metropolitan areas, a feature that has developed section of society, as can be seen from the home addresses of over the past five years. those dying from drug overdose, although some groups are We sought to learn from cities such as Frankfurt, which has identified as at particular risk. handled a similar situation with great success. It has employed Cannabis continues to be the most widely used illegal drug with strategies that include supervised injecting facilities. Deaths from 55 per cent of 17 year olds admitting having used cannabis.11 drug overdose in that city peaked at 147 in 1991, but had fallen to A Commonwealth Government survey in 1998 disclosed that 22 by 1997. The fundamental principle, adopted in 1991, was to 2.7 million Australians had used cannabis in the previous work with the drug users to get them off the streets into secure 12 months. Most are infrequent, casual users who get into no and clean environments, to eliminate public littering with syringes difficulty. However, a small proportion move to heavy and frequent and needles and, in due course, to get as many as possible of use, with a risk of potentiation of any tendency to schizophrenia or the drug users into treatment and rehabilitation. The strategies put even the development of psychosis directly attributable to forward by the Committee had many components, not only cannabis. While in 1997, deaths attributable to tobacco use were supervised injecting facilities. Regrettably, recent public debate assessed as 18,200 and to alcohol use at 3,700, those due to has focused only on the latter. illegal drugs amounted to around 800, with virtually no deaths It was our view that mobilisation of local communities, involving 12 directly attributable to cannabis. Many young people regard the local government, is essential. Three of the five councils have illegal status of cannabis products as hypocritical, given the expressed strong support for our injecting facilities widespread misuse of alcohol, and wrongly believe it is a drug recommendations. A number of professionals and others with that carries no risk. There is a great need for better health-based direct contact and experience of drug issues have also given clear education against heavy and harmful use of cannabis, because of public support. These include the Victorian branches of the its link to psychiatric illness and disturbed behaviour, but it is a Australian Medical Association, the Australian Nursing Federation, very different issue from that of the very much more addictive the Institution of Engineers, Australia, the Pharmaceutical Society drug, heroin. of Australia, Ambulance Employees Australia, the Law Institute of Amphetamine and its derivatives are another group of drugs now Victoria, the Victorian Bar Council and the Victorian Local widely used. The most common form, colloquially termed ‘speed’, Governance Association. In addition, a number of leading figures is used in tablet form as a party drug, and injected intravenously. It in the community have publicly called for implementation of the is highly addictive and damaging to the nervous system when recommendations. The proposed trial of supervised injecting used frequently and in high dose. It is manufactured in many facilities, however, depends on Parliament passing the necessary small illegal laboratories, some of which are mobile, and, in the legislation. past, has had a strong association with motorbike gangs. It is also Local governments have a critical role to play in many of the imported from South-East Asia where its production is booming. initiatives which need to be implemented across the State, not just Newer derivatives include ‘ecstacy’; many others are now injecting facilities appropriate for the small number of areas in appearing in the market. It is expected that these will become Melbourne with open drug use in the streets. The Committee is increasingly prevalent. Ecstacy is generally imported in tablet now working with State and local government to focus on those form. Casual use causes few problems except those associated strategies with need to be progressed to save lives, for the with disturbance of temperature control and water balance at a purpose of prevention, to improve access to treatment and time of intense exercise. However, for those prone to addiction, rehabilitation, and to facilitate reintegration of former drug users casual use carries a real risk of escalation to addiction. into the community. Mobilisation of local communities for these purposes needs to involve people from each of the relevant groups, including police and those in health and drug services, education and youth workers. These initiatives can all be undertaken without legislative change.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 9

1.3 The options available As in Sweden, where the possibility of prison for possession and use of drugs was introduced in the 1980s, many people are Many still wish to believe that the way to go is even more rigorous unwilling to admit use in public questionnaires. However, the drug law enforcement and government-authorised pronouncements to overdose deaths and other direct surveys by authorities show young people not to use drugs. The reality in the US is that, drug use to be increasing steadily in both the US and Sweden. despite its huge allocation of resources to law enforcement (10- Sweden, visited by members of the Committee in the course of its fold more per capita than in Australia) and six times the prison work, has admirable features from which we can learn, particularly population per capita, the number of drug overdose deaths in mobilising local communities to support rehabilitation. However, continues to rise. Deaths are similar on a population base to despite being further from the source of most illegal drugs than those in Australia. Emergency room overdose attendances also most other countries, it clearly does not have an answer to the continue to rise.13 problem overall. Deaths due to narcotic drugs are now many times those in 1980, when the decision was taken to introduce coercive measures,14 and deaths continue to increase. Figure 1.1: US - Deaths from drug-related causes, 1990-1997 Figure 1.2: 20000 Deaths in Sweden caused by drug addiction or drug abuse/poisoning, 1969 - 1996

15000 250 Drug abuse or poisoning

200 Drug Addiction (underlying) 10000 150 Number of deaths

Number 100 5000

50

0 0 1991 1992 1993 1994 1995 1996 1997 9 1 3 5 7 9 1 3 5 7 9 1 3 5 6 7 7 7 7 7 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Year Year

Source: Office of National Drug Control Policy, Washington. (2000) National Source: Centralforbundet for alkohol-och narkotikaupplysning, Sweden, Drug Control Strategy: 2000 Annual Report, Appendix: Drug Related Data, Rapport 99, Diagram 34, p. 160 (drawn from Tables 93 & 94, pp. 298-299). table 28, p. 134.

Introduction 10

Education and other strategies for prevention are critically Courts are seeing an inexorably increasing number of drug-related important and the Committee has reviewed evidence from around crimes and offenders with drug problems. The involvement of the world. There was valuable input from a recognised drug users in the criminal justice system is all too often part of a international leader in the field currently based in Sweden. As tragic cycle, but it can also direct them into treatment and help noted above, tobacco and alcohol misuse cause a far greater them access other services to assist in their rehabilitation and loss of life than any of the illegal drugs. Television campaigns, reintegration into the community. There are many issues to be which have had positive effects on attitudes to tobacco and on tackled to improve the working of our criminal justice and law drink driving in adults, have had less effect on adolescent enforcement systems to achieve the best possible impact and behaviour in terms of smoking and excessive alcohol use. This help to change outcomes for people caught up in use of illegal emphasises the need for different messages for young people. In drugs. particular, strategies to encourage more responsible approaches Unless there is better and more realistic understanding of all of to the use of drugs by the young need to include tobacco and the complex issues that must be tackled by our political system alcohol, if they are to be credible, realistic and effective. and by our society, we will never achieve the changes that must Making a major impact on prevention will require the community be embraced. The alternative is a continuing and inevitably rising at large to gain a far better understanding of many issues. wave of deaths, of suffering and of crime resulting from the illegal Increasing families’ capacity to handle drug problems in the drug trade. home, in schools and the community, depends on better While much valuable work was initiated under the Turning the Tide understanding of the factors that carry risk of becoming involved initiative, following the inquiry in 1995-96, it is clear that the tide with addictive drugs, and those factors that are protective. continues to come in. We cannot afford to take a ‘Canute’-like Parents, teachers, leaders of community organisations and young posture, assuming that ‘all will be well’ when the forces we are people themselves must all play a part in changing attitudes. confronting are far greater than can be overcome by slogans or Wide discussion of these issues is sought. An issues paper simplistic and poorly thought out remedies. entitled Developing a Framework for Preventing Drug Problems was released by the Committee in August, and is available on the 1.4 Some common myths about Committee’s web site.15 drugs and their use Much is already being done to improve treatment facilities and to develop new approaches to treatment. The Salvation Army and ‘The users of illegal drugs are all from the “drop-out”, misfit many other agencies working in the field join with us in calling for and marginal groups in society, so why bother about them.’ far greater community support in assisting those drug users who Examination of the primary residences of those dying from drug go through the difficult path of breaking the powerful grip of overdose show that they come from every part of Victoria, country addiction, into rehabilitation. They need support to achieve full as well as city, and from every section of society. No doubt young reintegration into the community. people from dysfunctional families, those who left school early Law enforcement is critical in many areas, and both its necessary with little chance of employment and some other special groups contributions and limitations in handling the problem need to be are particularly at risk. There is evidence that some individuals are better understood. The role of police in doing all they can to at greater risk than others of moving from intermittent or reduce supply remains a necessary component in any strategic recreational use of drugs into drug dependency for genetic approach to the drug problem, as does their commitment to reasons.16,17 By the time they have been drug dependent for some maintaining law and order on the streets and safety in the years, all are likely to fit the description of ‘drop-outs’. Many have community. It is increasingly recognised, however, that harm become engaged in crime, prostitution or drug trafficking because minimisation principles must also play a critical role in policing, as of the illegal status of the drugs. New recruits embark on drug use must diversion of young people from the courts to counselling from every section of society and will continue to do so unless we and treatment. Police are important partners in all that needs to be tackle the problem effectively. done, and they have the opportunity to be significant agents of ‘Society can’t afford to spend money on drug users.’ change with many young people. A heavily dependent heroin user is estimated to spend $50,000 to $100,000 per annum on purchase of drugs. For most, this comes from crime, prostitution or trafficking. The cost of care for orphans left by drug-using parents is great, as is the cost of care for those suffering brain damage through drug overdose. Society pays again and again. The estimated cost of effective treatment of a drug user is some $2,000 to $5,000 per annum, with enormous savings to our society.18

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 11

‘Drug users never recover, so why invest in treating them.’ ‘Putting all the drug users in prison or on an island and Accurate figures as to the number of dependent users of addictive keeping them there would be the answer.’ drugs who finally recover are hard to obtain, but the number is There is not a prison in Australia, in the US, in Europe or in Asia very significant. Most go through withdrawal (‘detox’) and relapse that is free of drugs. Where there is a high demand, the market into drug use many times before they finally recover, despite their will find ways around law enforcement. When people leave prison, best intentions. Drug dependency is a chronic relapsing disease. the great majority return rapidly to drug use and there is a high However, there are many valuable members of society who have incidence of death from drug overdose among this group. Simply ‘made it’ through this difficult path. It requires courage and isolating drug users would achieve little, at great cost to society determination on the part of the individual and support from (an estimated cost of some $50,000 per annum for prisons and families and the community to make it happen. $140,000 per annum for residential youth training centres). Such a ‘Heroin use is bound to damage their brains so they can never strategy would have no impact on people commencing drug use. again be useful members of society.’ ‘Sweden has the answer because they are strict about Heroin itself causes no damage to the brain apart from rapid arresting people and making treatment compulsory.’ development of dependency in most individuals who have used it There are things to be learned from Sweden in terms of repeatedly. Impurities injected with illegal heroin can cause major community support for treatment and rehabilitation but, as shown damage to health, as can viruses and other infections. There are in figure 1.2 above, it continues to face a steadily deteriorating well-documented examples of people, addicted through what problem with illegal drugs, not too different from Australia’s. might be termed ‘medical misadventure’, on long-term treatment ‘A media campaign, like that for drink driving, would solve the with pure morphine or heroin who have managed to lead problem.’ constructive, professional lives and have been useful members of Communication using the media is important, and governments society. have a special role to play here. However, ‘scare tactics’ heighten ‘It is pointless putting a heroin addict on methadone, because the aura of danger surrounding illegal drugs and may even it is itself an addictive drug.’ increase experimentation by adolescents. We need to work with Methadone attaches to the same receptor in the brain as heroin adolescents using their language and in their own culture to does and there is no doubt that it is also addictive. However, a change the peer pressure that leads to misuse of tobacco, person on daily methadone no longer needs to commit crime to alcohol and illegal drugs. obtain the drug, and is able to get back to normal domestic life ‘If the government really tried it would be able to stop the and then back to employment. There is much new knowledge drugs coming into the country.’ about the ways in which people can be helped through withdrawal No country in the world has managed to stop entry of illegal drugs from methadone. Some 8,000 current recipients of methadone even when hugely increased law enforcement resources have treatment in Victoria are benefiting from this treatment. They need been applied, as in the US. Countries with the death penalty for support in their commitment to rehabilitation and reintegration in trafficking, including Malaysia, Thailand and China, continue to society. face a deteriorating situation of drug use. Every effort should be ‘Once a person has started on methadone, they never come off.’ made to stop illegal drugs coming in, but we must recognise that Since 1 January 1998, the Department of Human Services has turning around the demand for drugs is the most fundamental and been notifiied of 979 clients completing a methadone program. important challenge. There is no doubt that methadone is the ‘sheet anchor’ of drug ‘Arresting all the dealers we see on the streets would solve the treatment currently available. It does not suit all, but is appropriate problem.’ for the great majority. Alternative drug treatments are also now The public commonly assumes ‘dealers’ seen on the streets are becoming available. the traffickers bringing in the drugs. In reality, they are mostly drug ‘Making drug treatment compulsory would solve the problem.’ users. When arrested, they are replaced rapidly by other ‘end- Initial treatment is simply withdrawal (detoxification). Following this, stage’ distributors. Intensive policing with many arrests leads to the vast majority return rapidly to heroin use unless they displacement of the trading to other neighbourhoods, with no themselves have a strong desire to break their dependency, and evidence of reduction in the overall scale of drug use or overdose are given all the necessary support to achieve this through incidents State-wide. professional services, by families and by local communities. ‘ “Zero tolerance policing” and “‘just say no” have been Compulsory detoxification on its own would achieve nothing. proved to work in the United States.’ Despite all the noise about ‘zero tolerance policing’ and moralistic policies, the problem continues to deteriorate in the US, as shown in figure 1.1 above. There is a prison population of more than two million, many there for drug related crimes. The US Federal Government estimates initiation into drug use is continuing to rise and to involve younger people.19

Introduction 12

‘Supervised injecting facilities in Frankfurt and in Switzerland ‘Marijuana should be freed up because it carries no risks.’ have made things worse because they send the wrong There is no doubt at all that repeated and especially heavy use of message.’ cannabis, in any of its forms, carries risks to health in a number of Figures from the Frankfurt city authorities, endorsed by police, by ways. These include behavioural disturbance which can lead to the courts and by treatment services, show a steadily improving dropping out of school and employment, the risk of development situation in that city with reduced drug related crime. The same is of psychosis, risk of respiratory disease and other complications.25 reported from Switzerland, where there has been progressive Dependency develops in something like one in 10 repeated users. improvement between 1992 and 1999.20 These matters need to be taken up as a health-based issue so ‘Syringe and needle exchange programs are dangerous young people can gain a better understanding of the risks because they lead to increased use of drugs.’ associated with regular use of cannabis. Studies by American authorities have established that syringe and ‘What matters is that we commit ourselves to a “drug free” needle programs do not increase the use of drugs in the society.’ community, and that they make a significant contribution to We would all like to live in a society free of the problems of drug reducing the transfer of disease.21 dependency, just as we would welcome a world free of crime, of ‘A single joint of marijuana can cause psychiatric illness.’ cruelty, poverty and of wars. Making a declaration of this kind achieves nothing. What matters is putting in place policies and Prolonged and repeated use of marijuana (cannabis) can strategies to save lives, to reduce the damage being caused by contribute to psychiatric disease but there is no evidence that a drugs in our community and to greatly lessen the likelihood of single exposure precipitates such disease. Some individuals may young people embarking on harmful use of potentially damaging have adverse reactions to a single exposure, experiencing anxiety substances. or panic attacks, which should caution them not to continue with use. They recover from the acute effects. The link with psychiatric illness is with frequent and heavy use.22 ‘Alcohol and tobacco may have some problems that we know about, but the illegal drugs are much more dangerous because they are all addictive.’ Studies of addictiveness, carried out in the US, have demonstrated that cannabis is marginally less addictive than alcohol. Tobacco is far more addictive, slightly more so than heroin.23 Amphetamines, used intravenously, are similar to heroin in addictiveness. Many heavy smokers have great difficulty in giving up tobacco, often reverting to smoking a number of times before finally stopping. The same happens with heroin. ‘Marijuana is the cause of schizophrenia.’ There is no doubt that many young schizophrenics, even in the early stages of their disease, turn to marijuana (cannabis) to relieve their unhappiness. There is now evidence that cannabis attaches to the receptor for a neurotransmitter that is deficient in people with schizophrenia, which partly explains this link. However, heavy and repeated use of cannabis can aggravate schizophrenia.24

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 13

1.5 The future Continued independent monitoring of the problems associated with illegal drugs, and related problems with legal drugs, with In 1996, the Premier’s Drug Advisory Council (PDAC) youth homelessness and suicide, should be carried out by a recommended Victoria accept a commitment to a trial of newly created independent statutory body, working in close prescription heroin treatment for a group of long term heroin association with government. This should have access to all the dependant persons for whom other approaches to treatment had necessary information to monitor progress, be able to failed.26 Most of these people are heavily involved in crime, commission research related to its terms of reference and to prostitution or trafficking to support their dependency, at a real make recommendations to government in relation to possible cost to society. The proposed trial would be in keeping with trials changes in policy relating to legal and illegal drugs. Such a body successfully completed in Switzerland, already underway in the should maintain close liaison with local government to encourage Netherlands and about to commence in a number of centres in continued mobilisation of local communities to tackle the relevant Germany. problems. Bipartisan support for the proposal was gained in Victoria, but the The Victorian Government has an opportunity to offer strong Commonwealth refused to allow the trial to proceed. The Prime leadership in bringing together a commitment for change in the Minister stated that there would be no such trial in Australia while way drugs are used in the Victorian community. This should be an he held that office. Importation of heroin for a trial depends on important element in the communication strategy. Once greater approval by the International Narcotics Control Board (INCB) on confidence is gained that the situation can be improved, the the recommendation of the Australian Government. Although the community can increasingly be mobilised to increase the INCB has since indicated that it would approve such a request, momentum of reform. this proposition will need to be held back until there is a change in leadership of the Australian Government. Nonetheless, Victoria could play a leadership role in preparing the ground for such a trial at a future date. PDAC, following a thorough review of all the evidence in 1996, recommended decriminalisation of possession and use of small quantities of cannabis, to be linked with a strong health based campaign against cannabis misuse.27 Neither strategy was implemented, but there has since been increased concern in the community over psychiatric complications of excessive and harmful use of cannabis. It is the view of the Committee that a vigorous strategy should be implemented, using an approach based on health rather than legal grounds, to seek reduction in hazardous use of the drug. Once a strategy to curb the excessive and hazardous use of cannabis has been implemented, consideration should be given to decriminalising possession and use of small quantities of cannabis products. Domestic cultivation of a small number of plants should, at that time, be permitted so as to take the trade out of criminal hands and to reduce the market for, and cultivation of more potent forms of cannabis by those engaged in trafficking. Such a change would also reduce the risk of those young people who experiment with cannabis being introduced to heroin by traffickers and give their parents authority to control production and use of the cannabis. This should be accompanied by explicit penalties for use of cannabis in public places and by persons driving vehicles or equipment in the work place. The independent body noted below should keep this matter under review.

Introduction 14

Endnotes

1 United Nations Economic and Social Council. (1999) World situation with 14 Tham, Henrik (1998) “Swedish Drug Policy: A Successful Model?”, European regard to illicit drug trafficking and action taken by the subsidiary bodies of Journal on Criminal Policy and Research, Vol. 6, pp. 395-414. the Commission on Narcotic Drugs: Report of the Secretariat, Commission 15 Online: http://www.dhs.vic.gov.au/phd/dpec/ on Narcotic Drugs: Vienna. Reference No: E/CN.7/2000/5, 22 December 1999, p. 5; United Nations Office of Drug Control and Crime Prevention. 16 Crabbe, J.C., and Phillips T.J. (1998) “Genetics of alcohol and other abused Drug and Alcohol Dependence (1999) Global Illicit Drug Trends, UNODCCP: New York, p. 18. drugs”, , Vol. 51, pp. 61-71. 2 Department of Health and Human Services Australia. (2000) Tough on 17 Comings, D.E. (1994) “Genetic factors in substance abuse based on studies Drugs Strategy; Australian National Council on Drugs. (2000) Recurrent of Tourette Syndrome and ADHD probands and relatives, 1 Drug abuse”, Drug and Alcohol Dependence Funding Objectives. , Vol. 35, pp. 1-16. 3 Government of NSW. (1999) “Defending Our Frontiers: A National Strategy” 18 Hall, W. (1996) “Methadone maintenance therapy as a crime control Crime and Justice Bulletin paper prepared for the NSW Drug Summit. (Online: measure”, , Vol. 29, pp. 1-12. http://forums.socialchange.net.au/material/seven-Defendin.html Accessed: 19 Executive Office of the President of the United States, Office of the National 27/09/2000.) Drug Control Policy. (1999) National Drug Control Strategy 1999 Annual Report 4 Weatherburn, D., and Lind, B. (1997) ‘The Impact of Law Enforcement , p. 31. (Online: Activity on a Heroin Market’, Addiction, Vol. 92, No. 5, pp. 557-569. http://www.whitehousedrugpolicy.gov/policy/99ndcs/99ndcs.pdf Accessed: 31/10/2000.) 5 Executive Office of the President of the United States, Office of National Drug Control Policy. (1999) “Drug Data Summary”, Drug Policy Information 20 Zurich City Police Criminal Commissariat 5, 2000. Clearing House, April 1999, p. 5. 21 Shalala, D. E. (US Health and Human Services Secretary). (1998) Press Research shows needle exchange programs reduce HIV infections 6 Cited by Knightly, P. (1999) War on drugs lost to market forces, The release: with out increasing drug use Australian, 6-7 March, 1999, pp. 1 and 6. . (Online: http://www.hhs.gov./news/press/1998pres/980420a.html Accessed: 7 Youth Substance Abuse Service. (undated) 100% Dependent: The First 100 10/08/2000.) Young People at the YSAS Residential Unit, YSAS: Fitzroy, p. 3. 22 Hall, W. (1998) “Cannabis use and psychosis” Drug and Alcohol Review, Vol. 8 Australian Institute of Health and Welfare. (1999) National Drug Strategy 17, pp. 433-444. Household Survey: 1998, table 34, p. 38 (in press). 23 Anthony, J.C., Warner L.A., and Kessler, R.C. (1994) “Comparative 9 Ibid, table 4, p. 17. epidemiology of dependence on tobacco, alcohol, controlled substances 10 Victorian Institute of Forensic Medicine, December 1999. and inhalants: basic findings from the National Comorbidity Study”, Clinical 11 Letcher T., & White V. (1999) Australian secondary students’ use of over-the- Experimental Psychopharmacology, Vol. 2, pp. 244-268. counter and illicit substances in 1996, National Drug Strategy Monograph 24 Hall, W., & Solowij, N. (1998) “Adverse effects of cannabis”, The Lancet, Vol. Series No 33, Department of Health and Aged Care: Canberra. 352 pp. 1611-1616. 12 Australian Institute of Health and Welfare. (1999) National Drug Strategy 25 Ibid, p.1611-1616. Household Survey: 1998, table 51, p. 50. 26 Premier’s Drug Advisory Council. (1996) Drugs and our Community: Report 13 Executive Office of the President of the United States, Office of the National of the Premier’s Drug Advisory Council, Victorian Government: Melbourne, Drug Control Policy. (2000) National Drug Control Strategy: 2000 Annual Recommendation 4.9. Report, Appendix: Drug-Related Data, table 29, p. 135. (Online: 27 Ibid, Recommendation 7. http://www.whitehousedrugpolicy.gov/policy/ndcs00/appendix.html Accessed: 31/10/2000.)

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 15

Key Challenges - Drug Strategy now and in the future

2 Key Challenges - Drug Stragtegy now and in the future 16

2.1 Introduction This chapter outlines the key challenges ahead. In the Committee’s view, the challenges are to: In recent years, increasing public and government attention has • establish a conceptual platform on which future drug policy been paid to legal and illegal drug policy issues. Positive changes can be based, and which sets out the basic requirements for have been made in the way that the drug problem is tackled. This ongoing policy and strategy development; report argues that much more needs to be done and that different • ensure the community is effectively involved in tackling drug priorities are emerging. While maintaining a commitment to harm issues at all levels; minimisation, a significant change is required in the way in which • significantly lift the profile and breadth of the prevention effort; government and the community deals with drugs. The challenges • strengthen the capacity of health and community services to of the next decade will not be met without the developments meet the needs of changing user groups; advocated in this report. • strengthen the overall capacity of the treatment system through The impact of drugs is now broad and is affecting the fabric of our developing enhanced pharmacotherapy services and more society. Drug misuse is a multifaceted phenomenon that causes, cohesive approaches to meeting the complex and multiple and is a result of, social exclusion and disruption. The service needs of drug users; consequences for the dependent user are often dire; the • develop a sustained and community-wide approach to consequences for the community and for the confidence and reintegrating drug users who wish to develop lifestyles that are cohesion of society are, in the long term, equally critical. The not dependent on a drug-using culture; impact on government-provided and funded services is also • develop an effective approach to reducing drug-related significant. Renewed community involvement is urgently required, deaths; but this cannot happen without the leadership and commitment of • ensure the drug strategy effectively deals with community the State Government. concerns about public nuisance and safety at the local level; Positive developments have been made in recent years that • make strategies for tackling drugs more responsive to the provide part of the foundation on which new approaches can be needs of the community, particularly to diverse cultures and based. These include the: changing circumstances; and • improve the skill base and support provided for the staff • establishment of the Police Diversion Program that has been involved in drug strategy. adopted as the model for the national Council Of Australian Governments (COAG) Drug Diversion Initiative; • piloting of court-based diversion strategies through the 2.2 The approach Magistrates’ Court via the Court Referral and Evaluation for Drug Intervention and Treatment (CREDIT) Program; In recent years, a considerable effort has been made to deal with • introduction of a systematic approach to school drug the drug problem as a health issue. In part, this approach stems education in all State schools and the majority of the Catholic from the recognition that law enforcement has received attention and independent schools in the State; while reducing demand or responding to the needs of drug users • introduction of school nursing services in secondary schools, has not received the same consideration. There is now an the strengthening of school welfare support services, and a increasing awareness that the extent and nature of drug use recognition that these generalist services have a significant role demand that a multifaceted approach is taken to drug policy. A to play in reducing drug use and misuse; broad approach to enhancing the health and wellbeing of all • redevelopment and expansion of drug treatment services; Victorians is required. • establishment of the Youth Substance Abuse Service and The First International Conference for Health Promotion was held regional youth drug services which, for the first time, allow the in Ottawa, Canada in 1986. The resulting charter outlines an State to offer specialist services for young drug users; and approach to health promotion that specifically identified the critical • funding of nationally significant research into alternative role all parts of the community and government play in promoting pharmacotherapies. health. In the context of this charter, health is interpreted in the The recent announcement of the Commonwealth/State funded widest sense of wellbeing, rather than in the more narrow sense of COAG Drug Diversion Initiative, and funding by the State physical health. Government for a range of new projects, add further momentum The charter framed the importance of health promotion, and to the State’s response to drug problems. The Committee enshrined the principle of enabling people to improve and welcomes these initiatives. increase control over their own health. The charter’s currency remains, 14 years after it was agreed. It is significant for the development of a multifaceted drug policy for this State given the importance of community engagement in the drug issue. The charter sets out five key action areas. These are outlined in the table on the following page.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 17

Table 2.1 Ottawa Charter action areas for health promotion

Action Areas Key elements

Building Healthy Public Policy • Health should be put on the policy agenda in all sectors and at all levels. • Complementary approaches including legislation, finance policy, taxation and organisation change should be identified. • Obstacles to adoption of healthy public policy in non-health related areas should be identified and removed.

Create Supportive Environments • Environments that support health should be developed and fostered, particularly with reference to the way society organises work and creates leisure opportunities.

Strengthen Community Action • Community development principles, and involvement of the community generally in health promotion, should underpin health promotion activities.

Develop Personal Skills • Information, education and enhancement of life skills is required.

Reorient Health Services • Responsibility for health promotion should be shared among individuals, community groups, health professionals, health service institutions and governments.

For many years, Australian governments (Commonwealth, State The word ‘minimise’ is also meant to be taken literally. Policies and Territory) have maintained a commitment to drug policies and drug strategies are sought that lead to minimal or no harm. based on the principle of ‘harm minimisation’. The National Drug Programs and services that advocate and achieve abstinence are Strategic Framework 1998-99 to 2002-03, endorsed by all important to achieving this goal. Other approaches are also Australian Governments, defines harm minimisation as including: necessary in a drug-using culture which, realistically, cannot be • supply-reduction strategies designed to disrupt the production expected to change in the near future. The issue of concern is the and supply of illicit drugs; potential for harm to individuals, families and society rather than • demand-reduction strategies designed to prevent the uptake of drug use per se. harmful drug use, including abstinence-oriented strategies to The commitment to harm minimisation has always been reduce drug use; and somewhat contentious, although public support has been greater • a range of targeted harm reduction strategies designed to in Australia than in most countries. Some criticism arises because reduce drug-related harm for individuals and communities. harm minimisation is equated solely with the harm reduction The core message of harm minimisation is that society wants aspect of the term; so that, for example, supply reduction none of its members damaged as a result of drug use. It means strategies are seen as being under-emphasised. Critics commonly society is prepared to take action to protect its citizens whether also raise concerns about the investments made in harm they are users or non-users. That core value is the same whether reduction strategies, and the perceived limited efforts to reduce the drug involved is tobacco, alcohol, a prescription product or an demand and supply. While limited data are available on illegal drug. Few Victorians would accept giving any message government expenditures in this area, it is clear that expenditure about drugs that does not include the message of care, concern made nationally and at the State level on controlling supply far and preparedness to act to reduce harm. exceeds outlays on prevention, treatment and harm reduction Both the ‘harm’ and the ‘minimisation’ words carry significance. strategies. Drugs do ‘harm’ in many ways. These include: Some see harm minimisation as implying acceptance that drug • harm to the health of users; misuse will occur, and that its consequences should be dealt with • economic harm to the user and others affected by rather than attacking its causes. These views give rise to the drug-related activity; concern about the message it sends to the community. No • social harm to families and through drug-related violence or government, in any way, condones the use of illegal drugs and criminal stigma; and most actively seek to reduce the misuse of legal drugs. However, • harm through public nuisance and drug-related crime. it is important to take active steps to minimise harm when and where it is happening. To do otherwise would be irresponsible.

Key Challenges - Drug Stragtegy now and in the future 18

Other concerns are based on the perception that the harm The Committee believes the principle of harm minimisation, linked reduction element of harm minimisation is essentially focused on with the action areas outlined in the Ottawa Charter on health the individual, and that minimising the negative impact on a user’s promotion, provides a platform for setting objectives and defining family and networks or the broader community has not been strategies for more effectively tackling the drug problem in our adequately considered. This concern can be dealt with by community. ensuring a broad approach is taken. Such an approach is advocated in this report. 2.3 Objectives While committed to a harm minimisation framework, few Australian governments have invested funds in a way that would This report is designed to assist the State Government with the strengthen community understanding and support for the implementation of its drug policy, and to propose a framework for fundamental objective. Relative to the investment in controlling ongoing development of drug policy and strategy. It is important supply, little has been done to reduce demand through that clear objectives be set to guide implementation and prevention, treatment and harm reduction programs. The State evaluation. Government’s drug policy, if implemented effectively, will Setting objectives in this area is complex, given the diversity of the contribute to shift toward a more balanced investment across the problem and the limited control the State Government or components of harm minimisation. community agencies have over the issue. A significant increase in In a practical sense, the key matter is not whether one supports production or an international price war, for example, can have harm minimisation; rather, it is a matter of acknowledging that: dramatic impacts on supply and price in this country. Chapter 3 • with the exception of alcohol and prescription drugs, there is includes comments on the growth in the global production of no safe level of drug use. In the case of other substances, heroin, and identifies changes to price and purity that have abstinence is the best way to avoid harm and it should be contributed to making heroin more accessible in this country. encouraged; Therefore, care needs to be taken in setting objectives and • in a drug- and risk-taking society, many will experiment with assessing the effectiveness of implementation. drugs or occasionally use them in a risky way. Without As part of the development of national drug strategy, the Illicit encouraging or in any way condoning such behaviour, society Drugs Expert Working Group has prepared a set of objectives as needs to acknowledge that it will happen and be prepared to part of a national action plan. The action plan and the objectives inform and advise its members about safe ways to use; and are currently subject to a national consultation before being • some people will use drugs in a highly dangerous manner and presented to Commonwealth, State and Territory Ministers for it is in society’s interest, as well as the interests of individuals, consideration. that we all take responsibility for reducing the damage they do The Committee has used the draft objectives as the basis for its to themselves and others. proposals. Not all have been used, and some have been varied to The Committee endorses the harm minimisation approach. It make them relevant to a State strategy. Several have been varied regards it as an essential underpinning for drug strategy. Australia to broaden their scope from illegal drugs to all drugs. All of the is a drug-using society and, as a result, reaps benefits (where objectives need to be considered in the context of the pharmaceuticals are used for therapeutic purpose or where commitment to health promotion and harm minimisation, and the alcohol is used in moderation) and substantial costs. If the impact of action on one group of objectives on others. No community is to reduce those overall costs, a harm minimisation objective can be considered in isolation, nor can action to approach is essential. implement one objective be justified in isolation. Effectively implementing a harm minimisation approach requires: The Committee believes the State Government should adopt the • evidence about what works, what doesn’t, and at what cost to following objectives for drug policy: understand who is being harmed and how to minimise that harm; PREVENTION • flexibility to find strategies that work in different settings and Through the reduction of demand and the promotion of situations; opportunities, settings, and values that promote resilience and • coordination and communication: there is a risk that while reduce risk, to: tackling one issue, unintended harm may be done in another • prevent the uptake of illicit drug use; area or to another group in the community; and • delay the uptake of drug use; • multiple strategies to deal with each component of the • reduce the level of use and harm resulting from drugs across approach and the different circumstances in various locations. the community; The approach also requires that the stereotype and negative image • increase community understanding of drug-related harm, and of drug users must be changed. Stigmatising users and isolating increase community capacity to participate in informed debate them into a devalued subculture is counterproductive. An effective and action about drugs and drug strategy; drug strategy will seek to re-engage drug users, and to establish • increase the positive alternatives to drug use that are positive communication and relationships as part of reintegrating acceptable, accessible and meaningful to those most at risk, them into the community. We need to revalue the person, but not and those from socially, educationally and culturally diverse accept the drug misuse as a normal part of society. backgrounds;

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 19

• foster a community attitude that supports the family and SAVING LIVES positive parenting; and In reducing drug-related harm, to: • provide educational environments that are supportive, inclusive • reduce the harm for individuals who use drugs and their and safe for young people. families and, in particular, to CRIMINAL JUSTICE AND LAW ENFORCEMENT - decrease drug-related overdose deaths, illnesses and Through interventions to reduce availability and supply, to: injuries; • prevent and effectively disrupt illicit drug supply and - decrease the spread of infectious diseases through distribution networks, and contribute to national and injecting drug use, and unsafe sexual practices as a result international supply control efforts; of intoxication; and • reduce street-level dealing in drugs and the associated public - decrease suicides and attempted suicides associated with nuisance as part of integrated community strategies to illicit drug use; manage drug issues; • improve community amenity in areas of high public drug use • refer minor offenders, appropriately diverted from the criminal and drug-related disruption; justice system, to counselling, treatment and other services; • encourage a strengthened focus and increased skill in using • impose sanctions with treatment conditions, where harm minimisation strategies; and appropriate, on offenders; • increase the capacity of law enforcement agencies to • punish those who traffick in drugs, or whose repeated contribute to reduction of harm caused by illicit drug use. offending poses an unacceptable burden on the community; CAPACITY BUILDING and Through workforce development to: • maximise the treatment and rehabilitation of offenders while • further develop an effective and informed workforce in the under sentence. health, welfare, education and law enforcement sectors; GETTING LIVES BACK ON TRACK • increase capacity to attract and retain a highly skilled specialist Through providing treatment and support, to: treatment workforce in the health system; • strengthen the capacity of mainstream health, welfare, • increase the capacity of the generalist health and welfare education and law enforcement systems to provide their core workforce to identify drug problems and related harm, and services and more effectively meet the needs of people apply evidence-based interventions; affected by substance use; • continue to educate the health, education, law enforcement • maintain a drug treatment system with strong links to mainstream workforce in principles that underpin strategies to reduce the health, welfare, education and law enforcement systems; harm caused by illicit drugs; • provide a treatment and support system that attracts and • maintain a skilled and supported specialist drug law retains drug users early in the course of harmful use, and enforcement workforce; and which continues to provide health care and other support • develop a skilled and supported health promotion workforce services; that is familiar with evidence-based health promotion and the • provide an integrated treatment system that is capable of antecedents of drug use. providing continuity of care across relapse episodes; Through research, the State Government aims to: • improve the health and status of drug users, and work to • increase evidence-based practice in health, education, welfare provide them with meaningful support and opportunities to and law enforcement sectors; influence the services provided; • increase instances of integrated and collaborative research, • increase capacity to provide the range of evidence-based development and dissemination between health, law treatment options for dependent drug users; enforcement and education and welfare sectors; • increase capacity to provide support to the families of drug • better focus research priorities; users, and to include them in treatment where appropriate; • increase participation in national and international law • increase capacity in the treatment system to undertake enforcement and health research projects; and systemic needs analyses, including the capacity to respond to • maintain and enhance support for policies, programs and emerging drug problems and institute new services; interventions that use the best available research evidence. • increase recognition that treatment only has meaning if it is Through performance measurement and formal evaluation, to linked with support to get drug users though the difficult monitor and evaluate the drug strategy. process to finally achieving secure and lasting abstinence; and In later sections of this report, the relevant objectives will be • increase the support for drug users seeking to establish new referred to and linked to the strategies and actions proposed. and different ways of life by creating personal support, educational, employment and housing options.

Key Challenges - Drug Stragtegy now and in the future 20

2.4 The need for a strategic approach

Focusing solely on the issues normally identified as the core of drug policy will not provide the solutions or strategies required in the future. A broader framework is required. The Committee has sought to take a systems view of the response to drugs, as an effective drug policy can no longer work in isolation from other social policy domains. Drug policy now affects many areas of the community and the Government’s infrastructure must be engaged in the response. The following figure presents an overview of the systems that are critical to this end.

Figure 2.1 Drug Policy and the Social Infrastructure

Public Nuisance & Saving Lives Disorder

Mental Health

Policing Health Services SOCIAL INFRASTRUCTURE

Government Community Corrections Non Government Youth Specific Services

Education Sports and Arts

Treatment support & Drug Treatment Services Prevention rehabilitation

Figure 2.1 attempts to draw together all the elements of Until now, relatively little has been done in relation to prevention prevention, saving lives, improved treatment and law enforcement. apart from school drug education. Prevention has often been THE NEED FOR INCREASED PREVENTION EFFORTS equated with such education and occasional mass media campaigns. A more sophisticated and multifaceted approach is The Committee is of the view that prevention, with government urgently required, and can be justified on the basis of agreed working in partnership with the community, represents one of the knowledge about how to proceed. major opportunities to more effectively tackle the drug problem. Prevention strategies do not replace treatment and criminal justice interventions, but they can, over the longer term, reduce demand for such interventions.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 21

Schools and the education system have significant capacity to The specialist treatment system has tended to be dealt with in promote resilience and support the vulnerable. Parents often isolation. Further development is required. In future, greater require information, advice and support to perform their critical attention will have to be paid to the relationships that specialist role. Local community involvement is vital. None of these treatment services have with each other, and with the other approaches alone will make a significant difference; together, far elements of the overall service system. The link between the more is possible. As with other parts of the drug strategy, criminal justice system and the treatment system is critical given prevention interventions must be based on evidence, not on that an increasing number of people are entering treatment as a popular opinion or assumptions. result of diversion, court requirements or imprisonment. Many effective prevention interventions may not have immediately The already rapid expansion of the specialist treatment system, obvious links to drug policy, yet they may contribute to reducing a and the further growth required over the next few years, mean the range of social problems including drug misuse. Prevention focus of this service network must now change. The priority must strategies that strengthen communities and enhance support for now be ensuring individual continuity of care within the specialist individuals must be encouraged and seen as part of an overall treatment system occurs, strengthening the role of the drug strategy, even though no specific drug issue is necessarily pharmacotherapy services, and improving linkages with other being tackled. elements of the social infrastructure. The linkages to the social The services established as part of the social infrastructure infrastructure are required because the specialist treatment outlined below can play critical roles in preventing drug misuse system has to have the clinical and practical skill to provide without in any way compromising their core roles, and without backup to others, and because effective rehabilitation and becoming part of the drug program. reintegration of people completing treatment will occur through these broader services. Prevention is often defined only as preventing use. The Committee uses the term more broadly to include each aspect of harm DRUG USER SUPPORT SERVICES minimisation. Preventing experimental use becoming dependent The Committee is of the view that inadequate attention has been use, and reducing the damage that dependent users do to paid to providing support to drug users, particularly those most at themselves and others, are therefore also included. Prevention risk and those causing significant public nuisance. There have strategies targeted at current users are a critical component of the been several important efforts made in recent years to involve overall approach recommended by the Committee. The Committee drug user representatives in policy formulation and service advocates a broad strategy and urges that cannabis, as the most development. The Committee acknowledges that many agencies widely used illegal drug, be given priority attention. working with drug users make substantial effort, above and Chapter 5 discusses these issues in greater detail and includes a beyond their core mandate, to provide health and other support to brief overview of the research now available to support expanded drug users. The Committee’s Stage One report dealt, in part, with prevention efforts. this issue. Later in this chapter, more detailed advice is provided about the implementation of a strategic response to drug THE PLACE OF TREATMENT IN A STRATEGIC DRUG overdose and street drug usage. The Committee regards this RESPONSE issue as a vital element of the overall framework and a key In recent years, attention has rightly been paid to the development challenge in its own right, and one that links to the important issue of specialist treatment services. The Government has made a of reintegration. commitment to substantially expand specialist treatment service Establishing and supporting organisations and networks of drug provision in response to clear need and considerable demand. users, ex-users and others able to interact with drug users in a The challenge of enhancing treatment effectiveness remains one constructive and positive manner is one of the most important of the most critical issues considered by the Committee. The initiatives that needs to be taken. importance of this element of the system cannot be overstated. While there is still much to learn about treatment effectiveness, LINKING CRIMINAL JUSTICE WITH OTHER PARTS there is no doubt that engaging drug users in treatment: OF THE SYSTEM • helps to prevent further harm; Law enforcement remains a critical part of the overall response to • helps keep people alive; illegal drug use. Reducing the flow of drugs into the country is • provides opportunities for reintegration into the community; important and, in this regard, the efforts of the Customs Service • is critical to alleviating the trauma and distress that drug users’ and the Australian Federal Police are crucial. At the State level, families and friends may be experiencing; tackling commercial trafficking is critical. It is also vital that Victoria • cuts costs to traders, local government, courts and police; and Police, the courts and the corrections system maximise their • helps reduce other causes of local harm including contribution to reducing demand and harm, and controlling supply. drug-related crime.

Key Challenges - Drug Stragtegy now and in the future 22

The introduction of the police cautioning scheme and the trialling of In focusing on the broad social infrastructure, the goals are to: court-based diversion schemes such as CREDIT are positive • improve prevention and early intervention capacity across the examples of the way harm minimisation principles can guide the State; response to drug issues. The expansion of these services through the • develop a more resilient service system that is able to meet the Commonwealth/State Drug Diversion Program is a welcome reform. range of current demands effectively; and Considerable effort will have to be put in to ensuring these services • enhance the capacity to reintegrate drug users into the are used to maximum effect, particularly in some areas where there is community, and provide supports that maximise the chance pressure for more assertive policing against drug users. they will not return to drug dependency. With an increase in drug misuse, the demands on Community Understanding the patterns and trends of typical ‘drug using Corrections Services, prisons and the juvenile justice system have careers’ is important in planning interventions. This is particularly also increased. Such demands have added emphasis to the need so at a time when the rates of induction into serious drug use are for skilled staff across the corrections system, and for post-release increasing, the age of induction is decreasing, and the patterns of and community support programs that link offenders to drug drug use are more complex. The information provided in chapters treatment and other components of the social infrastructure. 3 and 4 demonstrates the multiple demands that typical drug Managing demand in these systems will require system reforms in users make on State-funded services. One of the major courts as well as internally, and will also be affected by the consequences of the current epidemic of drug use will be an development of treatment and prevention initiatives. increased demand for a range of State-funded services over the The Local Priority Policing initiative being introduced across next 10 to 15 years. Victoria has the potential to further improve police responsiveness The Committee’s intention in developing and explaining the to community needs and local circumstances, and to the overall framework, and in emphasising the implications of drugs for many process of engaging communities in tackling the drug problem. parts of the social infrastructure, is to facilitate better long-term These issues are further discussed in chapter 7. policy making, and to inform investment choices across policy SOCIAL INFRASTRUCTURE - ROLES OF THE KEY domains. ELEMENTS IN RESPONDING TO DRUG MISUSE The State needs a drug policy and a drug policy element in each Data provided in chapter 3 of this report, and discussed further in major area of social policy. No mental health policy or children’s chapter 4, demonstrate the pervasive effect drugs are now having policy can be complete without a component that articulates the on many State Government programs and other parts of the responses to drugs that are possible and appropriate through that social infrastructure. The implications of these data are: policy domain. The Government has recognised the importance • services are experiencing increased demand as drug use of this principle in the emphasis placed on the role of the school leads otherwise independent people to rely upon a range of nursing program and the school welfare service in dealing with support services; drug issues. • some programs have reduced capacity to deliver their core In advocating that substantial energy be put into enhancing the services as a result of dealing with an increasingly large drug- capacity of every element of the State’s social infrastructure to affected population. This is not always acknowledged by respond to drugs, the Committee recognises that drug policy program managers, even when staff lack the skills and cannot become the central issue for every program. However, it is confidence to meet the needs of a growing drug-using client clear that failure to integrate drug issues into policy and program group; and design across the social infrastructure will have a damaging effect • some drug users are disenfranchised because they are unable on services and increase costs to the State Government. to receive services to which they would otherwise be entitled It is also clear that the drug-specific components of prevention, because service providers refuse them access on the basis of treatment and the saving lives strategy need to be designed to their drug dependence. share the load with other service systems. Special attention needs Drug use is now a substantial cause of demand for services. It also to be paid to targeting services at the pressure points in the leads to disturbance and disruption for individuals and families. community and developing both a short and long-term perspective. Early treatment of a drug user is a benefit in its own right. It is a greater benefit if it can stop that person occupying a prison bed. Establishing a drug policy, which is integrated into all the relevant aspects of the social infrastructure, requires application within each program and across programs. How to achieve cross- program collaboration has been a major dilemma facing governments for some years. This is discussed in chapter 8.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 23

SUPPORT SERVICES The Committee has had the opportunity to consider these matters As recognition of the complexity and diversity of the drug issue in its Stage One Report, Drugs: Responding to the Issues. That grows, so too must the acknowledgement of the need to provide report dealt specifically with the need to develop local drug more extensive and sophisticated program support services. The strategies in the municipalities most affected by heavy street drug drug policy and strategy field has changed remarkably in a very usage, and the framework for a trial of injecting facilities. The short time. In recent years, there have been substantial changes Committee believes both of these proposals are important and to school drug education, treatment services and drug diversion need to be seen as part of an overall saving lives strategy. programs. Considerably more money is now invested and many A ‘saving lives’ strategy is not just about the period leading up to of the changes are positive. Yet these changes and improvements or immediately after an overdose. It is about services that increase are jeopardised because virtually no new recurrent funds were the health of current users and reduce the likelihood that they will made available for data collection, monitoring systems, workforce overdose. A ‘saving lives’ strategy needs to give priority to the development and evaluation. A significantly expanded and most vulnerable (who are street drug users) and include other changed system is not backed up by the necessary support dependent users. A ‘saving lives’ strategy can help them lead services. Current service provision will be less effective than healthier lives, reduce the impact of drug use on the community, expected, and future developments will be slowed or stopped if and provide a new and responsive way into the treatment system. these support deficiencies are not confronted. It is regrettable that the injecting facility trial has not received The Committee is aware that the community and the Government parliamentary approval at this time. The Committee remains want to ensure as much expenditure as possible is focused on convinced that the trial would have provided valuable information services directly dealing with drug users. Both the Government and was very likely to have contributed to saving lives and and community are rightly wary of proposals to expand the reducing public nuisance. The Committee also believes there bureaucracy that supports these services. While acknowledging remains a strong base of support for the proposed trials, these concerns, the Committee believes it is important to ensure particularly in the affected communities. sufficient support is provided to the service systems so maximum The Committee considers that it is important that the Government benefit can be gained from the funds invested to maintain their seeks to achieve the same goals as articulated for the injecting core functions and deal with drug issues appropriately. These facilities trial through alternative means, while acknowledging their issues are discussed in more detail in chapter 8. essential limitations. The Committee’s Stage One report identified the key goals for the 2.5 Saving lives injecting facilities trial. The goals are repeated here because they encapsulate the requirements of a ‘saving lives’ strategy. Much Many drugs can and do cause death. Alcohol, prescription drugs can still be done to achieve these. and tobacco all have the capacity to kill, as do most illegal drugs. The key goals of the trial [‘saving lives’ strategy - added for this The Committee has sought to ensure the community is aware of report] should be: the risks, and of the unacceptable level of drug-related deaths in • a decrease in the public nuisance resulting from drug use, our community. In the first stage of its work, the Committee’s evidenced by a: issues paper, Heroin: Facing the Issues, highlighted the current - reduction in incidence of injecting in public places; death rates and projected further increases in heroin deaths in - reduction in injecting equipment litter on the streets; future years. This remains one of the key challenges that must be - reduction in the disruption to businesses and their tackled as part of the overall drug strategy. customers; All elements of drug policy make a contribution to saving lives. - reduction in the bodily fluids on, in and around buildings Prevention of all kinds keeps people alive, including the overdose and public spaces; and prevention strategies targeted at current drug users. Getting drug - greater availability of access to public spaces that had users into treatment and rehabilitation is a critical part of the been at risk of being ‘taken over’ as a result of the strategy. Law enforcement can save lives directly and indirectly. drug situation; While specific and additional steps need to be taken, it is • a reduction in the number of deaths and serious injury due important to recognise the breadth of activities that contribute to to overdose among street-based drug users accessing the saving lives. facilities; Contrary to speculation in some sections of the media earlier this • facilitation of access to drug withdrawal and treatment, other year, the number of overdose events continues to increase. This is health services, housing, education, employment, social clearly unacceptable. Data on overdose events and death rates welfare, child and family services, legal, and recreational are included in chapter 3. services; and • a reduction in the number of infections among drug users, particularly hepatitis B and C, HIV and bacterial infections including abscesses.1

Key Challenges - Drug Stragtegy now and in the future 24

The major ways to tackle these goals within the current legal The local area strategies need to be linked together, particularly in framework include: adjacent areas. They also need to be linked to broader strategies • developing self-care training and support programs that that complement their work. Examples of broader strategies that encourage drug users to better care for themselves and their might be developed are: peers; • providing improved information, education and training for • using professional staff to provide more outreach. They can drug users in a manner most likely to positively influence their build working and supportive relationships with drug users, behaviour. This issue is discussed further in chapter 5; supply more information and advice, and link users to • training drug users in CPR to enable them to assist friends and treatment and support services wherever possible; associates; • expanding the range of services that provide support and • providing information and training in overdose response to the assistance, practical and emotional, accepted by drug users; families and friends of drug users; and • providing health-care services in places and ways that are • providing information to those leaving prison, residential health relevant to drug users to improve their general health; care and treatment services about the particular risks they face. • building upon the work of the Metropolitan Ambulance Service The Metropolitan Ambulance Service (MAS) has the lead role in to provide better and more sustained recovery services to the current response to overdose. Officers deserve special reduce the number of overdoses and respond when they recognition for their efforts, as these are often undertaken in very happen; and difficult circumstances. With their practical experience and • improving links between services. specialist knowledge, the MAS must be a part of the local team The Committee’s Stage One recommendations on local planning envisaged by the Committee. A ‘saving lives’ strategy needs to and the role of the ‘planning round tables’ deserve further enhance the efforts made by the MAS. Ambulance services, attention. The work on local drug strategies that resulted from police and users need to be linked to ensure users are not these recommendations is a vital component of the ‘saving lives’ reluctant to contact the MAS when an overdose happens. There approach. The Committee is aware of the progress being made in are additional options for enhancing the role of the MAS that the five municipalities and welcomes these efforts. In four of the should be considered in the budget process alongside other five key municipalities, detailed consultation processes have demands on this emergency service. commenced and, in some instances, been completed. A broad The Needle and Syringe Program also currently performs an range of options is included in each strategy. Major themes important function in saving lives through its core work of include: providing clean injecting equipment. International research • drug prevention through public awareness and education; demonstrates that needle and syringe services reduce HIV • prevention of overdose; transmission and do not contribute to, or encourage, drug usage.2 • integration and collaboration between service providers; and In addition to providing a vital direct benefit, needle and syringe • reducing risk through improved syringe retrieval. services provide a contact point with drug users. The Committee The Committee is also aware that several other municipalities are wishes to affirm the importance of that role, and to encourage the developing and implementing drug strategies that are relevant to strengthening and/or creation of strong working linkages between their circumstances. The development of these strategies is needle and syringe services and others providers. In many ways, welcome and should be encouraged and supported. this service can be the cornerstone of a new and responsive It is vital that all of the organisations and individuals capable of service for drug users and local communities. contributing to these goals work as part of a team. An effective Many welfare and drug treatment agencies have worked hard with ‘saving lives’ strategy will combine those things made possible by limited resources to respond to the needs of drug users. These new resources, with existing services and resources used to their organisations need to be encouraged and assisted. Minor changes optimum. A coordinated approach is required and needs to to funding and accountability arrangements for these organisations respond in a wholistic manner to the needs of drug users rather may return a large dividend in prevention and rehabilitation. than having a specific issue or program focus. This will require many organisations to change their approach to create integrated local responses that meet the goals outlined above. Each local area with heavy and visible street drug use will have different issues to face and different ways to respond. The saving lives strategy needs to be developed as part of the local drug strategy to capture these opportunities. The Committee believes the diversity of each area must be respected, but that to establish an integrated service system, each function outlined above must be included in each area’s response.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 25

The revised arrangements at local level can also contribute to the Research currently being conducted into treatment options for goal of reducing public nuisance. A more supportive service for opiate-dependent people focuses upon alternatives to street drug users, which provides health and other services as well methadone, with buprenorphine currently being considered. as outreach, should reduce some of the visible aspects of drug Buprenorphine is a relatively safe drug that is longer acting than use. Outreach services designed to prevent overdose or assist other drugs and is therefore attractive to treatment professionals recovery will also reduce the impact of drug use on communities. and to drug users. This drug may be able to be safely prescribed Other aspects of local drug strategies will also contribute. for people whose lifestyle remains relatively chaotic. The The Committee is aware of the need to improve the rate of Committee supports a trial of providing buprenorphine for such appropriate disposal of injecting equipment in many areas of the drug users provided that a competent agency, working directly State. The Committee believes reshaping and more effectively with street users, is prepared to auspice the trial. Further supporting the Needle and Syringe Program, and making more consideration should be given to this proposal six months after systematic efforts at retrieval of discarded injecting equipment, is a the fully developed local drug strategies have been implemented high priority. Community support for needle and syringe services in the five municipalities affected by heavy street drug usage. and the drug strategy will be enhanced if injecting litter is reduced. The Government’s pre-election policy includes a proposal to Support for the needle and syringe service at the local level will make Narcan available to non-medical and ambulance officers as contribute to the service’s capacity to maximise return rates. There part of a trial. This proposal has considerable merit. Narcan is an is evidence overseas that there are ways to achieve this goal opioid antagonist that reverses the effects of opioids. It can be without diminishing the effectiveness of needle and syringe injected into the bloodstream or into muscles and, within one to services, or reducing drug users’ access. It is in the interest of drug five minutes, positive effects are seen. There are risks in the use of users and the community that retrieval receives a higher priority. Narcan, but use by ambulance officers indicates these can be The development of a new and responsive health and care managed through careful training. service for drug users, focused on the most vulnerable street drug Overseas trials have provided Narcan directly to users, their users, represents a major step toward an effective drug strategy. families and friends. More conservative options involve providing The local services outlined in this report will be providing critical the drug to a number of professional staff employed in services services to users, working with communities, and offering a new likely to come into contact with drug users at high-risk times. The interface with treatment and other support services. integrated support services envisaged in this section of the report Achieving these aspirations will also require a highly skilled and will employ such staff. committed workforce. Staff will require professional training and experience in relevant disciplines. Senior staff will require 2.6 Reintegration - The missing qualifications and experience in areas such as nursing, social work, youth work and psychology. Ongoing training will be a element of the strategy priority. It is essential that the Government recognise the need for Most drug users become disconnected in some way from family, skilled and experienced staff, and support the development of non-drug using friends, work and other activities that are these services with appropriate funding. Funding arrangements important to leading a meaningful life. Those who have become for the saving lives strategies will need to accommodate enmeshed in the drug-dependency culture during adolescence appropriate salary levels and staff development costs. Further may not develop in important ways, and so they may need more comment on this issue is made in chapter 8 in regard to the support when they finally reach the stage of needing to rebuild overall development of the drug strategy. their lives. Strengthening and/or rebuilding personal capacities The outreach, health and recovery services envisaged in this and constructive social connections are important at all stages of report should be subject to specific evaluation in the same way as handling the problems of drug users, and hence must be an had been anticipated for the injecting facilities trial. The evaluation integral component of a drug strategy. Effective implementation of design prepared for the proposed injecting facilities trial should be a harm minimisation approach requires that efforts are made to amended to assess the effectiveness of the responses proposed de-stigmatise drug use to reduce the extent to which drug users in this report. Critical questions will include: are excluded from normal community services. • does the formalisation of the linking of needle and syringe There is evidence that early cannabis use is linked to poor services with other services diminish or enhance the core role educational performance, although it is not always clear whether of distributing clean injecting equipment? cannabis is the cause or an effect.3 However, retaining young • what are the features of the new service that should be cannabis users in school, providing counselling and using every common to all locations, and which are optional depending effort to change their use of the drug is a first step toward getting upon the needs of the particular area? a life back on track. The alternative of condemning and expelling • what skills mix and organisational arrangements maximise the the user from school is likely to increase these young people effectiveness of the local services? identifying themselves with elements of criminality. It can also mean continued drug use, and the likelihood of that young person moving into experimentation with more addictive drugs, as well as a greater risk of a life of crime, prostitution or trafficking.

Key Challenges - Drug Stragtegy now and in the future 26

In general terms, overcoming serious drug problems requires not 2.7 Expenditure on the drug effort only withdrawal from the physical dependence that drugs create, but major changes to lifestyle to reduce the social dependence on A key challenge for Government is to determine how it should drugs. It is almost impossible to give up drug use if all one’s close spread its efforts and its investment across the various elements friends and other associates continue to use them. Most dependent of drug policy. It is clear that, until now, efforts at the users have given up contact with friends who do not use drugs, and Commonwealth and State level have failed to achieve an every day is taken up with the commitment to get the next urgently appropriate balance between controlling supply and reducing needed ‘hit’. Handling the transition to a non-drug using milieu is demand and harm. The greatest effort has gone into law extremely difficult; even finding things to do to occupy attention and enforcement and, until recently, little or no funds were invested in time presents problems initially. In the long run, it is crucial to re- prevention. The treatment system was significantly under- establish non-drug using relationships and lifestyles. resourced, while high-profile harm reduction strategies have only Too often, the community expects the drug treatment service been modestly resourced. system to achieve the full reintegration of a former user into Meeting the challenges of the future requires a clear understanding society through ‘rehabilitation’. The Committee agrees that the of the nature and quantum of efforts and related expenditure to drug treatment system has a vital role in reintegration, but that role date. Unfortunately, there is little information that describes recent is necessarily limited. Rehabilitation is the first step toward and current expenditure on the overall drug effort. reintegration but is not the whole journey, and it is unreasonable to Systems are in place to identify some of the relevant expenditures. expect the treatment system, on its own, to fulfil this role. The Essentially, these are the things that are funded from the whole community must play a part in supporting the government dedicated drug budget allocation. There is clear evidence of systems and the voluntary agencies. No drug policy will be growth in that budget, and an ability to disaggregate effective until sufficient attention is paid to creating long-term expenditures. The State Government has already publicly pathways out of drug use. Without these pathways, a cycle of committed itself to spend an additional $55 million over the next treatment and relapse is created and this comes at heavy cost to three years through the dedicated drug budget. Dedicated the drug user and society. Commonwealth expenditures on drugs can similarly be identified. In this context, education and training, avenues to employment and Growth in this budget in Victoria is also planned largely as a result appropriate support for housing are all necessary components. of the COAG Drug Initiative. Meaningful employment is important for economic security and Regrettably, many expenditures that directly relate to the ‘drug social connections. The labour market is changing in ways that effort’ in this State cannot be accurately identified. Only a small make it far more difficult for people who are, or have been, involved percentage of the overall expenditure by Victoria Police on drug in dependent drug use and may have criminal records. law enforcement can be quantified with any accuracy. The budget The Committee accepts that the primary responsibility regarding allocations to specialist units can be identified, but the great bulk employment and income support for those seeking work rests of police involvement through general policing activities cannot. with the Commonwealth Government, and that the systems Current data collection and accounting practices do not allow an currently in place are only minimally responsive to the needs of accurate assessment to be made. Similar difficulties are faced in those affected by drugs. There is virtually no incentive, support or understanding the expenditures of the Australian Customs Service assistance provided to people in these circumstances and, for and the Australian Federal Police. The Committee understands some, there are active disincentives to access income security that the expenditures are substantial and considerably exceed the and work preparation activities. While advocating strongly that the outlays made through the dedicated drug budget. Other areas of Commonwealth Government develop more responsive strategies, expenditure that cannot currently be detailed include: things can be done through the State Government’s employment • the costs associated with accident and emergency, hospital and training strategy, through local government (which is a major care and the work of general practitioners; local employer), and through partnerships with employers and • the long-term cost of caring for people who experience brain local communities. The willingness of some employers and many damage as a result of overdose; local community groups to engage in these issues has been • costs of services required when families break up or are highlighted during consultations. The Government should traumatised as a result of the substance abuse of a family capitalise on this through general activities linked to drug strategy, member; and and through the community strengthening recommended in the • costs to the courts, juvenile justice and corrections systems of Committee’s Stage One report. Further comment is made on this those whose offences primarily result from their drug use. issue in chapter 8. Planning for and monitoring expenditures made through the The issue of secure and supported housing is discussed in more dedicated drug budget allocation is relatively simple. The detail in chapter 4. It is also vital in helping many drug users to re- following chart demonstrates the growth in expenditures which establish non-drug dependent lifestyles. Access to housing have occurred in recent years, or which the Government has (whether crisis, short term or secure and sustainable) plays a committed itself to make over the next three years. critical role as people move through their drug-using career. In this context, housing support is crucial at early stages as well as being a necessary precondition to effective reintegration into the community. This is discussed further in chapter 4.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 27 Figure 2.2 Budget Trends 1998-99 - 2002-03 The recommendations made in this report demonstrate that a wide range of options is available to Government. Throughout the 120 report, comment is made on the priority to be given to those State Government Initiative options. In the context of the key challenges, the following should 100 receive priority: COAG 19.25 28.0 30.0 • mobilising the community to be involved in prevention, 80 reintegration and tackling drug-related issues in their area or Ongoing 8.4 10.3 13.4 community; 60

$ - Million • developing and sustaining a multifaceted prevention strategy. A series of high priority new initiatives is proposed: some involve 40 commitments of drug funds, others the continued reform of 60.5 67.2 67.65 67.65 67.65 20 other service systems. The overall proportion of funding put into prevention must grow rapidly in the next five years;

0 • resourcing the range of social services working with drug- 1998/99 1999/00 2000/01 2001/02 2002/03 affected clients to be effective in their core business, and as providers of prevention and reintegration services; A framework in which the other major outlays can be identified • establishing ‘saving lives’ and drug user services that keep and assessed is urgently required. The framework needs to these people healthy and alive and reduce street nuisance; and integrate what might be called the ‘inner’ and ‘outer’ budget • building the support systems of workforce development, sectors for drugs. Future policy decisions will require judgements research and evaluation that are required in a complex and about whether the best return on investment will be achieved, for rapidly changing field such as drug policy. example, through more specialist treatment or new homelessness services. It is conceivable that five years from now, the 2.8 Responding to different Government can confidently commit funds to a range of initiatives that appears to have nothing directly to do with drugs while cultural needs knowing there will be a benefit. The Committee believes a significant investment in data gathering and economic analysis is Just as acknowledging that we are a drug-using society is central required. The Government should rapidly develop financial and to constructing a viable drug policy framework, recognising both program tools to ensure budget decisions can be made on the our indigenous history and multicultural nature of our society today basis of evidence and with clear understandings of overall are central to ensuring programs are responsive to client needs. priorities. The reassessment of State-funded programs across the KOORI COMMUNITIES social infrastructure will provide the information needed for the The impact of drug use on Koori communities is perhaps more economic analysis and priority decision making. significant given the health and economic deficits it faces. In planning for the continuing development of drug strategy, it Throughout this report and the Committee’s Stage One report, would be desirable to make some comparison with the effort emphasis has been placed on the need to engage the community being made in other jurisdictions. Unfortunately, reliable national in tackling the drug problem. This is particularly the case in Koori comparisons of expenditure are not available. Efforts in recent communities. The Committee strongly affirms the principle of years to produce meaningful national data specifically on empowering Aboriginal people and their organisations to act on treatment have failed because data are not available or not their own behalf in dealing with this and other health problems. In comparable. Difficulties in apportioning drug law enforcement saying this, the Committee recognises the importance of efforts also limit the validity of any current cost analysis. So little is mainstream services in supporting and assisting communities in spent on prevention that no efforts have been made to undertake every way possible. This imposes obligations on all health, national data collection. A national project designed to address welfare, law enforcement and government agencies to act in ways this failure is currently being developed for consideration by that are accessible and culturally relevant to Koori people. Commonwealth, State and Territory Ministers. The Committee It is particularly important that the collaboration between Koori understands that the Victorian Government has indicated it is communities and mainstream services include a focus on prepared to provide financial support to this project. research and integrating knowledge about what works for Aboriginal people and what does not. Best practice approaches will be different from those that apply in non-Koori communities, but will be equally important.

Key Challenges - Drug Stragtegy now and in the future 28

Consideration needs to be given to developing Koori-specific Diverse communities do not have fundamentally different kinds of approaches to drug issues. Community controlled health drug issues; rather, all communities share core needs in relation to organisations and cooperatives need to be resourced to develop prevention, treatment and law enforcement. However, the degree interventions as part of their ongoing programs, and to enhance of support needed may vary. In addition, culturally and linguistically the network of drug and alcohol services funded by diverse communities can experience particular frustrations that Commonwealth and State Governments. Particular attention also result from their lack of familiarity with the drug treatment and other needs to be paid to the needs of Aboriginal people who come systems, or from language barriers that jeopardise their ability to into contact with the law enforcement system. Koori communities’ take advantage of prevention initiatives such as drug education specific needs will be best addressed through the development of and parent support programs. They can feel reluctant about using a comprehensive and distinctive approach that should not, services that they interpret as not being designed for them, or however, be separated from the overall drug strategy because of which do not cater for their specific cultural, religious and even the critical linkages that must be made. culinary needs. Culturally and linguistically diverse communities For some years, the Department of Human Services has can also feel isolated from community debate about complex and employed a Koori project officer within the Koori Health Unit to often confronting issues, particularly if they have a different provide advice and assistance on drug matters. For many perspective to those being advanced during debate. reasons, the work has focused upon Koori staff in drug services Successive governments at the Commonwealth and State levels and Koori treatment services. This work needs to be continued have made commitments to culturally responsive service delivery. and broadened to ensure there is senior level Koori input to all Translating such commitments into programs on the ground elements of the drug policy. The Committee believes a Koori requires sustained effort and focus. Research carried out in perspective is required in the Government’s drug policy Victoria has highlighted the need for particular initiatives to be management team. The Government also needs to work with developed across the drug strategy for key communities. The Aboriginal peak bodies in health, justice and education to language and cultural requirements must be better dealt with in strengthen the overall support given to Aboriginal communities prevention strategies, treatment services and the law enforcement dealing with the drug problem. system. The community strengthening strategy proposed by the MULTICULTURAL COMMUNITY Committee can play a key role. However, without significant changes across the various systems, little will change. Key steps A number of studies, as well as consultations held by the that should be taken are: Committee, have highlighted the acute needs of some cultural • including culturally specific components in drug information and linguistically diverse (CALD) communities. Research recently and education strategies that provide facts about drugs, completed by the Macfarlane Burnet Centre for Harm Reduction explain harm minimisation and assist families to address has noted the disproportionate numbers of offenders from some cultural and generational issues. This will also involve working cultural communities in the juvenile justice and adult corrections with community leaders and ethnic media; systems. Although this can be partly attributed to the greater • developing formal working arrangements between drug visibility of some groups, and hence their increased likelihood of services and ethnic welfare services. This should include apprehension by police, it is clear that certain groups are subject formal protocols on referral, support and other matters; and to an elevated risk of social exclusion. Some communities • improving communication within the law enforcement system. experience particular socioeconomic disadvantage and social or cultural discrimination. These factors can contribute to members The Committee was particularly impressed with the efforts to of communities abusing drugs.4 Issues such as traumatic refugee include people from diverse backgrounds in community or migrant history, inter-generational conflict, English language consultations about local drug strategies, and would encourage problems and cultural displacement may increase vulnerability to this approach to be continued through the implementation of the drug abuse. The needs of recently arrived migrants are also drug strategy. significant, particularly if they have come from countries in which These issues are further discussed in relevant chapters of the report. drugs are produced and supplied to Australia. These factors make a strong case for the pronounced needs of many of those from CALD backgrounds. However, the Committee is aware of evidence that suggests services and programs for these communities are less responsive than for those from an Anglo-Celtic background or for whom language is not a barrier.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 29

2.9 Coroner’s input In April 2000, the Victorian Coroner released a report on an inquest into six of the 25 deaths investigated as part of a heroin-related research project. This report is part of a major study designed to increase understanding of the heroin overdose problem. The Committee welcomes this project and the Coroner’s report. The Government asked the Committee to give consideration to the report’s findings as many related to its terms of reference. Having now completed its work, the Committee believes it has considered all of the relevant issues, and that its proposals and recommendations have satisfactorily responded to the Coroner’s recommendations. Appendix 4 includes a response from the Committee to all of the Coroner’s recommendations.

Endnotes

1 Drug Policy Expert Committee. (2000) Drugs: Responding to the Issues: Stage One Report, p. 34. 2 National Commission on Acquired Immune Deficiency Syndrome. (1991) The Twin Epidemics of Substance Use and HIV, U.S. General Accounting Officer: Washington DC. 3 Lynsky, M., & Hall, W. (2000) Educational Outcomes and Adolescent Cannabis Use, NSW Department of Education and Training: Sydney, p. 17. 4 National Crime Prevention. (1999) Pathways to Prevention: Developmental and Early Intervention Approaches to Crime in Australia, Commonwealth Attorney General’s Department: Canberra.

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The problem of drug use in Victoria today

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 3 31

3.1 Introduction • suppliers diversify their activities to protect their profits from disruption caused by difficulties in obtaining any one drug. Production and distribution of drugs occurs across the globe and There are reports that South American cocaine cartels are Australia is a popular destination for suppliers. The Committee becoming involved in opium cultivation and heroin trafficking, believes Victoria’s drug problems can only be understood in the and that Asian heroin syndicates are trafficking context of a global drug market. Trends in the production of legal amphetamines;5 and illegal drugs are summarised in this chapter. The features of • more sophisticated marketing of illegal drugs takes place. This global and Victorian drug markets and patterns of legal and illegal increases their availability to novice and experienced users; drug use in Victoria are also described. The various impacts of • the potential for conflict in the market place is increased as drug use on the community are discussed and, where possible, suppliers seek to expand their market share. This creates an quantified to provide a basis for the analysis of the drug problem incentive for producers to lower prices and raise the purity of and the strategies proposed in this report. their products; 3.2 The global market in • production methods are becoming increasingly sophisticated; for example, hydroponic methods are used to cultivate illegal drugs marijuana; It has been estimated that, during the 1990s, the international • governments have no capacity to regulate through taxation or trade in illegal drugs had an annual turnover of around $US400 licensing, and there is no consumer protection in relation to the billion.1 This would represent around 8 per cent of global trade. composition or purity of drugs. Despite its illegal status, the illegal drug trade is a major industry In some countries, there is also evidence that alcohol producers in its own right. The removal of barriers to global trade in legal are actively competing with illegal drug suppliers through different commodities is likely to create increased opportunities for trading and more assertive marketing strategies; for example, by targeting in illegal drugs. the dance culture where ecstasy has become popular.6 The illegal drugs consumed in Australia come from a variety of On the demand side, a key issue is how far demand for drugs sources. Heroin, cocaine and ecstasy are almost entirely imported. can be affected by driving up their price.7 Some key points to The cannabis used in Australia is largely grown here, and most consider here include: amphetamines consumed in Australia are manufactured locally.2 • the addictive nature of drugs means demand for them might There is little evidence that Australia exports significant quantities of be expected to remain fairly steady, even as prices increase. illegal drugs, apart from some diversion of steroids manufactured Dependent users may have a limited ability to reduce their legally for veterinary use.3 Whether substances are manufactured consumption, even at very high prices, and price increases locally or overseas, the Australian trade in illegal drugs needs to be may simply lead them to run more risks and commit more seen as part of a global market for these products. crime to buy drugs; • the market is not homogenous and many users are not 3.2.1 Trade in illegal drugs: A market analysis addicted. Recreational users are likely to be more sensitive to The trade in illegal drugs is highly organised and increasingly price changes, and even heavy users may be motivated to global. Although it is necessarily conducted underground, without give up or cut consumption if prices rise; the formal mechanisms that govern other areas of international • higher prices, even if they have a minimal short-term effect, trade, it is clear that it shares many features of global markets for might discourage new users from taking up a drug, or legal commodities. At the same time, the illegal nature of the trade recreational users from continuing their use, thus reducing gives this particular market certain unusual qualities. demand in the long term. If use of one drug becomes too In the illegal market: expensive, users may switch to a cheaper alternative; • large profits are made at each point in the production and • the little empirical evidence available suggests that price supply chain. These are generated by the risks of participation increases do influence demand, particularly for relatively in an illegal activity, which in economic terms impose large expensive drugs. Demand for cannabis, which may consume transaction costs; less of a user’s income, is more stable; • investment is made in elaborate security and transport systems. • price increases may be one way of reducing demand for This can occur because there are high profits to be made, and drugs. It is not clear by what amount price must increase to it increases the cost and difficulty of supply control efforts. An generate a significant and sustained reduction in demand; extreme example is provided by the recent discovery in the • reduction in demand through price increases creates mountains of Colombia of a partially constructed full-scale significant risks because of likely market and dependent user reactions. For example, there are health risks through unsafe submarine designed to transport cocaine;4 injecting practices when police activity is increased. Price rises may also increase the amount of crime dependent users commit to buy drugs, and cutting the supply of one drug may lead users to switch to other, more harmful drugs.

The problem of drug use in Victoria today 32

3.2.2 Production of illegal drugs Growth in stimulant seizures has been a major feature of the world The United Nations Office for Drug Control and Crime Prevention drug market in the 1990s. Production of these drugs is not limited monitors the cultivation of opium and coca, and seizures of all by climate, and a diversified and active world market has illegal drugs. The figures below show some general trends in developed. This is spurred by the introduction and widespread global drug supply since 1986. For opium and coca, it is possible distribution of new synthetic drugs such as ecstasy. to estimate actual production and measure the amounts of heroin Overall, it appears that strategies to reduce cultivation of opium and cocaine seized. For other drugs, trends in supply can only be and coca, and to seize the product before it reaches the market, indicated by trends in seizures, which obviously depend on other are having limited impact. At the same time, production of factors, such as the effectiveness of law enforcement. Figure 3.1 synthetic drugs seems to be booming. This is occurring despite shows the amount of heroin that could be produced from the sustained and very expensive efforts at supply control led by the amount of opium estimated to have been grown worldwide, and United States. In 1998-99, the US Federal Government spent an the volume of heroin that could have been produced from the estimated US$17.9 billion on activities described as drug control, opium, morphine and heroin seized. Opium production reached a including criminal justice, prevention, treatment and enforcement.9 new peak in 1999 after a period of relative stability since the mid- The largest single component was the US$8.5 billion spent on 1990s.8 Seizures rose until 1993, and have remained relatively criminal justice. A further US$1.8 billion was spent on interdiction, stable since then. Seizures have never accounted for more than and US$559 million on international programs designed to reduce 15 per cent of global production. the flow of drugs into the US. For all the resources spent on crop Figure 3.2 shows global seizures of the three major drug types eradication, alternative development and law enforcement traded internationally: heroin, cocaine and stimulants (including worldwide, these figures suggest that supply control can only play ecstasy). Cannabis is excluded, as the Australian situation is a small role in reducing the impact of drug use in our community. currently not significantly affected by global trends. Seizures of all three drugs have grown rapidly in the past 15 years.

Figure 3.1: Global heroin seizures and estimated volume Figure 3.2: Global seizures of heroin, cocaine, and remaining on the global market, 1988-1999 stimulants, 1984-1998 g,,, 600 35 400 Heroin seizures Stimulant seizures Cocaine seizures Heroin potentially available 350 500 30

Heroin seizures 300 25 400 250 20 300 200 15 150 200 Heroin (metric tonnes) 10 100 Cocaine seizures (metric tonnes) 100 5

Heroin and stimulant seizures (metric tonnes) 50

0 0 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 Year Year

Source: United Nations Office for Drug Control and Crime Prevention. Source: United Nations Commission on Narcotic Drugs. (2000) World (1999) Global Illicit Drug Trends 1999, UNODCCP: New York. Production in Situation With Regard to Illicit Drug Trafficking and Action Taken by the 1999 is from United Nations Commission on Narcotic Drugs. (2000) World Subsidiary Bodies of the Commission on Narcotic Drugs, Item 5(a) of the Situation With Regard to Illicit Drug Trafficking and Action Taken by the provisional agenda for the 43rd session, Vienna, 6-15 March 2000. Subsidiary Bodies of the Commission on Narcotic Drugs, Item 5(a) of the provisional agenda for the 43rd session, Vienna, 6-15 March 2000. The 1998 and 1999 global availability figures are based on the 1997 seizure volume being repeated.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 33

3.2.3 Global demand for illegal drugs 3.2.4 The international markets for individual drugs In a global market for illegal drugs, supply and demand in Victoria Heroin are affected by the worldwide demand. The United Nations Drug Opium is cultivated in three main areas: the Golden Crescent Control Program estimates that 3.3 to 4.1 per cent of the global (Afghanistan and Pakistan), the Golden Triangle (Burma, Thailand 10 population use illegal drugs annually. Cannabis is the most and Laos), and Latin America (Mexico and Colombia). The single widely used drug, and it is used by an estimated 2.5 per cent of largest source is Afghanistan, which accounted for over 75 per the population. This is followed by amphetamine-type stimulants cent of global production in 1999.13 In the Golden Triangle, which (including ecstasy), cocaine and heroin. However, consumption of is the source of 80 per cent of heroin imported into Australia, heroin is more widespread geographically than cocaine. production fell in 1999.14 This is likely to have been as a result of The UN Drug Control Program also looks at changes in demand climatic factors rather than a permanent reduction. It is not yet for drugs over time, based on the number of countries reporting clear what effect the shift in production from the Golden Triangle increases or decreases in use.11 For all illegal drugs considered to the Golden Crescent will have on the availability of heroin in (except opium), more countries reported increases than Australia. The Australian Bureau of Criminal Intelligence notes that decreases during the 1990s. The decline in opium use is largely increased demand in China may reduce the supply of heroin to due to increased use of refined heroin in areas where opium was Australia unless a route is established to supply Golden Crescent traditionally used. heroin to Australia. At the same time, growing demand for heroin Most major drug types, with the possible exception of cocaine, in Australia creates a powerful incentive to develop new methods 15 are already widely available in Australia. The major implication of of importation. Confirming this, recent advice from the Australian this diversification in supply for Australia is that the range of illegal Customs Service suggests that new routes are being opened 16 drugs is likely to continue to enter this country, and that cutting off from the Golden Crescent to Australia. one route of supply, or suppressing domestic production, is likely A record amount of heroin was seized in Australia in 1998-99, and to lead to another route opening. one seizure of nearly 400 kilograms accounted for most of the

17 At the same time as demand has grown, the price of most drugs total. This single seizure was the largest ever made in Australia, has decreased.12 The price of heroin and cocaine has been and was comparable to the total amount of heroin seized in steadily falling in Western Europe and the US over the past 15 Australia in previous years. The Australian Bureau of Criminal years at the wholesale and retail levels. Generally, it would appear Intelligence notes that ‘it is perhaps surprising that police services, that growth in demand has been matched, or driven, by sufficient drug agencies and research institutes around Australia have growth in supply to keep prices down. This experience is reported no substantial changes in the drug market to date as a 18 replicated in Australia and Victoria. result of this seizure’. Research conducted in Sydney and Melbourne in the months following this seizure detected no There is no one single global market for illegal drugs. Although change in price or availability of heroin.19 The New South Wales there are interactions between them, it may be more useful to think Bureau of Crime Statistics and Research monitored the Sydney of a series of markets for different drugs in different places. The heroin market over a two-year period but failed to find any following section outlines some characteristics of the markets for evidence that seizures affected the drug’s street price.20 various illegal drugs, and focuses on their implications for Australia. Cocaine Global cocaine production is estimated to have remained relatively stable throughout the 1990s.21 Coca cultivation occurs almost exclusively in the South American countries of Bolivia, Colombia and Peru. Eradication programs in these countries appear to have halted increases in cultivation, but not caused any sustained decline in production. Inability to expand production may have restricted the desire of traffickers to expand into new markets. However, there is now concern that declining demand in the US may lead to a search for new markets, possibly including Australia.22 A recent seizure of 317 kilograms of cocaine in Adelaide may be an indication that this is beginning to happen.23

The problem of drug use in Victoria today 34

Amphetamines 3.2.5 Australian supply control Globally, increased production of amphetamines and other Australia is a popular destination for illegal drugs. Our relative stimulants was a major feature of the illegal drug industry during affluence means many people can afford to buy drugs at prices the 1990s. Not relying on the cultivation of natural ingredients, that create the profit levels demanded by suppliers. amphetamine production can take place across the world, and Australia is also a popular destination because of the ease with the geographic spread of production has expanded considerably which drugs can be introduced into the country. Australia is a 24 in recent years. Amphetamines and methamphetamines are large country with a long coastline and an economy based on produced in Europe, the USA, across Asia, and in Australia and trade. The Australian Customs Service and the Australian Federal New Zealand. Police work across the world and in Australia to reduce the supply In Australia, domestic production seems to be the dominant of illegal drugs reaching this country, or getting into the hands of source of amphetamines. The amount detected at the border users when they arrive here. The Australian Government has decreased in 1998-99 while the number of laboratories detected recently invested an additional $213 million to expand these in Australia rose.25 However, production in South-East Asia efforts.31 appears to be rising and increasing in quality, and may soon Despite this, there are clear limits on the capacity of the Customs become more competitive in the Australian market. It is likely that Service to inspect items being imported given the number of any decrease in Australian production would lead to increased containers, and items in those containers, coming into the country. 26 attempts to import these drugs. In 1997, it was estimated that only 0.03 per cent of cargo entering Ecstasy and other designer drugs Australia is searched compared to 3 per cent in the US.32 Recent The emergence of ecstasy was a major feature of the worldwide funding increases may have lifted this percentage, but the best drug scene during the 1990s.27 Ecstasy originally became popular efforts of the Customs Service can only hope to detect a small in Europe among relatively affluent young people, particularly proportion of the drugs entering Australia. Given the limitations, it those involved in the emerging ‘rave’ dance party culture. Its is understandable that only some 10 per cent of the illegal drugs spread followed the growing popularity of dance music and being smuggled into the country are estimated to be intercepted.33 events, and their spread into mainstream culture. There are recent 3.2.6 Key issues reports that consumption is declining in Europe, possibly because The trends in the global production and supply of illegal drugs the drug is going out of fashion, or because users are dissatisfied have some major implications for Australia and Victoria: 28 with what is sold to them as ecstasy. • the global supply of illegal drugs is expanding over the long Ecstasy sold in Australia appears to be primarily imported, mainly term. There has been very limited success in stopping from Europe.29 Australian customs seized a record weight of increases in the cultivation of opium and coca leaf. There are ecstasy in 1998-99. Imports came mainly from the UK, Belgium, clear signs that production levels may increase in coming the Netherlands and Indonesia, which is likely to be a transit point years. Production of cannabis, which can be grown in most for European ecstasy. Five laboratories manufacturing ecstasy climates, and of synthetic drugs is extremely difficult to control were detected in Australia in 1998-99 and one was in Victoria. and the incentives for increased global production seem to be However, this is a small percentage of all clandestine laboratories in place; detected in Australia. • the global supply of drugs is diversifying as well as expanding Alongside ecstasy and amphetamines, an increasing number of in volume. Existing drugs are being supplied to new markets, ‘designer’ synthetic drugs are being manufactured and and new drugs such as ecstasy are emerging. It seems certain distributed. These are relatively rare in Australia, but are of that supply to the Australian market of the range of existing concern because their effects are relatively unknown, particularly and emerging drugs will continue to expand for the to users. As with ecstasy, an additional problem is that users have foreseeable future; and no way of knowing whether a pill actually contains what is • its illegal nature means the market for these drugs is advertised. Drugs identified by the Australian Bureau of Criminal characterised by high levels of risk to traffickers, and this leads Intelligence as available in Australia include GHB or ‘fantasy’ (a to high levels of profit. These profits are so attractive, new depressant formerly used as an anaesthetic) and ketamine suppliers are generally quick to fill gaps created by successful (another anaesthetic with hallucinogenic properties).30 law enforcement activities. The effect of each individual law enforcement success is temporary, and simply to prevent drugs becoming cheaper and more widely available, a string of these successes will be necessary.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 35

3.3 Drugs in Victoria 3.3.1 Illegal drug markets in Victoria Information on the key characteristics of markets for illegal drugs in Melbourne and other Australian capital cities is collected through the Illicit Drug Reporting System, chiefly from surveys of injecting drug users and other key informants.34 Other studies and the evidence gathered by the Committee during its consultation programs flesh out the picture painted by these figures. These trends are summarised in the table below.

Table 3.1: Illicit Drug Reporting System - Findings on drug markets in Melbourne

Substance Price Purity Availability Comments

Cannabis 1997: $20-25/gram, $350/ounce No hard data at this Easy There is not an established street 1998: $20-25/gram, $320/ounce stage, but reports market, but cannabis is easily 1999: $20/gram, $300/ounce that potency may be obtained at friends’ or dealers’ homes. increasing. Hydroponic production methods have become widespread. Heroin 1997: $30-40/cap, $450/gram 1996-97: 35% Easy Established street markets in Melbourne 1998: $20-25/cap, $400/gram 1997-98: 62% have become a major supply point in 1999: $20-25/cap, $300/gram 1998-99: 69% Victoria. These remove the need to have personal contacts to buy heroin. The trends in price and purity combined mean the amount of heroin that can be purchased for the same price increased nearly fourfold between 1997 and 1999.

Amphetamines 1997: $50/gram 1996-97: 5% Mixed While there is not an established street 1998: $50/gram, $820/ounce 1997-98: 11% reports market, amphetamines can be obtained 1999: $50/gram, $750/ounce 1998-99: 11% reasonably easily with the right contacts. Unlike many other drugs, the amount of pure amphetamine available for a fixed price does not appear to be increasing.

Cocaine 1997: $300/gram 1996-97: 37% Difficult Cocaine is not widely used or easily 1998: $200/gram 1997-98: 54% available in Victoria in contrast with 1999: $250/gram, $65/cap 1998-99: 49% recent reports from Sydney. Use is unlikely to increase significantly while the price is high and the drug is not readily available in street markets.

Ecstasy35 1997-98: $80/tablet 1998-99: 22-40% Increasing Ecstasy use is spreading from the 1998-99: $40-70/tablet dance scene, and it is now reported to be used by a range of people in a variety of contexts. Its relatively high price is likely to be a factor reducing ecstasy use. Recent decreases in price may change this.

Source: Dwyer, R. & Rumbold, G. (2000) Victorian Drug Trends 1999: Findings from the Illicit Drug Reporting System (IDRS), National Drug and Alcohol Research Centre: Sydney, except for ecstasy figures, which are from Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report 1998-99, ABCI: Canberra, pp. 55-56.

The problem of drug use in Victoria today 36

Key findings and implications • it is illegal to sell tobacco and alcohol to people aged under 18 From the above discussion, some key conclusions about illegal in Victoria, but it appears that young people have little trouble drug markets in Victoria can be drawn: in obtaining these drugs. By Year 9, the majority (52 per cent) • in Australia and Victoria, the price of most drugs is steady or have had a drink in the past month, and by Year 11 the 43 falling, and purity is steady or rising. Most drugs are easily majority (53 per cent) have had a drink in the past week. available to users; and Regular tobacco smoking is less common, but by Year 12, 78 • these trends are occurring despite significant law enforcement per cent of students have tried smoking and 33 per cent have 44 efforts. Chapter 7 looks at the relationship between law smoked in the past week. In the 1998 Victorian Drug enforcement activity and the price and availability of drugs in Household Survey, drinkers and smokers were asked where more detail. It seems that maintaining current prices, and the they usually obtained alcohol and tobacco. Twenty-one per level of risk to traffickers that underlies them, is a realistic goal cent of drinkers aged 14 to 17 usually obtained alcohol from a 45 for law enforcement; however, we are reaching the point where retailer. A more common source was friends and additional investments reap minimal returns. At a global level, it acquaintances (the usual source for 42 per cent of these has been estimated that 75 per cent of drug shipments would drinkers). Parents (18 per cent) and siblings (11 per cent) were need to be intercepted to significantly reduce the profitability of also prominent. Among smokers aged 14 to 17, 50 per cent the drug trade.36 It is asking too much to expect law usually purchased cigarettes from a retailer, while the next enforcement alone to significantly reduce drug consumption most common source (used by 43 per cent) was friends and 46 beyond current levels. acquaintances. A recent study by the City of Melbourne found that 43 per cent of tobacco retailers were prepared to 3.3.2 Supply of legal drugs sell to minors;47 Alcohol and tobacco • the use of alcohol in particular seems to be normalised among Alcohol and tobacco are the most widely used recreational drugs young people who are well under the age at which alcohol can in Australian society. Although controls are in place, they are legally be sold to them. At the same time, public concern often essentially freely available to adults. The supply of these drugs focuses on young people’s use of illegal drugs. The has all the characteristics of a legal, if relatively highly regulated, Committee has heard ample evidence in its community industry. consultations that drinking alcohol is regarded as normal and These drugs also appear to be widely available to people under inevitable behaviour for young people. It is either condoned by the legal age for purchasing them. Among Victorian secondary adults or supervised as part of a harm-minimisation approach students, over 80 per cent report having tried alcohol by Year 7.37 that assumes that young people will consume alcohol; and Thirty-eight per cent of Year 7 students report having tried • restriction in the sale of these products to young people tobacco, and 78 per cent had tried it by Year 12.38 Their legal undoubtedly affects their consumption. However, it is clear that status has meant harm minimisation strategies in relation to this impact is limited, and needs to be backed up by effective alcohol and tobacco have focused on demand reduction and demand-reduction strategies. encouraging responsible consumption. Prescription drugs The literature supports the following conclusions about the There were almost 200 million prescriptions for therapeutic drugs relationship between the supply of these products and their issued in Australia in 1998.48 Of these, over 36 million were for consumption: drugs acting on the central nervous system. The pharmaceutical • one major strategy to reduce demand for these legal drugs, or industry is a major part of the economy, and use of these drugs at least to meet some of the costs caused by their use, has brings great benefits to the community. Community concern been to increase their price through taxation. Tax may account focuses on inappropriate prescription of these drugs and their for at least 70 per cent of the retail cost of a packet of 25 non-medical use. Concern over the inappropriate use of cigarettes.39 The price of alcohol is more variable, but the prescription drugs has centred on tranquillisers. Benzodiazepines brewing industry has estimated that around a quarter of the account for the majority of tranquilliser prescriptions in Victoria, bar price of a glass of heavy beer is made up of tax.40 with over 1.8 million prescriptions in 1999. This is an increase of Consumption of tobacco and alcohol appears to be price- 5.9 per cent over 1998.49 Of those entering specialist drug sensitive.41 A US study of the effect of changes in the price of treatment services in Victoria in 1998-99, 4 per cent reported that cigarettes on consumption among different groups between their primary problem drug was tranquillisers.50 It is likely that a 1976 and 1993 found that young people and those on low significant number of those whose primary problem was with incomes were most price-sensitive.42 These groups were also other drugs, particularly heroin, also used tranquillisers. most likely to respond to increased prices by quitting rather than reducing consumption;

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 37

Some information on the availability of benzodiazepines for non- The relative numbers of dependent and recreational users are medical use is collected through the Illicit Drug Reporting System, difficult to estimate, and are likely to vary from drug to drug. For as the sample of injecting drug users surveyed commonly use opioids, a recent study estimated that there are 19,600 dependent benzodiazepines.51 Those working with drug users suggested that users in Victoria.53 When this figure is compared to survey results these drugs were easy to obtain, either through ‘doctor shopping’ on the extent of heroin use in the general population, it would (the practice of obtaining prescriptions from many doctors in the suggest that there are at least as many recreational users as same period to avoid detection) or through an established black dependent users. Some commentators believe the extent of casual market. Drug users surveyed also reported using a range of other use may be as much as three times that of dependent use.54 prescription drugs including opiates and anti-depressants. It was Although the data on which the following section draws look at not clear how much of this use is under medical supervision. use of specific substances, it is important to acknowledge the Although stringent controls are in place, prescription drugs are extent of poly drug use. People use many different substances clearly being used for non-medical purposes in Australia. There is separately, at the same time, or both. The same people are likely no evidence that there are underground sources of manufacture to be turning up as users of different substances, and the overall for these drugs. Rather, they are obtained through inappropriate extent of illegal drug use is likely to be much lower than the sum prescription, fraud involving stolen prescription pads and other of those using individual drugs. The extent of poly drug use methods, and on a secondary market for medicines obtained suggests that, for some people, there are factors influencing their through these channels. More stringent controls and better substance use that operate independently of the particular education for prescribers are possible strategies to cut off this substance chosen. Changing trends in the use of different supply. substances will reflect the availability of these substances and 3.3.3 Measuring prevalence of drug use in Victoria changing fashions among particular groups, but may not reflect significant changes in the underlying reasons for use. The way in which drug use has been measured makes it easiest to look at patterns of use in two categories: secondary students 3.3.4 Adolescents’ substance use and the adult (over 14) population. This will inevitably simplify the Data sources complex patterns of use that people experience across their The major source for information on the extent of adolescents’ use lifetimes. However, the data do validate the view that adolescence of various substances in Victoria is the School Students and Drug is chiefly a time of experimentation that is likely to be quite Use Survey.55 This survey was last conducted in Victorian different to adult drug use. We also know that the incidence of secondary schools in 1999, and comparable data are available 52 substance dependence in the population decreases with age. from surveys in 1992 and 1996. Another important data source is An important distinction is made in this chapter between the Adolescent Health and Well-Being Survey conducted by the experimentation with a drug and more habitual use. For most University of Melbourne’s Centre for Adolescent Health.56 This drugs, the information available is limited to lifetime prevalence survey asked students about their use of various substances, (the number of people who have ever tried a drug) and the alongside other health and behavioural outcomes, and their number of people using a drug in periods such as the year, month exposure to a number of factors that might increase or decrease or week before a survey. This provides a rough measure of current the likelihood of certain behaviour. At this stage, this survey has use as opposed to past experimentation, but it may hide quite only been conducted once in Victoria and because of this, it is of different types of use, such as recreational use confined to more use in detecting trends across age groups than over time. weekends as opposed to habitual use that interferes with a A different perspective is provided by longitudinal research. The person’s daily life. major longitudinal research conducted on young people in Although it is difficult to pin down, the distinction between casual and Victoria has been the Australian Temperament Project, which more habitual use is important in terms of the types of risks involved. provides some limited information on participants’ drug use.57 Casual use carries acute risks related to the act and circumstances Some information also comes from the Centre for Adolescent of using drugs; for example, the risk of heroin overdose, or of death Health’s Victorian Adolescent Health Cohort Study, which has now and injury due to drink driving. Secondary prevention strategies need tracked a group of young Victorians from Year 9 to the age of to be put in place to deal with these problems. However, habitual around 18 and asked them about a number of health issues use requires specific responses from the drug treatment system to including substance use.58 The analysis on the following page deal with the dependence itself, and with the disruption it causes to primarily uses the school students survey because it is the most the lives of users and those around them. established and detailed in terms of drug issues. Other sources are used to validate the conclusions drawn.

The problem of drug use in Victoria today 38

Trends and key issues The table below summarises the trends in adolescents’ substance use that emerge from the survey work outlined above, and draws out some of the key issues.

Table 3.2: Adolescent drug use - Key issues

Substance Year level of peak Trends in use Comments

Tobacco Year 11: males Between 1996 and 1999: reported While not quite as prevalent as alcohol, some Year 12 : females smoking levels generally declined or experimentation with tobacco is very common. By remained steady. There were significant Year 7, 38 per cent of students reported having tried falls in reported lifetime use at all year tobacco, and this rises to 78 per cent in Year 12. levels; but a significant decline in reported Use rises with age and, by Year 12, 33 per cent of monthly smoking only at Year 7; and the students reported smoking in the past week, and 39 only significant decline in weekly smoking per cent in the past month. was among Year 7 females. Females are more likely to report smoking in the past Some rises in reported smoking rates month than males at all year levels, but differences in between 1993 and 1996, but generally reported weekly smoking are less pronounced. reversed by 1999.

Alcohol Year 12 Increases in reported monthly use Reported alcohol use rises with age, and 19 per cent between 1992 and 1996 at Years 7, 9 of Year 7 students and 61 per cent of Year 12 and 11, but little change between 1996 students said they had a drink in the week before the and 1999. survey. The only significant increase in reported Binge drinking is most common among males, and drinking in the past week was among increases with age. Fifty-six per cent of Year 12 Year 7 males between 1993 and 1999. students reported engaging in binge drinking in the Female use is now as common as male past fortnight. Males are more likely to engage in use in Years 11 and 12. binge drinking than females at all year levels. Weekly use is almost the same among males and females by Year 11. This is a change from previous surveys, and indicates that young women’s levels of use have caught up with those of young men.

Sedatives Year 9: males Significant increases in reported lifetime Medical use of sedatives was included in the survey Year 10: females use between 1992 and 1996 at Years 7, 9 question. and 11, but some decreases between Reported weekly use peaked in Year 8 at 2.5 per 1996 and 1999. cent. Monthly use peaked in Year 10 at 5.7 per cent. No significant changes in recent use. By Year 12, around one in five students reported having used sedatives, but reported weekly use has declined to 1.1 per cent, the lowest of any year level.

Analgesics Year 9: males Significant increases in reported lifetime Medical use of over-the-counter analgesics such as Year 12: females use between 1992 and 1996 at Years 7, 9 Panadol is included in these figures. and 11, but some decreases between Some use of these substances is almost universal. 1996 and 1999. At Year 7, 94 per cent of students reported having No significant changes in recent use. ever used them, and the figure rises to 98.5 per cent by Year 12. Regular use is highest in Year 12 and 45 per cent of students reported use in the past week, and 77 per cent in the past month. Females are more likely to be regular users than males, and the gap increases with age.

Cannabis Year 11 Stable or declining since 1996 for all year By Year 12, around half of all students reported levels and genders following increases having tried cannabis. between 1992 and 1996. Males are more likely to be regular users at all year levels but, by Year 12, as many females as males have tried cannabis. Use peaks in Year 11 and 11.4 per cent of students reported using cannabis in the past week. In Year 12, this drops to 8.4 per cent. Cannabis is easily the most commonly used illegal drug, and most users do not use other illegal substances.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 39

Substance Year level of peak Trends in use Comments

Ecstasy Year 8: males Some increase since 1992. Ecstasy is not widespread in schools. Five per cent Year 12: females Trends hard to detect because of low of Year 11 students reported having tried it, and numbers. fewer at all other year levels. Males reported using ecstasy more commonly than females at all levels except Year 11.

Amphetamines Year 7: males The only significant increase between High levels of reported use among younger males Year 10: females 1992 and 1999 is among Year 7 males. probably reflect the inclusion of Ritalin (prescribed for Attention Deficit Hyperactivity Disorder) in the survey question. Amphetamine use seems to peak in the middle to late years of school, although at all year levels reported use in the past month is only around 2 per cent.

Opiates Years 9 and 10: males No significant differences over time, Use of opiates is low among students, especially in the Year 8: females partly due to low numbers reporting any later years of school. By Year 12, 4 per cent of students use. reported having tried opiates. At the peak of reported regular use in Year 8, 1.5 per cent of students reported having used opiates in the past month. Use of opiates peaks among students in the middle years of school. It is lowest at Year 12. It is likely that use is more common among young people outside the school system. Reported use is higher among males than females at all levels except Year 8. There is other evidence that the age of initiation into heroin use is declining, and that early initiation is associated with a range of negative outcomes.59 In the most recent household survey, 7 per cent of heroin users reported commencing use before age 16, where fewer than 1 per cent of those surveyed in 1993 had commenced this early.60

Hallucinogens Year 10 No significant differences over time, After cannabis, these are the illegal drugs with which except for a drop in lifetime use by Year 9 students most commonly experiment. In Years 11 students between 1996 and 1999. and 12, around 10 per cent of students reported having tried hallucinogens. Reported monthly use never rises above 3 per cent. It appears that most use is infrequent or experimental. Reported regular use declines by Year 12. Reported use is higher among males than females at all levels except Year 8.

Cocaine Years 7 and 8: males No changes over time in recent use, Cocaine is not commonly used. At no year level does Year 7: females largely due to low numbers reporting use. reported use in the past month reach 2 per cent. Some decreases in reported lifetime use Reported monthly use is highest in Year 7 for males since 1992 among Year 11 students and and females, and by Year 12 has declined to 0.3 per Year 9 females. cent. This is a surprising finding, but gains some support in the survey conducted by the Centre for Adolescent Health, where reported lifetime use is highest in Year 7.61 Even so, dishonest responses may well be a factor here.

Inhalants Year 7: males Little change between 1996 and 1999. Inhalant use is highest in the early years of school. Year 8: females Significant increases in Years 7 and 9 According to the survey, even lifetime use decreases between 1992 and 1996. with age.62 Reported use of inhalants in the past month peaks in Year 7 at 17 per cent of students. By Year 12, only 2 per cent report having used inhalants in the past month. Females are more likely to report use than males in Years 7 and 8, while males are heavier users than females from Year 9.

Source: Victorian Department of Human Services. (2000) School Students and Drug Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Substances Among Victorian Secondary Students, DHS: Melbourne. Tobacco data are unpublished data supplied by the Anti-Cancer Council of Victoria.

Introduction 40

Key findings and implications Federal research undertaken in 1999 found that: Most commonly used drugs • binge drinking is the norm for under-age drinkers; • the aim of most under-age drinkers is to get drunk quickly; and Although students commonly experiment with a range of drugs, • parents believe there is little they can do about under-age the most frequently used drugs continue to be alcohol, tobacco drinking and are more concerned about illegal drugs.64 and cannabis (in that order). Legally available drugs such as inhalants and sedatives are also used more commonly than any The same study also found that nearly 19 per cent of 15 to 17 illegal drug except cannabis. Use of analgesics, including medical year olds stated that they had 10 or more standard drinks on their 65 use, is very widespread. Students’ reported use of some drugs last drinking occasion. Thirty-two per cent of those indicating appears to have escalated between 1992 and 1996, and to have they had drunk ‘too much’ claimed that it had been in a situation remained stable since then. where there was adult supervision (such as in the home or at a party).66 Patterns of teenage drinking Binge drinking is a particular health concern for adolescents and Some experimentation with alcohol is almost universal among adults. In the 1999 secondary student survey, 56 per cent of Year secondary students. By Year 12, 98 per cent of students have 12 students reported binge drinking (defined as drinking five or tried alcohol and over 60 per cent are drinking weekly.63 It appears more drinks on a single occasion) in the past fortnight.67 Binge that restrictions on the sale of alcohol to people under 18 are not drinking carries significant acute risks, and the potential for long- sufficient to stop under-age drinking becoming widespread. This term damage to health. While some level of drinking appears to is hardly a new phenomenon. Under-age drinking is entrenched in be entrenched in youth culture, there is scope to reduce the harm Australian culture, and its frequency appears to be increasing. caused by binge drinking. Tobacco Tobacco use is also widespread, and increases with age. By Year Figure 3.3: Victorian secondary students, percentage 12, 33 per cent of students reported smoking weekly, and 78 per reporting drinking alcohol in the past week, by year level and cent reported having tried tobacco. More females than males gender, 1999 reported smoking monthly at all year levels.68

80 Males Females 70 Figure 3.4: Victorian secondary students, percentage 60 reporting smoking tobacco in the past month, by year level 50 and gender,p,yyg, 1999 40 50

Males Females 30 Percentage of students Percentage 40 20

10 30

0 Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 20

Year of students Percentage

Source: Victorian Department of Human Services. (2000) School Students 10 and Drug Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Substances Among Victorian Secondary Students, DHS: Melbourne. 0 Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 Year

Source: 1999 survey of over-the-counter and illicit substances among Victorian secondary school students, unpublished data provided by the Anti- Cancer Council of Victoria.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 41

No decline is visible in regular smoking in the early years of Other illegal drugs secondary school. This means that rates are likely to remain high It appears that a small but significant proportion of Victorian in the more senior years of school in years to come unless more secondary students experiments with illegal drugs other than effective interventions are implemented. The long-term cannabis. Experimentation with a range of drugs is common. By implications of this for the health of the Victorian population are Year 12, around one in 10 students has tried amphetamines and significant considering the contribution of tobacco-related illness hallucinogens.70 However, far smaller numbers of young people go to overall mortality. on to use these substances regularly. At all year levels, fewer than Cannabis 3 per cent of students reported using any of the illegal drugs other than cannabis in the past month. Given the emergence of ecstasy as a ‘mainstream’ drug over the past decade, some increase in use might be expected over time. Figure 3.5: Victorian secondary students, reported use of No such trend is visible in figures for use in the past month, selected substances ever and in the past month, all year largely because of small numbers reporting any use at all. levels, 1999 However, the number of students reporting lifetime use of ecstasy 0.30 increased between 1992 and 1999. The increase was statistically Ever Used Used in past month significant for students in Years 9 and 11.71 Increased ecstasy use 0.25 in the general population seems to have occurred mainly among people older than this sample of students. Data from the Victorian 0.20 Drug Household Survey show that ecstasy use is most common among people aged over 20, perhaps partly because of its 0.15 relatively high price.72

0.10 Community concern about heroin use by young people has Percentage of students Percentage grown in recent years. Across all year levels, 1.1 per cent of 0.05 students reported using opiates in the past month, although the number of students who had ever used them was not far below 0.00 the numbers trying some other illegal drugs. It may be that opiate Cannabis Hallucinogens Amphetamines Opiates Ecstasy Cocaine use is more commonly experimental, or that young people who Type of substance used become regular opiate users are unlikely to remain in the school Source: Victorian Department of Human Services. (2000) School Students system. The Adolescent Health and Well-Being Survey is clearer and Drug Use: Summary Report 1999 Survey of Over-the-Counter and Illicit on this point, and heroin registers as the drug least commonly 73 Substances Among Victorian Secondary Students, DHS: Melbourne. experimented with and least commonly used. There is little evidence of any change in patterns of opiate use over time, largely because the percentages involved are so small. Figures While Victorian secondary students appear to experiment with a from the 1992, 1996 and 1999 surveys are not significantly range of illegal drugs, cannabis is far and away the most different. However, there is other evidence that the age of initiation commonly used. By Year 12, around half of males and females into heroin use is declining, and that users born in the 1970s reported having tried cannabis.69 At the peak of regular use in Year commenced use on average at 16.5 years of age.74 In the most 11, 20 per cent of students reported using cannabis in the past recent household survey, 7 per cent of heroin users reported month, and 11 per cent in the past week. Based on these figures, commencing use before age 16, where fewer than 1 percent of cannabis use appears to be a mainstream activity among young those surveyed in 1993 had commenced this early.75 There is also people. Use may well be higher among those young people evidence that early initiation into heroin use is associated with a outside the school system, so figures for the entire age group range of negative health and social outcomes, such as overdose may be even higher. and criminal activity, compared to users who began later.76 Given the possibility of negative outcomes, any level of heroin use is of concern.

The problem of drug use in Victoria today 42

Both these surveys are limited to young people who are at school. Differences between legal and illegal drug use Heroin use, in particular, is likely to be much higher among young There is some evidence in the survey work outlined in this chapter people outside the school system. There is some evidence for this that patterns of drug use vary between legal and illegal drugs. in US studies that have found people who had not completed Use of alcohol and tobacco appears to increase over time, and high school had higher rates of substance use than those who remains high in the later years of school. The use of illegal drugs 77 had finished school. In Australia, some work has been done on seems more likely to be experimental, and often decreases by the the profile of young people engaging in problematic substance time students reach Years 11 and 12. It may be that using alcohol use. A Melbourne study of injecting drug users aged 14 to 22 and, to a lesser extent, tobacco, is part of a progression into an found that 90 per cent were not enrolled in school, the median adult world where these drugs are widely used. While using other age at which they had left school was 15.7 years, and some had drugs is more often part of an adolescent period of 78 left as early as age nine. In addition, the majority of those experimentation, it only becomes regular for a small percentage of attending Victoria’s Youth Substance Abuse Service who are not in young people. This is not to deny that some young people will 79 school, left school early. Lower usage rates in the later develop serious drug problems, especially since these young secondary years are likely to reflect those with higher rates of people will be less likely to still be at school, and therefore are substance misuse leaving the school system. However, it may excluded from much of the available data. also be that students who use drugs recreationally, cut down Some support for this pattern is found in longitudinal data collected during Year 12 as they devote more time to their studies. for the Australian Temperament Project.83 This study looked at Experimentation with drugs students’ substance use at ages 13 to 14 and 15 to 16. It found Illegal drug use is often experimental, and seems to peak in the that very few students gave up tobacco and alcohol between these middle years of school. Teachers claim this is a time of high stress ages, while significant numbers began smoking and drinking. for students, partly because of the physical and emotional Twenty-six per cent of the cohort went from no or infrequent use of changes of adolescence. The use of most drugs peaks by Year alcohol to frequent use over this period, and 15 per cent began 11 at the latest and, by Year 12, levels of regular use have frequent tobacco use. However, of those who used cannabis in the generally declined, at least among those still in the school system. first survey, 85 per cent had given up by the second. It is worth These middle years have been identified as a time when the noting that the Adolescent Health Cohort Study found a greater traditional school system does not work well for young people. It degree of stability in cannabis use among an older cohort tracked does not provide sufficient individual links between students and over three years.84 Three-quarters of those using cannabis in Year teachers, and personalised preparation for the senior secondary 10 continued to use in Years 11 and 12.

80 years is inadequate. The patterns of youth drinking suggest that our concern over the Gender differences increase in illegal drug use should not cause us to lose sight of In the past, young women’s experimentation and frequency of drug the huge problem of adolescent alcohol misuse. It has been use has been significantly lower than that of their male estimated that alcohol dependence is more common than counterparts; however, this gap is closing across most illegal dependence on all other drugs combined in the Australian adult substances, particularly cannabis. By Year 12, as many women as population, and over 17 times as common as opioid 85 men are drinking weekly, and as many have tried cannabis, dependence. although men are more likely to use regularly.81 Women are more 3.3.5 Substance use in the general population 82 likely to report smoking monthly than men at all year levels. There Victorians are regularly asked about their drug use through the may be a need for strategies specifically targeted at reducing Victorian Drug Household Survey.86 This provides information on harmful substance use among young women. use of various substances over time among people aged 14 and over. It should be noted that the survey methodology changed between 1995 and 1999, mainly in an attempt to ensure there were sufficient young people included in the sample, and to encourage honest responses. These changes are likely to have made the 1999 results more accurate, but to have limited the validity of comparisons with previous surveys.87

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 43

Trends and key issues The table below summarises the trends in Victorians’ substance use that emerge from the household survey, and draws out some of the key issues.

Table 3.3: Adult drug use - Key issues

Substance Prevalence of use Trends over time Key issues / comments

Tobacco Lifetime: 67% Little change in regular smoking during The age of initiation remains steady at around 15 Current smokers: 26% the 1990s following a decline since the years. More than 20 per day: 1970s.88 Female smoking rates are converging with those of men 6% Lifetime use declined from 1991 to 1995 as more men are giving up than women. but has risen since. The number of The decline in use has levelled off during the 1990s, and current smokers has remained stable new strategies may be required to further reduce use. since 1991.

Alcohol Lifetime: 91% Lifetime and current drinking have Men are more likely to drink regularly than women in Current drinker: 75% remained steady since 1991. all age groups. The gap is greatest among people Weekly drinker: 46% Increase in drinking at hazardous or aged over 25. harmful levels since 1991. Health concerns focus on heavy drinking. The percentage of the population who regularly drink more than two standard drinks for women or four for men has increased from 15 per cent in 1991 to 28 per cent in 1998. Men are more likely to be heavy drinkers than women.

Tranquillisers89 Lifetime:7% Large increases since 1995 when 4 per Non-medical use of these drugs is about as common Past year: 4% cent of Victorians had ever used these as use of the most commonly used illegal drugs drugs non-medically, and 0.9 per cent apart from cannabis. had done so in the past year. Tranquillisers are one of the few drugs where use is greater among females than males. Lifetime and recent use both peak among people aged 25 to 34. The median age of initiation is relatively high at 22 years.

Analgesics90 Lifetime: 12% 1998 was the first year this question was Non-medical use of these drugs is more common Past year: 6% asked. than use of any illegal drug except cannabis.

Cannabis Lifetime: 35% Increases in recent and lifetime use since Use in the previous year is highest among people Past year: 18% 1995. aged 14 to 24, and lifetime use is highest among those aged 25 to 34. More than half of people aged under 35 have tried cannabis compared to 4 per cent of those over 55. Males are more likely to use regularly than females. The median age of initiation is steady at 18 years. With use most common in the younger age groups, rates are likely to continue to rise.

Ecstasy/ Lifetime: 5% Sharp increase since 1995 when 1.9 per Ecstasy is the most commonly used illegal drug in designer drugs Past year: 3% cent had tried these drugs, and 0.6 per the past 12 months among 20 to 24 year olds apart cent used them in the past year. from cannabis. Eleven per cent of these people have used it in the past year. However, lifetime use is lower than for amphetamines and hallucinogens, perhaps reflecting its recent emergence. The median age of initiation is 21 years. At approximately $40-70 per tablet, the cost of ecstasy will affect who uses it and how often it is consumed. It appears that most ecstasy users are relatively affluent, use the drug recreationally, and do not need to commit crimes to support their use.91

The problem of drug use in Victoria today 44

Substance Prevalence of use Trends over time Key issues / comments

Amphetamines Lifetime: 9% Increases in lifetime and recent use since Alongside hallucinogens, these are the most Past year: 3% 1995. commonly used illegal drugs in Victoria apart from cannabis. Use is highest among those aged 25 to 34, with 9 per cent using amphetamines in the previous year and 21 per cent having ever tried them.

Heroin Lifetime: 2.2% Increases in lifetime and recent use, from Given the risk of overdose, even experimental use is Past year: 1.0% a low base, since 1995. of concern. Use peaks among those aged 25 to 34, with 5 per cent trying the drug and 4 per cent using in the past year. Males are more likely to use than females. At 24, the median age of initiation is the highest for any drug. However, other studies have suggested that the age of initiation is declining among younger users.92

Hallucinogens Lifetime: 9% Increases in lifetime and recent use since After cannabis, these are the most commonly used Past year: 4% 1995. illegal drugs along with amphetamines. Use is heavily concentrated among younger people. Among Victorians aged 20 to 24, 23 per cent have tried hallucinogens, and 10 per cent have used them in the past year. Only 4 per cent of people aged 35 and over have tried hallucinogens.

Cocaine Lifetime: 4% Increases in lifetime and recent use since Cocaine remains among the least used drugs in Past year: 1.3% 1995. Victoria along with heroin. Use is highest among those aged 25 to 34, with 9 per cent having tried cocaine and 5 per cent using it in the past year.

Inhalants Lifetime: 4% Increases in recent and lifetime use since Inhalants are not commonly used among adults. Past year: 0.8% 1995 with both returning to levels seen in They are the only drug where regular use is highest the early 1990s. among those aged 14 to 19, although lifetime use is higher among those aged 20 to 34. At 16, the median age of initiation is lower than for any illegal drug, although it has risen since 1993.

Source: Victorian Department of Human Services. (in press) 1998 National Drug Household Survey: Victoria Results, DHS: Melbourne.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 45

Key findings and implications Illegal drugs Most commonly used drugs Cannabis is far and away the most commonly used illegal drug in The major legal drugs, alcohol and tobacco, are easily the most Victoria. Other illegal drugs are relatively uncommon, and fewer 102 widely used. Some alcohol use is almost universal, and nearly half than 9 per cent of the population reported having tried each drug. the population uses it weekly. Of more concern is the number of people drinking at hazardous or harmful levels. Between 1991 and 1998, the percentage of Victorians reporting that they regularly Figure 3.6: Use of illegal drugs in the past 12 months, drink at hazardous or harmful levels has remained in a range Victoria, 1991-1998 between 6 and 8 per cent.93 Binge drinking, using two separate

94 definitions, appears to have increased between 1995 and 1998. 20 Cannabis In 1999, 14 per cent of men and 7 per cent of women reported Hallucinogens binge drinking in the previous fortnight. Amphetamines Ecstasy 15 Cocaine Regular use of tobacco is much lower, and around a quarter of Heroin the population reported that they are smokers.95 However, two- thirds of the population have tried tobacco. Tobacco and alcohol are the greatest sources of harm in the community, and tobacco 10 is the largest single cause of death and ill health in Victoria.96 Non-medical use of prescription drugs is slightly more common Percentage of population Percentage 5 than the use of any illegal drug other than cannabis.97 This may underestimate the problem, as medical use can also become problematic. Again, this is a problem that should not be forgotten 0 in the face of concern about illegal drugs. The wide availability of 1991 1993 1995 1998 Year these drugs for legitimate purposes creates a potential for misuse. Cannabis Source: Victorian Department of Human Services. (in press) 1998 National Drug Household Survey: Victoria Results, DHS: Melbourne, p. 17. Cannabis is the only illegal drug where consumption levels approach those for the major legal drugs. In 1998, 18 per cent of the population reported using cannabis in the past 12 months, Figure 3.6 looks at the use of illegal drugs in the previous 12 and 35 per cent had tried it.98 In a recent study on the economics months. In 1998, amphetamines, hallucinogens and ecstasy were of marijuana consumption, it was concluded that Australians are all used by 3 to 4 per cent of the population, while heroin and spending an estimated $5 billion per annum or $351 per capita on cocaine were used by around 1 per cent of Victorians. For all marijuana.99 This amounts to 1 per cent of Australia’s gross illegal drugs, use rose between 1995 and 1998.103 domestic product and represents double the expenditure on wine The increase in illegal drug use between 1995 and 1998 was most and three-quarters of the money spent on beer. The recent use of pronounced in the case of ecstasy and heroin. Given the high cannabis in the overall population increased between 1995 and levels of risk associated with heroin use, this last development 1998 (from 11 to 18 per cent).100 should be regarded with particular concern. A major reason for the increase in cannabis use appears to be The impact of heroin use continuing high levels of use among young people. For example, Heroin is a drug of major concern to the community, and often in the 14 to 24 year age group, 53 per cent of Victorians have tried dominates public debate on drug issues. An assessment of the cannabis and 37 per cent reported using it in the past year.101 place of heroin in the Victorian drug scene needs to balance the Cannabis use can hardly be regarded as abnormal among this undoubted evidence of the significant and growing level of harm group. As long as these levels of use continue among the caused by heroin with the relatively low number of people who younger age groups, lifetime use, and quite possibly regular use, reported using the drug. While heroin emerges from surveys as in the general population will continue to increase. one of the least used drugs in Victoria, it has a substantial impact on the lives of those who use it, their families and communities. Even though only 1 per cent of the population reported using heroin in a 12-month period in 1998, one-third of people entering drug treatment services in Victoria in 1998-99 had opiates as their main drug problem, the same number as had problems primarily with alcohol.104 The impact of heroin relative to other drugs is discussed in detail in the section on the impacts of drug use on the following page.

The problem of drug use in Victoria today 46

Illegal drug use among young people Comparison with the student survey A notable feature of the use of all illegal drugs is that it is confined The school students’ survey asks about use in the past month almost entirely to the younger age groups. For most drugs, the and the household survey about use in the past 12 months, so proportion of people aged over 35 who have even tried them is comparisons of recent use are not possible, even allowing for under 5 per cent, and no more than 1 per cent have used them in differences in the phrasing of the questions. However, some the past year.105 The picture for cannabis is slightly different. Here, tentative comparison of lifetime use is possible. From this, it use is highest among those aged under 35, but a significant appears that alcohol and cannabis are tried by around as many minority of those aged 35 to 55 use the drug. In this case, use is people at school as in the younger age groups of the minimal among those aged over 55.106 population.108 However, the peak age for use of amphetamines, Use of illegal drugs may be fairly routine among some groups of hallucinogens and ecstasy seems to be later. In the general young people. For example, 11 per cent of Victorians aged 20 to population, use of these drugs peaks between 20 and 34 years of 24 had used ecstasy in the past 12 months, 10 per cent had used age, and these drugs have been more commonly tried by people hallucinogens and 9 per cent amphetamines.107 More than one in in these age groups than by the sample of school students. five Victorians in this age group have tried amphetamines and hallucinogens. The extent of poly drug use means there is likely to be significant overlap between these groups of young people.

Figure 3.7: Use of selected illegal drugs in the past 12 months by age, Victoria, 1998

12 Heroin Amphetamines Cocaine Hallucinogens Ecstasy

10

8

6

Percentage of population Percentage 4

2

0 14 - 19 20 - 24 25 - 34 35+ Age

Source: Victorian Department of Human Services. (in press) 1998 National Drug Household Survey: Victoria Results, DHS: Melbourne, p. 37.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 47

3.4 The impact of drug use on For alcohol, the study projects that a decline in drinking levels will reduce the harm caused by alcohol among men.116 Harmful the Victorian community drinking among women is rising. However, the beneficial effects of Drug use has a range of impacts on the Victorian community. alcohol will also decrease, as the heart disease it helps to prevent Some are highly visible and frequently publicised; others are less becomes a less prominent cause of death. The overall effect will commonly understood. The impacts range from deaths that can be that the proportion of the burden of disease attributable to be directly attributed to drug use, to crime committed to pay for alcohol will remain steady at about 2 per cent. drugs, to resources diverted from other more productive uses. The study does not estimate the overall burden of disease There are also positive impacts, not just from the use of drugs in attributable to illegal drugs in the future. However, it finds that by medicine, but from the social and health benefits of a substance 2016 heroin dependence and poly drug use will be the sixth like alcohol used in moderation. largest cause of DALYs lost among men (up from sixteenth Some of the impacts of drug use cannot be quantified. The pain position in 1996).117 The projection of the mortality study is even and suffering, and disruption to lives and communities caused by more striking. It projects that by 2016 illicit drug use will be the drug misuse can be immense and can never be fully estimated. third largest cause of years of life lost among men (up from tenth However, figures are available on many drug-related harms, and place in 1996), behind only heart disease and lung cancer.118 This attempts have been made to put dollar values on the impact of is based on the rate of increase in heroin deaths up to 1996, and legal and illegal drugs. An advantage of this sort of approach is that the authors note that their projections fall short of the actual it can provide some basis for identifying those drugs that cause the number of deaths between 1996 and the report’s publication in most harm and allow strategies to be targeted to these areas. 1999.119 At the same time, this outcome could be averted if the 3.4.1 Ill health and death increase in deaths could be slowed. 3.4.2 Drug-related crime Using 1996 data, the Department of Human Services has conducted a comprehensive study of the causes of mortality One of the major concerns that the community has about drugs is (death) and morbidity (ill health) in Victoria.109 The health burden is the level of crime committed by drug users to finance drug use. measured in disability adjusted life years (DALYs), which are the Drug-related crime can be seen as having two main aspects. The equivalent of one year of healthy life lost.110 first is offences against drug laws: possession, trafficking or cultivation/manufacture of illegal drugs. The second is offences Of the risk factors considered, tobacco smoking made the biggest committed to obtain money to buy drugs and/or committed under contribution to the burden of disease in Victoria and accounted for the influence of drugs. Victoria Police figures show that the 9.8 per cent of total DALYs lost.111 Smoking was the most significant recorded crime rate fell in Victoria during 1999-2000.120 The number risk factor for men and accounted for 12 per cent of the burden of of crimes per 100,000 population fell by 1.2 per cent. Drug disease. Tobacco accounted for 7 per cent of the burden of disease offences fell by 13.6 per cent, but this is likely to reflect changed in women, ranked second behind physical inactivity. policing practices as much as any change in the level of drug This finding is consistent with other findings on mortality. This activity in the community. Of more concern is a rise in the types of component of the study found that tobacco smoking is the risk crimes against property that are often committed to obtain money factor causing the loss of the most years of life overall and among to buy drugs. In 1999-2000, compared to 1998-99, robbery rose men, and equal second among women.112 Tobacco was by 5.7 per cent, burglary by 4.9 per cent, and theft from motor responsible for 16.7 per cent of the years of life lost among men, vehicles by 8.1 per cent. and 9.3 per cent among women. There is some evidence that large proportions of these property The case of alcohol is more complex, as moderate consumption crimes are drug-related. A survey conducted of 800 robbery has been shown to have health benefits (for example, in offenders charged in 1999-2000 showed that 64 per cent of this preventing cardiovascular disease). The study found that alcohol crime was drug-related.121 The Australian Institute of Criminology actually prevented more deaths than it caused in Victoria in surveyed a sample of prisoners convicted of break, enter and 1996.113 However, the harm caused by alcohol was steal offences.122 The vast majority (85 per cent) had used illegal overwhelmingly among young people, and it contributed 2.1 per drugs in the six months prior to their arrest. Forty-one per cent cent of the overall burden of disease. The study notes that the attributed their offending to illegal drugs. The most commonly health benefits of alcohol are only seen among older people and used drug was cannabis followed by amphetamines and heroin. when consumption is moderate. The majority (58 per cent) had used more than one drug in the six Illegal drugs accounted for slightly less of the overall burden of months prior to their arrest. Forty-two per cent of offenders disease than alcohol, at 1.9 per cent.114 Most of the burden is reported offending weekly or more often in the six months prior to caused by heroin use. Heroin-related deaths cause a particularly their arrest. Those who offended to support a drug habit were large number of years of life lost as they tend to occur among more likely to offend weekly than those who did not. However, the young people. As with the legal drugs, the health burden of illegal simple fact of having used illegal drugs did not make offenders drug use falls predominantly on males. more likely to offend regularly. The study also estimates the burden of disease caused by alcohol and tobacco to the year 2016. Based on past changes in smoking patterns, it estimates that the burden of disease caused by tobacco will decline to around 8 per cent.115 The decline will be concentrated among men, and by 2016 the gender difference in tobacco-related morbidity will have disappeared. The problem of drug use in Victoria today 48

Given that those who attributed their crime to drug use committed The Victorian Drug Household Survey asks Victorians about their more crime than those who did not, it is probably a conservative experiences as victims of alcohol-related crime.132 In 1998, 27 per assumption that 40 per cent of these break and enter offences are cent of the population reported being verbally abused by drug-related. This would give a figure of around 30,000 drug- someone affected by alcohol in the past year. Seventeen per cent related burglaries reported to police in Victoria in 1999-2000.123 had been put in fear, 6 per cent had been physically abused, and Survey data shows that 83 per cent of break and enter offences 8 per cent had had property damaged. Encouragingly, the were reported to police in Victoria in 1998, so the total number of percentage of people reporting being victims of all types of these offences may be over 35,000, even on these conservative crimes declined strongly between 1992 and 1998. Of people who assumptions.124 had been victims of all types of these crimes, fewer than 30 per In Victoria, a sample of prisoners serving sentences of less than cent reported them to police. This suggests that reported crime 133 12 months was surveyed in January 2000.125 Of these, 75 per cent figures are significant underestimates. reported that they had a drug or alcohol problem. This rose to 84 It is difficult to directly track the amount of drug-related crime per cent among those who were not serving their first prison occurring in Victoria. However, there is evidence that property sentence. A significant minority (38 per cent) reported that they crimes in particular are often committed by people who also use had committed their offence to support a drug habit. Again, this illegal drugs, and that these offenders will often attribute their figure was higher among those who had been imprisoned before offending to drug use. Furthermore, these are the types of crimes (at 40 per cent). The proportion of the prison population serving that are rising in Victoria at the same time as the overall crime rate these shorter sentences of less than 12 months has increased is dropping. from 28 per cent in 1995-96 to 33 per cent in 1999-2000. This is 3.4.3 Street sex work creating pressure on the prison system overall. Victoria’s prison In addition to the drug-related crime discussed above, another population grew by 27 per cent between June 1996 and activity commonly used to finance dependent drug use is street November 1999126 and, at 30 June 1999, the system was running sex work. The Prostitutes’ Collective of Victoria estimates that over at 102 per cent of its capacity.127 90 per cent of street sex workers are injecting drug users, mainly Taken together, these figures paint a picture of a growing group of using heroin.134 Their participation in sex work and drug use offenders who are repeatedly committing (mainly) property causes major harms to these workers and the broader offences that are related to their drug use in one way or another. community. These include: the risk of transmission of blood-borne These people are likely to have multiple problems, and their rate diseases, given that unprotected sex is sometimes available in of reoffending makes it difficult for courts to impose non-custodial these markets; the risk of violence toward workers, particularly sentences. This is reflected in the fact that the percentage of drug given the lack of regulation of the street industry; and loss of offences attracting a custodial sentence has increased between amenity and sense of safety for residents of areas where street 1994-95 and 1998-99 from 5 to 11 per cent for consumption sex work is conducted. All of these are in addition to the risks to offences, and from 8 per cent to 38 per cent for supply offences. which most street sex workers are exposed through their drug use The percentage of those charged with drug offences refused bail alone. rose from 2.8 per cent in 1995-96 to 9.0 per cent in 1998-99.128 The combination of these harms creates a critical situation for all Chapter 7 discusses mechanisms to link those whose offending is concerned, and one in which harm minimisation principles are drug-related to treatment, and to broaden the bail and sentencing invariably compromised. options available. The Committee has not had the opportunity to fully examine this The survey of injecting drug users conducted as part of the Illicit complex issue. However, the Committee believes that a review of Drug Reporting System in 1999 found that 54 per cent of these the current regulatory regime around street sex work may be users had been involved in some form of crime in the last required. The illegal status of their work currently exposes street month.129 Dealing drugs was the most common form of crime sex workers to a level of harm that could be avoided and is over (engaged in by 38 per cent of users) but property crime was and above that which results from their drug use. More pragmatic second (at 21 per cent). regulatory regimes in place in New South Wales and parts of Drug use also affects the crime rate through offences committed Europe may offer models for reducing these harms in Victoria. under the influence of drugs, particularly alcohol. An analysis of The Committee has not been in a position during its work on assault figures in Victoria between 1995-96 and 1998-99 shows Stage 2 of its terms of reference to give this particular situation the that around a quarter of assaults consistently occur in ‘high consideration it needs. It is aware that local drug strategies are alcohol hours’. These are evenings and early mornings when a being developed in the areas most affected by the problems. It high proportion of assaults is known to be alcohol-related.130 In believes, however, that there may be a need to consider the issue 1998-99, alcohol was recorded as definitely involved in 31 per at a broader level, including examining the current regulatory cent of family incidents attended by police, and possibly involved framework, to see whether changes could be made which would in a further 12 per cent.131 These proportions had remained help to mitigate its numerous harms. relatively constant since 1995-96, although the overall number of incidents has increased.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 49

The newly formed Law Reform Commission may be an Figure 3.8: Non-fatal heroin overdoses attended by appropriate body to consider these issues. Melbourne ambulances and heroin-related deaths in Victoria, 3.4.4 The impact of heroin June 1998 to April 2000

In recent years, heroin has become the focus of increasing 500 Non-fatal heroin overdoses community concern about illegal drugs in Victoria. The balance of Fatal heroin overdoses evidence presented in this report suggests that heroin is having 400 an impact disproportionate to the low percentage of the population who report using it. The Committee’s Stage One report 300 provided a detailed analysis of the heroin situation in Victoria.135 In brief, this report concluded that: 200 • the high and growing number of overdose deaths is the most No. of deaths/attendance compelling argument for action to address the heroin problem. 100 There were 365 such deaths in 1999 and 242 by October 2000.136 0 It appears that the number of deaths in 2000 is likely to be almost

exactly the same as in 1999. The current figure is running slightly Oct 99 Oct 98 Jan 00 Jan 99 Jun 99 Jun 98 Mar 00 Mar 99 Nov 98 Aug 99 Aug 98 Dec 99 May 99 below the 1999 figure, but further investigation of deaths

occurring in 2000 is likely to lift the number attributed to heroin. Source: Turning Point Drug and Alcohol Centre, using Metropolitan Figure 3.8 adds the 2000 figures to the projection presented in Ambulance Service data for non-fatal overdoses; Victorian Institute of the Stage One report, and it shows that they broadly confirm the Forensic Medicine data for fatal overdoses. projection in that report of 496 deaths by 2005; • the number of non-fatal overdoses attended by ambulance officers dwarfs the number of fatal overdoses, and is growing. Metropolitan ambulances attended 3,696 non-fatal overdoses Figure 3.9: Heroin-related deaths, Victoria, 1991-1999 and in 1999, and have already attended 1,484 in the first four projection to 2005 months of 2000 (an increase of 4 per cent on the same period 500 in 1999). Figure 3.9 maps heroin overdose trends and projects Number of deaths 496 deaths projected for 2005 the number of fatal overdoses to the year 2005; 450 Projection for the rest of 2000 • the age of initiation into heroin use is declining. Heroin users 400

born in the 1970s began using at 16.5 years of age on 350 average, compared to an age of initiation of over 20 years for 300 those born in the 1940s; and • a key feature of the Victorian heroin trade in the 1990s has 250

been the emergence of highly visible street markets that have Number of deaths 200

removed the need to use personal contacts to buy heroin. This 150 has resulted in increased use near these street-based markets 100 by some users. Along with this comes a significant public nuisance, in terms of reduced feelings of safety, crime and 50 violence, litter and vomit. 0 2001 1992 2000 2002 2003 2004 2005 An analysis of the residences of 102 people who fatally overdosed 1991 1993 1994 1995 1996 1997 1998 1999 in Victoria in the first three months of 2000 shows the spread of Year heroin use across the State.137 The overdose victims lived in 36 of Victoria’s 78 local government areas covering the whole State. It is Source: Victorian Institute of Forensic Medicine. clear that, while the locations where people overdose are concentrated in those areas where there are active street markets, 3.4.5 Economic costs of drug use overdose victims live in all areas, including regional Victoria. Collins and Lapsley conducted the definitive study on the costs of drug use in Australia, looking at costs in 1992.138 While there has been no significant updating of this research since, examining trends in some of the major cost factors can give an overall idea of what may have happened to costs since 1992 and likely future trends. This study found that the total cost of the misuse of legal and illegal drugs in Australia in 1992 was $18.845 billion.139 Tobacco was the cause of 67.3 per cent of these costs, while alcohol accounted for 23.8 per cent and illegal drugs 8.9 per cent. The largest single costs were the ‘intangible’ costs related to premature death. These included the lost consumption of the deceased and the value of the lost years of life to the deceased.140

The problem of drug use in Victoria today 50

Loss of production, paid and unpaid, was also a significant the overall burden of disease related to tobacco to 2016. At the source of costs, and it was followed by the use of resources in same time, it predicts that the burden of disease relating to alcohol addictive consumption, and health care costs. The study will remain steady, and that years of life lost directly attributable to concludes that around half these costs are avoidable, in the heroin use will significantly rise among young men.144 Given the sense that they would not occur if Australia were able to match major contribution that tobacco-related disease makes to the the lowest rates of misuse achieved in comparable countries.141 overall costs of drug misuse, it seems likely that this trend would In 1999, the same authors produced an estimate of the costs of lead to an overall reduction in the level of these costs. However, tobacco use in Victoria, still using the 1992 data.142 They this will only occur if recent trends to lower smoking rates can be concluded that the costs of smoking in Victoria in 1992 were $3.2 sustained. The proportion of costs attributable to illegal drugs is billion, or around 25 per cent of the total Australian costs.143 likely to rise under this scenario unless an intervention can be Applying this percentage to the figure for all drugs yields an made to reverse recent increases in overdose deaths. estimate of a total cost of drug misuse in Victoria in 1992 of about 3.4.6 Other quantifiable impacts $4.7 billion. The estimate is conservative, as costs that could not The impact of legal and illegal drug use is felt across Victorian be quantified have been left out, and it fails to cover the full range society. Table 3.4 summarises some of the impacts where data are of impacts of drug use on the social infrastructure discussed in available, however imperfect. This is not a definitive list of the chapter 4 of this report. impacts of drug use, or even of those where data are available. The vast majority of these costs are related to mortality and, to a Chapter 4 looks in more detail at the impact of drug use on some lesser extent, morbidity caused by drug misuse. Looking at major government-funded services, many of which are now recent and projected trends in mortality and morbidity, it is struggling to deliver their core services under the pressure of their possible to draw some conclusions about likely future trends in clients’ drug use. costs. The Victorian Burden of Disease Study projects a decline in

Table 3.4: Some impacts of drug use

Impact Dimensions Trends over time Main drugs involved Comments / key issues

Use of specialist In 1998-99, at least 19,217 Funding increases in recent Alcohol and opiates were More detail and proposals for drug treatment clients received 36,125 years have expanded the each the primary problem for the future are provided in services episodes of care in Victoria.145 system. The budget has more 33 per cent of drug treatment chapter 6 on treatment and In 1999, there were around than doubled from $23.6 clients. A further 18 per cent support. 6,700 clients on the million in 1996-97. However, had their main problem with methadone program in 1998-99 is the first year of cannabis. Victoria.146 reliable data on numbers of The 1998-99 drug treatment clients. budget was $54 million. Numbers of methadone Private spending on clients have grown each year treatment and the use of non- since the program’s inception specialist services such as in 1985. In 1990, there were general practitioners for drug 1,407 clients, in 1998 5,334 problems are unknown. and by 1999 6,700.

Deaths directly There were 365 heroin-related Heroin deaths have grown Deaths directly attributable to Heroin overdose deaths are rising, attributed to drug deaths in Victoria in 1999, the rapidly from 49 in 1991 to drug use overwhelmingly and their impact in terms of years use largest number of deaths 365 in 1999. involve heroin, often in of life lost is becoming more directly caused by drug Alcohol and tobacco deaths combination with other drugs. prominent. use.147 declined slightly between When diseases caused by Health-promotion efforts seem to Estimates prepared by 1990 and 1998. drug use are taken into be having an impact on deaths Turning Point Alcohol and account, tobacco is the major related to alcohol and tobacco. Drug Centre suggest that cause and accounts for 91 Further reductions depend on the there were 4,866 drug-related per cent of these deaths. continued effectiveness and deaths in Victoria in 1998, Alcohol, opioids and poly relevance of health promotion. In including those from diseases drug use account for most of addition, many deaths relate to caused by alcohol and the remaining deaths. consumption in the past, and tobacco use.148 there will be a certain number of unavoidable deaths into the future.

Ambulance Ambulances attended over Attendances increased by 9 For the 18 months to attendances 12,000 drug-related events in per cent in the nine months December 1999, heroin Melbourne in 1999.149 In the to September 2000 over the accounted for 42 per cent of nine months to September same period in 1999. drug-related ambulance 2000, there have been 9,973 attendances.150 ‘Other drugs’, drug-related ambulance mainly benzodiazepines and attendances. analgesics, were the next largest category, followed by alcohol.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 51

Impact Dimensions Trends over time Main drugs involved Comments / key issues

Hospital Turning Point Alcohol and Tobacco accounts for admissions Drug Centre estimates that around two-thirds of drug- over 60,000 hospital related admissions, or admissions were attributable around 40,000 admissions. to drug-related causes in Alcohol was next, with over Victoria in 1998-99.151 15,000 admissions. Opiates were the illegal drug accounting for most admissions (around 2,500), while benzodiazepines accounted for over 2,000.

Road traffic Forensic reports of 209 fatally The total number of drivers Alcohol is the most common Alcohol, in particular, remains accidents injured drivers in Victoria in and riders killed with blood single drug present in 27 per a major factor in road traffic 1998 found that 24 per cent alcohol levels over .05 was 43 cent of fatally injured drivers. accidents and fatalities. The had blood alcohol levels in 1998.154 This was the same Cannabis was next, present role of other drugs is less above .05, and a further 3 per as in 1992, but lower than the in 15 per cent, although it easily quantified, but may cent had lower levels of average of 114 between 1984 stays in the system for weeks also be significant. alcohol.152 and 1989. This mirrors trends after consumption, and Twenty-nine per cent had in the overall toll, which has intoxication may not have other drugs in their systems. remained relatively steady been a factor in many of In the 1998 Victorian Drug since 1992.155 these accidents. Household Survey, 19 per However, the percentage of Opioids were present in 5 per cent of Victorians reported Victorians admitting to drink cent of fatally injured drivers. that they drove after drinking driving in the past year nearly too much in the past year.153 doubled between 1995 and 1998 (from 11 per cent to 19 per cent).

Drug crime Some 15,952 drug offences Drug offences fell by 13.6 per In 1998-99, 48 per cent of Nearly 80 per cent of arrests were recorded in Victoria in cent between 1998-99 and drug arrests were for were of consumers (that is, for 1999-2000.156 1999-2000. However, this is cannabis-related offences.157 possession or use rather than The amount of other crime likely to be more a reflection Heroin and other opioids trafficking or that may be drug related is of changes in policing accounted for another 42 per cultivation/manufacture).158 difficult to measure, but is practices than of changes in cent, and amphetamines The number of drug arrests discussed above. levels of drug activity in the were the only other drug and the split between community. where a significant number of consumers and providers, arrests were made. and between different drug types, are likely to continue to change as a result of changes in policing strategies.

Perceptions of 75 per cent of Victorians The perception of illegal From these results, it seems Victorians were more likely crime nominated illegal drugs as a drugs as a major problem that illegal drugs are seen as than people in any other major problem in their increased since 1997-98 a greater problem for State or Territory to see illegal neighbourhood in 1998-99.159 when 72 per cent of Victorians than alcohol in drugs as a major problem in Five per cent saw drunken Victorians saw it as a major terms of their feelings of their neighbourhood. Their and disorderly behaviour as a problem in their safety in their local perception of housebreaking major problem, and a further neighbourhood. neighbourhood. as a problem was at the 24 per cent saw it as The percentage of Victorians national average, despite somewhat of a problem. citing housebreaking as a Victoria having the lowest rate Housebreaking, which is problem also rose from 61 of these crimes in the often drug-related, was seen per cent in 1996-97. nation.161 as a major problem or Victorians’ perceptions of Victorians’ overall perceptions somewhat of a problem by 65 their safety in their home and of safety were at or around per cent of Victorians. local neighbourhood have the national average. remained steady since 1996- 97. However, perceptions of safety on public transport have declined over this period.160

The problem of drug use in Victoria today 52

Impact Dimensions Trends over time Main drugs involved Comments / key issues

Blood-borne Around half of those clients Levels of Hepatitis C and HIV Heroin was the drug of While the decline in rates of viruses tested at four Melbourne in injecting drug users choice for 80 per cent of the needle sharing is needle and syringe providers remained steady between sample of injecting drug encouraging, Hepatitis C between 1995 and 1998 1995 and 1998. users who were surveyed for remains a major health tested positive for Hepatitis The percentage and number the 1999 Illicit Drug Reporting concern for injecting drug C.162 This is a far greater of HIV cases where injecting System.165 However, a users and the wider concern than HIV, where the drug use is the likely mode significant proportion had community. The relatively low figure was consistently of transmission have recently injected levels of HIV in this population around 1 per cent. declined since 1990 when amphetamines, opiates other should not detract from the Of those HIV cases they peaked at 12 per cent, than heroin, and importance of health diagnosed in Victoria in 1999, or 35 cases. benzodiazepines. promotion concerning needle injecting drug use was Needle sharing by injecting sharing. identified as the likely route of drug users in 1999 was well transmission in six cases, below the levels reported in representing 5 per cent of 1997 and 1998 when 33 per total cases.163 cent had lent a used needle Of the injecting drug users and 22 per cent had used surveyed as part of the 1999 one. Illicit Drug Reporting System, 22 per cent had lent someone a used needle, and 9 per cent had used one in the past month.164

Needle and In 1999, needle and syringe The number of needles and As outlined above, heroin is Analysis of the 1999 data syringe programs programs in Victoria syringes distributed has the most commonly injected shows that 71 per cent of distributed over 5.2 million grown every year since the drug, but many users also visits to these programs were needles and syringes.166 Early program’s inception in 1987. inject other drugs.168 by males and 25 per cent by figures for 2000 remain The number distributed in females.169 Over half of these incomplete, but numbers 1999 was a 24 per cent visits were by people aged 21 have increased or remained increase on that in 1998 to 30 years. An average of 12 steady for those larger which, in turn, represented a syringes were collected on providers who have 43 per cent increase on 1997. each visit. reported.167

3.4.7 Key findings and implications • tobacco is the drug causing the most harm, in terms of overall It is clear that drug use has a range of serious impacts across costs to the community, followed by alcohol. The damage Victorian society. Many of these simply cannot be quantified and caused by these drugs is created by the nature of their relate to the disruption caused to people’s lives and the pain and negative effects and their widespread use. Heroin stands out suffering they face. However, some impacts can be measured, as the illegal drug that has the most significant consequences and these begin to give a picture of the complexity and for users and for communities where its use is prevalent. Other seriousness of the problem of drug misuse: drugs do not cause the same levels of harm in relation to the • around 10 per cent of the overall burden of disease in Victoria community as a whole, although there is no doubt that can be attributed to tobacco use. Alcohol and illegal drugs significant harm can come to individual users. each account for around 2 per cent; The range of impacts outlined in this chapter are only those where • drug use appears to be a significant factor in property crime in some data are available. The impacts that are not quantified here Victoria, although it is difficult to quantify precisely. Property are significant and wide ranging. The impact that drug use is crime is rising at a time when the overall crime rate is falling in having on various aspects of the social infrastructure is discussed Victoria. There is evidence of a group of people with multiple in chapter 4. All this serves to underline the importance of tackling problems who are repeatedly committing drug-related crime; the drug problem on a number of fronts. The benefits to be • the social costs of drug abuse were estimated at nearly $19 gained from effective action in this area are significant, and argue billion nationally in 1992, and around a quarter of these costs, strongly for an increased investment. At the same time, the data or $4.7 billion, was borne by Victoria. Although some factors presented in this chapter emphasise how complex and leading to these costs (such as smoking rates) are declining, entrenched the problem is. Constructive, innovative and evidence- the costs will remain significant for the foreseeable future. based solutions will be required. These figures are likely to be understated, as many costs that could not be estimated have simply been excluded;

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 53

27 European Monitoring Centre for Drugs and Drug Addiction. (1999) Annual Endnotes Report on the State of the Drug Problem in the European Union, EMCDDA: Lisbon pp. 82-84. Australian Bureau of Criminal Intelligence. (2000) 1 United Nations International Drug Control Programme. (1999) World Drug Australian Illicit Drug Report 1998-99, Commonwealth of Australia: Canberra, Report 1999, Oxford University Press: Oxford, p. 124. pp. 49-54. 2 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report 28 European Monitoring Centre for Drugs and Drug Addiction. (1999) Annual 1998-99, Commonwealth of Australia: Canberra. Report on the State of the Drug Problem in the European Union, EMCDDA: Lisbon, p. 85. 3 Australian Bureau of Criminal Intelligence. (1999) Australian Illicit Drug Report 1997-98, Commonwealth of Australia: Canberra, p 93. 29 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report 1998-99, Commonwealth of Australia: Canberra, pp. 52-54. 4 Anonymous. (2000) ‘High in the mountains, a drug lord’s submarine’, “Sydney Morning Herald”, 9 September 2000. 30 Ibid., pp. 86-87. http://www.property.smh.com.au/news/0009/09/world/world/world12.htm. 31 Commonwealth Government Illicit Drugs Strategy website: 5 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report http://www.health.gov.au/pubhlth/drugs/illicit/index.htm (Accessed: 27 1998-99, Commonwealth of Australia: Canberra, pp. 36 and 51. October 2000.) 6 European Monitoring Centre for Drugs and Drug Addiction. (1999) Annual 32 NSW Government. 1999, Defending our frontiers: a national strategy, paper Report on the State of the Drug Problem in the European Union, EMCDDA: prepared for the NSW Drug Summit 1999. (Online: Lisbon, p. 86. http://fourms.socialchange.net.au/material/seven-Defendin/html. Accessed: 10 October 2000.) 7 United Nations International Drug Control Programme. (1999) World Drug Report 1999, Oxford University Press: Oxford, p. 125 provides a summary of 33 Ibid. Information supplied to the Committee by those working in this field the debate and evidence on price elasticity. confirm that 10 per cent is a common estimate, although the percentage of drugs intercepted is notoriously difficult to measure. 8 United Nations Commission on Narcotic Drugs. (2000) World Situation With Regard to Illicit Drug Trafficking and Action Taken by the Subsidiary Bodies 34 Dwyer, R. and Rumbold, G. (2000) Victorian Drug Trends 1999: Findings from of the Commission on Narcotic Drugs, Item 5(a) of the provisional agenda the Illicit Drug Reporting System, Turning Point Drug and Alcohol Centre and for the 43rd session, Vienna 6-15 March 2000 p. 3. United Nations Office of National Drug and Alcohol Research Centre: Sydney. Drug Control and Crime Prevention. (1999) Global Illicit Drug Trends, 35 Ecstasy was not commonly used among the injecting drug users surveyed UNODCCP: New York, p. 40. for the Illicit Drug Reporting System. These figures are from Australian 9 US Office of National Drug Control Policy. (1999) Drug Data Summary, Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report 1998-99, ODCP: Washington DC, p. 5. (Online: Commonwealth of Australia: Canberra, pp. 55-56. http://www.whitehousedrugpolicy.gov/pdf/95253.pdf. Accessed: 23/10/00.) 36 United Nations International Drug Control Programme. (1999) World Drug 10 United Nations International Drug Control Programme. (1999) World Drug Report 1999, Oxford University Press: Oxford p. 123. Report 1999, Oxford University Press: Oxford, p. 31. 37 Victorian Department of Human Services. (2000) School Students and Drug 11 United Nations Office of Drug Control and Crime Prevention. (1999) Global Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Substances Illicit Drug Trends, UNODCCP: New York, Section 2. among Victorian Secondary Students, DHS: Melbourne, p. 25. 12 Ibid., pp. 88-89. 38 Survey of over-the-counter and illicit substances among Victorian secondary students, unpublished data supplied by the Anti-Cancer Council of Victoria. 13 United Nations Commission on Narcotic Drugs. (2000) World Situation With Regard to Illicit Drug Trafficking and Action Taken by the Subsidiary Bodies 39 Based on applying excise rates and 10 per cent GST to a retail price of $8.00. of the Commission on Narcotic Drugs, Item 5(a) of the provisional agenda 40 From the Australian Associated Brewers website: for the 43rd session, Vienna 6-15 March 2000, p. 3. http://www.itsyourshout.com.au/theissue/theissue.cfm (Accessed 6 October 14 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report 2000.) 1998-99, Commonwealth of Australia: Canberra, p. 33. 41 Davison, T., Ferraro, L., and Wales, R. (2000) ‘Review of the Antecedents of 15 Ibid., p. 45. Illicit Drug Use with Particular Reference to Adolescents’, Paper prepared for the Drug Policy Expert Committee, Section 5. pp. 2-4. 16 Presentation to the Ministerial Council on Drug Strategy, Perth 13 July 2000. 42 United States Centre for Disease Control. (1998) ‘Response to Increases in 17 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report Cigarette Prices by Race/Ethnicity, Income and Age Groups - United States, 1998-99, Commonwealth of Australia: Canberra, p. 37. 1976-1993’, Morbidity and Mortality Weekly Report 47(29), 31 July 1998, pp. 18 Ibid., p. 37. 605-609. 19 Rumbold, G., and Fry, C. (1999) The Heroin Market Place Project: Examining 43 Victorian Department of Human Services. (2000) School Students and Drug the Short-Term Impact of the Port Macquarie Heroin Seizure on the Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Characteristics of the Retail Heroin Market in Melbourne, Turning Point: Substances among Victorian Secondary Students, DHS: Melbourne, p. 25. Melbourne. 44 Survey of over-the-counter and illicit substances among Victorian secondary 20 Weatherburn, D. and Lind, B. (1995) The Impact of Law Enforcement Activity students, unpublished data supplied by the Anti-Cancer Council of Victoria. on a Heroin Market, NSW Bureau of Crime Statistics and Research: Sydney. 45 Victorian Department of Human Services. (in press) 1998 National Drug 21 United Nations Commission on Narcotic Drugs. (2000) World Situation With Household Survey: Victoria Results, DHS: Melbourne, p. 31. Regard to Illicit Drug Trafficking and Action Taken by the Subsidiary Bodies 46 ibid., p. 21. of the Commission on Narcotic Drugs, Item 5(a) of the provisional agenda for the 43rd session, Vienna 6-15 March 2000, p. 9. 47 City of Melbourne. (1998) Prevention of Tobacco Sales to Minors: A Report on the Findings of Stage One Retail Compliance Checks in the City of 22 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report Melbourne, City of Melbourne: Melbourne. 1998-99, Commonwealth of Australia: Canberra, p. 69. 48 Drug Utilisation Sub Committee. (1999) Australian Statistics on Medicines 23 Vanstone, A., Federal Minister for Justice and Customs 2000, Press release: 1998, Commonwealth Department of Health and Aged Care: Canberra, p. Record cocaine seizure, 18 August 2000. (Online: 18. http://www.customs.gov.au/media/news00/m000819.htm. Accessed: 5 October 2000) 49 Victorian Department of Human Services. (in press) The Victorian Drug Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, 24 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report DHS: Melbourne, pp. 37-38. This figure includes only prescriptions 1998-99, Commonwealth of Australia: Canberra, pp. 49-54. United Nations subsidised by the Commonwealth Government, which are estimated to be Office of Drug Control and Crime Prevention. (1999) Global Illicit Drug around 80 percent of benzodiazepine prescriptions. Trends, UNODCCP: New York, pp. 60-63. 50 Victorian Department of Human Services. (2000) Alcohol and Drug 25 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report Information System (Interim ADIS) Annual Report 1998/99, DHS: Melbourne, 1998-99, Commonwealth of Australia: Canberra, pp. 52 and 54. p. 20. 26 Ibid., p. 58.

The problem of drug use in Victoria today 54

51 Dwyer, R. and Rumbold, G. (2000) Victorian Drug Trends 1999: Findings from 78 Crofts, N., Louise, R., Rosentahl, D., and Jolley, D. (1996) ‘The First Hit: the Illicit Drug Reporting System, Turning Point Drug and Alcohol Centre and Circumstances Surrounding Initiation into Injecting’, Addiction, 91(8), p. 1189. National Drug and Alcohol Research Centre: Sydney, pp. 42-43. 79 Information provided by YSAS to the Committee. 52 Hall, W., Teeson, M., Lynsky, M., and Degenhardt, L. (1998) The Prevalence in 80 Fuller, A. (2000) Promoting Resilience and the Prevention of Substance the Past Year of Substance Use and ICD-10 Substance Use Disorders In Abuse, Violence and Suicide, Paper prepared for the Drug Policy Expert Australian Adults, National Drug and Alcohol Research Centre: Sydney, p. 18. Committee, pp. 8-9. 53 Hall, W., Ross, J., Lynskey, M., Law, M., and Degenhardt, L. (2000) How Many 81 Victorian Department of Human Services. (2000) School Students and Drug Dependent Opioid Users are there in Australia?, National Drug and Alcohol Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Substances Research Centre: Sydney, p. 53. among Victorian Secondary Students, DHS: Melbourne, pp. 25 and 27. 54 Hall, W. (2000) personal communication. 82 Survey of over-the-counter and illicit substances among Victorian secondary 55 Victorian Department of Human Services. (2000) School Students and Drug students, unpublished data supplied by the Anti-Cancer Council of Victoria. Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Substances 83 Williams, B., Sanson, A., Toumbourou, J., and Smart, D. (2000) ‘Patterns and among Victorian Secondary Students, DHS: Melbourne. Predictors of Teenagers’ Use of Licit and Illicit Substances in the Australian 56 Bond, L., Thomas, L., Toumbourou, J., Patton, G., Catalano, R. (2000) Temperament Project Cohort’, unpublished paper prepared for the Drug Improving the Lives of Young Victorians in Our Community, A Survey of Risk Policy Expert Committee, pp. 43-45. and Protective Factors, Centre for Adolescent Health: Melbourne. 84 Coffey, C., Lynskey, M., Wolfe, R. and Patton, G. (in press) ‘The Natural 57 Williams, B., Sanson, A., Toumbourou, J., and Smart, D. (2000) ‘Patterns and History of Cannabis Use and Progression to Daily Use in a Population- Predictors of Teenagers’ Use of Licit and Illicit Substances in the Australian Based Australian Adolescent Longitudinal Study’. Temperament Project Cohort’, unpublished paper prepared for the Drug 85 Hall, W., Teeson, M., Lynsky, M., and Degenhardt, L. (1998) The Prevalence in Policy Expert Committee. the Past Year of Substance Use and ICD-10 Substance Use Disorders In 58 Coffey, C., Ashton-Smith, C and Patton, G. (1999) Victorian Adolescent Health Australian Adults, National Drug and Alcohol Research Centre: Sydney, p. 18. Cohort Study Report:1992 to 1998, Centre for Adolescent Health: Melbourne. 86 Victorian Department of Human Services. (in press) 1998 National Drug 59 Lynskey, M. and Hall, W. (1998) ‘Cohort Trends in Initiation to Heroin Use’, Household Survey: Victoria Results, DHS: Melbourne. Drug and Alcohol Review, Vol. 17, p. 293. 87 Victorian Department of Human Services. (in press) The Victorian Drug 60 Hall, W. and Lynskey, M. (1998) Age of Initiation to Heroin Use: Cohort Trends Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, and Consequences of Early Initiation for Subsequent Adjustment, National DHS: Melbourne, p. 91. Drug and Alcohol Research Centre: Sydney, pp. 14-17. 88 Ibid., p. 78. 61 Bond, L., Thomas, L., Toumbourou, J., Patton, G., Catalano, R. (2000) 89 Many people who develop problems with these drugs use them in a medical Improving the Lives of Young Victorians in Our Community, A Survey of Risk context. The survey only asks about non-medical use of these drugs. and Protective Factors, Centre for Adolescent Health: Melbourne, p. 92. 90 Again, only non-medical use is included, and problematic use in a medical 62 This finding may reflect misunderstanding of the survey question among context is not captured. younger students. 91 Victorian Department of Human Services. (in press) The Victorian Drug 63 Victorian Department of Human Services. (2000) School Students and Drug Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Substances DHS: Melbourne, p. 34. Prices are from Australian Bureau of Criminal among Victorian Secondary Students, DHS: Melbourne, p. 25. Intelligence. (2000) Australian Illicit Drug Report 1998-99, Commonwealth of 64 Commonwealth Department of Health and Aged Care. (1999) Developmental Australia: Canberra, pp. 55-56. Research for a National Alcohol Campaign; Summary Report, DHAC: 92 Lynskey, M. and Hall, W. (1998) ‘Cohort Trends in Initiation to Heroin Use’, Canberra. Drug and Alcohol Review, Vol. 17, p. 293. 65 Ibid., p. 20. 93 Victorian Department of Human Services. (in press) The Victorian Drug 66 Ibid., p. 21. Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, 67 Victorian Department of Human Services. (2000) School Students and Drug DHS: Melbourne, p. 21. Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Substances 94 Ibid., p. 22. among Victorian Secondary Students, DHS: Melbourne, p. 9. 95 Victorian Department of Human Services. (in press) 1998 National Drug 68 Survey of over-the-counter and illicit substances among Victorian secondary Household Survey: Victoria Results, DHS: Melbourne, p. 18. students, unpublished data supplied by the Anti-Cancer Council of Victoria. 96 Victorian Department of Human Services. (1999) Victorian Burden of Disease 69 Victorian Department of Human Services. (2000) School Students and Drug Study: Morbidity Melbourne, p. 76. Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Substances 97 Victorian Department of Human Services. (in press) 1998 National Drug among Victorian Secondary Students, DHS: Melbourne, p. 27. Household Survey: Victoria Results, DHS: Melbourne, p. 17. 70 Ibid., p. 22. 98 Ibid., p. 34. 71 Ibid., pp. 32-33. 99 Clements, K., and Daryal, M. (1999) The Economics of Cannabis, Economic 72 Victorian Department of Human Services. (in press) 1998 National Drug Research Centre, University of Western Australia, p. 58. (Online: Household Survey: Victoria Results, DHS: Melbourne, p. 37. http://www.ecel.uwa.edu.au/econs/erc/Mari/Mari.pdf. Accessed: 29/10/00). 73 Bond, L., Thomas, L., Toumbourou, J., Patton, G., Catalano, R. (2000) 100 Victorian Department of Human Services. (in press) 1998 National Drug Improving the Lives of Young Victorians in Our Community, A Survey of Risk Household Survey: Victoria Results, DHS: Melbourne. As outlined earlier, and Protective Factors, Centre for Adolescent Health: Melbourne, p. 94. comparisons between the 1995 and 1998 surveys are affected by changes 74 Lynskey, M. and Hall, W. (1998) ‘Cohort Trends in Initiation to Heroin Use’, in methodology. Drug and Alcohol Review, Vol. 17, p. 293. 101 Ibid., p. 34. 75 Victorian Department of Human Services. (in press) 1998 National Drug 102 Ibid., p. 17. Household Survey: Victoria Results, DHS: Melbourne, p. 38. 103 This may, in part, reflect a change in the survey methodology designed to 76 Hall, W. and Lynskey, M. (1998) Age of Initiation to Heroin Use: Cohort Trends ensure a sufficient number of young people are included in the sample. and Consequences of Early Initiation for Subsequent Adjustment, National 104 Victorian Department of Human Services. (2000) Alcohol and Drug Drug and Alcohol Research Centre: Sydney, pp. 16-17. Information System (Interim ADIS) Annual Report 1998/99, DHS: Melbourne, 77 Cole, P and Weissberg, R. (1994) ‘Substance use and Abuse among Urban p. 20. Adolescents’ in Gullotta, T., Adams, G. and Montemayor, R. (eds), Substance 105Victorian Department of Human Services. (in press) 1998 National Drug Misuse in Adolescents, Sage Publications: Thousand Oaks, p. 101. Bates, S. Household Survey: Victoria Results, DHS: Melbourne, p. 37. (1997) ‘Volatile Solvent Use: Patterns of Gender and Ethnicity Among school 106 Ibid., p. 34. Attendees and Dropouts’, Drugs and Society, 10:1/2, p. 61. United Nations International Drug Control Program. (1997) World Drug Report, Oxford 107 Ibid., p. 37. University Press, New York, p. 324.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 55

108 Victorian Department of Human Services. (2000) School Students and Drug 141 Ibid., p. 51. Use: Summary Report 1999 Survey of Over-the-Counter and Illicit Substances 142 Collins, D. and Lapsley, H. (1999) The Social Costs of Tobacco in Victorian among Victorian Secondary Students, DHS: Melbourne, pp. 25-30, and and the Social Benefits of Quit Victoria, Quit Victoria, Melbourne. Victorian Department of Human Services. (in press) 1998 National Drug 143 Ibid., p. 5. Household Survey: Victoria Results, DHS: Melbourne, pp. 24, 34 and 37. 144 Victorian Department of Human Services. (1999) Victorian Burden of Disease 109 Victorian Department of Human Services. (1999) Victorian Burden of Disease Study: Morbidity, DHS: Melbourne, pp. 78, 80 and 92. Study: Mortality, DHS: Melbourne, and Victorian Department of Human Services. (1999) Victorian Burden of Disease Study: Morbidity, DHS: 145 Victorian Department of Human Services. (2000) Alcohol and Drug Melbourne. Information System (Interim ADIS) Annual Report 1998/99, DHS: Melbourne, p. 20. Episodes of care figure is an update supplied by the Department of 110 Victorian Department of Human Services. (1999) Victorian Burden of Disease Human Services. Study: Morbidity, DHS: Melbourne, p. 1. 146 Dietze, P., Laslett, A-M., McElwee, P. (2000) Trends in Drug Use and Harm in 111 Ibid., pp. 76-77. Victoria: Implications for Treatment, report prepared for the Drug Policy Expert 112 Victorian Department of Human Services. (1999) Victorian Burden of Disease Committee by Turning Point Drug and Alcohol Centre: Melbourne, p. 23. Study: Mortality, DHS: Melbourne, pp. 25-26. 147 Data supplied by Victorian Institute of Forensic Medicine. 113 Victorian Department of Human Services. (1999) Victorian Burden of Disease 148 Victorian Department of Human Services. (in press) The Victorian Drug Study: Morbidity, DHS: Melbourne, pp. 78-80. Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, 114 Ibid., p. 81. DHS: Melbourne, p. 12, using data from the Australian Bureau of Statistics. 115 Ibid., p. 78. 149 Metropolitan Ambulance Service data supplied to the Committee. 116 Ibid., p. 80. 150 Victorian Department of Human Services. (in press) The Victorian Drug 117 Ibid., p. 92. Note that these rankings are for direct causes of death, such as Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, particular diseases, road accidents and so on, not the risk factors discussed DHS: Melbourne, p.11. above that contribute to these various causes of death. 151 Ibid., p.11. Note that this estimate derives from using aetiological fractions to 118 Victorian Department of Human Services. (1999) Victorian Burden of Disease admissions for causes that may be related to alcohol and tobacco, but only Study: Mortality, DHS: Melbourne, p. 34. includes admissions directly attributable to illicit drugs. Tobacco data are for 119 Victorian Department of Human Services. (1999) Victorian Burden of Disease 1997-98. Study: Morbidity, DHS: Melbourne, p. 91.. 152 Victorian Department of Human Services. (in press) The Victorian Drug 120 Victoria Police. (2000) ‘Crime Rate Falls in Victoria’, Media Release, 9 August Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, 2000. DHS: Melbourne, p. 13. 121 Ibid. 153 Victorian Department of Human Services. (in press) 1998 National Drug Household Survey: Victoria Results, DHS: Melbourne, p. 44. 122 Makkai, T. (1999) ‘Drugs and Property Crime’ in Australian Bureau of Criminal Intelligence. (1999) Australian Illicit Drug Report 1997-98, 154 From the Victorian Transport Accident Commission website: Commonwealth of Australia: Canberra, pp. 105-113. http://www.tac.vic.gov.au/DOCS/521et/htm (Accessed: 4 October 2000.) 123 Applying the estimate of 40 per cent to the number of burglaries in Victoria 155 Ibid. Police. (2000) ‘Crime Rate Falls in Victoria’, Media Release, 9 August 2000. 156 Victoria Police. (2000) ‘Crime Rate Falls in Victoria’, Media Release, 9 August 124 Reporting rate taken from Steering Committee for the Review of 2000. Commonwealth/State Service Provision. (2000) Report on Government 157 Victorian Department of Human Services. (in press) The Victorian Drug Services 2000, Productivity Commission: Canberra, p. 616. Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, 125 Results quoted in Victorian Department of Justice submission to the DHS: Melbourne, p. 13. Committee. 158 Ibid., p. 13, using data from the Australian Bureau of Criminal Intelligence. 126 Department of Justice Submission to the Committee. 159 Steering Committee for the Review of Commonwealth/State Service 127 Office of the Correctional Services Commissioner. (2000) Statistical Profile: Provision. (2000) Report on Government Services 2000, Productivity The Victorian Prison System 1995-96 to 1998-99, OCSC: Melbourne, Table Commission: Canberra, pp. 611-612. Comparison is made with the 1999 1, p. 8. report, pp. 439-440 and the 1998 report p. 309. The questions on illegal drugs and drunken and disorderly behaviour changed between 1996/97 and 128 All figures taken from the Victorian Department of Justice’s submission to the 1997/98, so only housebreaking results are compared over this period. Committee. 160 Ibid. pp. 609-10. Comparisons are made with the 1999 report, pp. 437-38 129 Dwyer, R. and Rumbold, G. (2000) Victorian Drug Trends 1999: Findings and the 1998 report, pp. 306-08. from the Illicit Drug Reporting System, Turning Point Drug and Alcohol Centre and National Drug and Alcohol Research Centre: Sydney, p. 48. 161 Ibid., p. 615. 130 Dietze, P., Laslett, A-M., McElwee, P. (2000) Trends in Drug Use and Harm in 162 Victorian Department of Human Services. (in press) The Victorian Drug Victoria: Implications for Treatment, report prepared for the Drug Policy Expert Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, Committee by Turning Point Drug and Alcohol Centre: Melbourne, p. 30. DHS: Melbourne, pp. 63-64. 131 Ibid., p. 30. 163 Ibid., p. 63. 132 Victorian Department of Human Services. (in press) 1998 National Drug 164 Dwyer, R. and Rumbold, G. (2000) Victorian Drug Trends 1999: Findings Household Survey: Victoria Results, DHS: Melbourne, p. 41. from the Illicit Drug Reporting System, Turning Point Drug and Alcohol Centre and National Drug and Alcohol Research Centre: Sydney, p. 47. 133 Ibid., p. 43. 165 Ibid., pp. 12-13. 134 Data supplied to the Committee by the City of Port Phillip. 166 Victorian Department of Human Services. (in press) The Victorian Drug 135 Drug Policy Expert Committee. (2000) Drugs: Responding to the Issues, Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, Engaging the Community: Stage One Report, DPEC: Melbourne, pp. 5-8. DHS: Melbourne, p. 58. 136 Figures supplied by the Victorian Institute of Forensic Medicine. The 1999 167 Preliminary 2000 data supplied by the Victorian Department of Human figure is slightly higher than that presented in the Stage One report, as six Services. deaths occurring in 1999 have since been investigated and found to be heroin related. The 2000 figure will be slightly lower than some figures 168 Dwyer, R. and Rumbold, G. (2000) Victorian Drug Trends 1999: Findings published in the media as some published figures include deaths that are from the Illicit Drug Reporting System, Turning Point Drug and Alcohol suspected, but not yet proven, to be heroin related. Centre and National Drug and Alcohol Research Centre: Sydney, pp. 12-13. 137 Data supplied by the Victorian Institute of Forensic Medicine. 169 Victorian Department of Human Services. (in press) The Victorian Drug Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria, 138 Collins, D. and Lapsley, H. (1996) The Social Costs of Drug Abuse in Australia DHS: Melbourne, p. 58. In the rest of these cases, gender was not stated in 1988 and 1992, Australian Government Publishing Service: Canberra. or couples attended. 139 Ibid., p. vii. 140 Ibid., pp. 41-44. Introduction 56

The social infrastructure

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 4 57

4.1 What is the social Problems resulting from drug use and misuse affect people from across our community. Family background, income or residential infrastructure? address do not provide immunity from the risk of drug problems. The importance of a comprehensive approach to health Poverty can be a contributing factor to some people’s initiation into promotion is now widely recognised and is central to the drug use. It is also a widespread consequence of sustained, approach outlined by the Ottawa Charter. This is discussed in dependent use. Education, employment and income security more detail in chapter 2. This charter sought to provide a policies can contribute to the prevention of drug use and, perhaps framework in which all of the relevant government and community more importantly, to the rehabilitation and reintegration of former organisations act individually and collaboratively to maximise the drug users. The Committee believes the Commonwealth overall health and wellbeing of the community. As a major health Government, in its response to these important issues, has yet to issue in our community, the drug problem requires exactly this fully take into account the implications of the current drug problem. approach. All sectors of society where drugs have an impact need The primary focus of this chapter is on the social infrastructure to be engaged in developing solutions. There is little point in provided or supported by the State Government. This is not developing treatment and other specialist services in isolation because the services provided by communities, non-government from other services, and there is no logic in failing to assist the full organisations, local government and the Commonwealth are not range of community services to meet the needs of their clients. important. It is simply because the Committee is reporting to the The ‘physical infrastructure’ is commonly understood to refer to State Government, and the recommendations contained in this physical structures (such as roads and buildings) and the physical report are largely for it to act upon. services that make our towns, cities and states functional. The Elements of the social infrastructure funded and/or managed by social infrastructure is no less important. When the Committee the State Government include: refers to the ‘social infrastructure’, it is describing all those • education; services that make up the social fabric of life (for example, • welfare (including community services); education, health, housing and income support). The social • housing; infrastructure is at least as important as the physical to the • health; wellbeing of individuals, families and the broader community. • mental health; and The Committee is strongly of the view that to meet the challenges • law enforcement. that drugs present to our community, we must deal with system- Although these services are provided to the whole population, wide issues. Therefore, this chapter precedes the discussion of they are often heavily utilised by some of the most disadvantaged prevention efforts, the drug treatment system, criminal justice and and marginalised people in our community. law enforcement arrangements. As drug use and misuse increases, substantial additional Responsibility for developing and maintaining the social pressure is being placed on the social infrastructure. The infrastructure rests with all levels of government and the Committee has repeatedly heard that elements of the social community. The Commonwealth Government is responsible for infrastructure are struggling to respond to different, and often taxation, income security, employment and many other policies complex, client needs. that form part of the social infrastructure. State Governments People with substance use problems figure prominently in the provide a range of core services such as schools, child welfare service profile of all of the services considered in this chapter. For and housing services. Local governments also play a key role, some services, people with substance use problems form the often in partnership with the State Government, in providing majority of service users. Figure 4.1 provides a picture of the services such as kindergartens and community aged care pressures on services as a result of clients’ substance use services. A great deal of the social infrastructure has nothing to do problems. However, it must be emphasised that data available with government and is provided through the efforts of non- for each service varies and these figures are not directly government organisations and local community bodies. comparable. This further underlines the need for better data All elements of the social infrastructure are important and can collection (see endnotes for further source details). assist in reducing the impact that drugs have on our community. From time to time, the social infrastructure requires maintenance and refurbishment to meet new challenges or changed priorities.

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Figure 4.1: Pressure on selected elements of the social infrastructure - estimated numbers of people with substance use problems using services

Of the total Victorian population of 4,753,900,1 it is estimated that 370,804 people (7.8 per cent of the total population 2 ) have a substance use problem

Mental Specialist Supported See a Inpatient Adult Juvenile Child Health Drug accomm. general hospital Corrections Justice Protection Services Treatment practitioner admissions (registered Services user)

To t a l 51,56434 19,217 43,100 5 3,803,120 67 1,116,740 4,8798910 1,002 7,183 estimated number of service users

Estimated number of 40,000 19,217 4,310 296,643 61,28511 3,648 912 4,202 service users with a substance use problem

% of service 12 13 14 15 16 17 18 users 80% 100% 10.6% 7.8% 5.4% 74.8% 91% 58% estimated to have a substance use problem

Where possible all figures relate to client numbers over a 12 month period. Only snapshot figures are available for corrections, juvenile justice and child protection.

Many people with substance use problems also require assistance for other problems in their lives. These problems are often, though not always, related to that person’s substance use. The following case study exemplifies that many people have inter-related problems. The following case study is based on an actual life story (the name has been changed to ensure confidentiality).

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 59

Case study

By the time he was 18, Craig had spent nine months in a youth training centre for thefts and burglary related to his drug use. His history included several protective notifications and disconnection from his family. Craig attended 11 separate primary schools and left school after Year 9. While in the youth training centre he formed a strong connection with the health worker. He also undertook TAFE studies and was able to develop skills, especially those related to motor mechanics. After being paroled, he was linked to a post-release service provider with transitional housing and was assessed for drug counselling. Craig lived in the supported housing for four weeks after his release, but he began using drugs again with his co- tenants. He stopped attending drug counselling. He had two overdoses in one week and was revived by ambulance officers. Workers tried to link him with his family, but this failed after an incident of physical abuse by his father. Craig was arrested for armed robbery and eventually imprisoned.

This clearly demonstrates that the complex needs of people with Supporting these sectors is likely to be one of the greatest drug use problems often require a response from more than one challenges in drug strategy in the coming years. In addition to service. The sad fact is that ‘Craig’s’ story is not uncommon. achieving traditional goals and objectives, drug-specific services Appendix 5 further supports this and outlines some typical case and programs (including treatment and prevention) must now also histories from the Alcohol and Drug Information System. It accept a role to support, advise and assist other sectors to provides details of some of the other services accessed by clients respond to their clients’ needs. This section of the report does not of drug treatment services. attempt to deal with all elements of the social infrastructure. Key None of this is an argument for other sectors or services to sectors are considered, and there is a particular focus on how the embark on new program activity in the name of achieving drug- current drug problem puts pressure on them and their capacity to related goals. Rather, it is an argument for services to: serve their clients. • recognise that the changing needs of clients, brought about by As the drug problem is now so pervasive, all areas of the social drug problems, may diminish their capacity to perform their infrastructure must clearly frame their response to the increasingly existing roles as effectively as is desirable; complex needs of those with substance use problems as well as • acknowledge that in performing their core function effectively, meeting the needs of their traditional client bases. they have opportunities to tackle their clients’ drug issues that To meet these challenges, most elements of the social are currently being missed; and infrastructure will require some structural change and additional • identify their capacity to effectively contribute to the financial support from the Government. Government’s prevention agenda and to the reintegration strategy articulated in this report. In recent years, there has been significant infrastructure development. However, this has not been matched by the necessary funding for data collection, monitoring systems, workforce development and evaluation. A number of services have yet to acknowledge that responding to drug issues is part of their core role.

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4.2 Education services Research indicates there are key transition points in people’s lives that increase their risk of misusing drugs and developing other 4.2.1 Overview problems. Some key transition points that have been identified are: The State Government has identified its number one priority as • entry to school; providing better support for education and the enhancement of • transition from primary to secondary school; skills development through schools, apprenticeships and • moving from compulsory to post-compulsory education; and traineeships, and other forms of post-compulsory education. • commencing work and independent adult living. Access to education is a fundamental right and provides an During most of these key transition periods, young people are important foundation for accessing work and further educational likely to be engaged with the education system. The problems that opportunities. may be encountered at each of these periods go beyond the This section considers the impact of drugs on the school system issues of drug use and misuse; therefore, the benefits of and on post-compulsory education more broadly. effectively managing these transitions are significant. Comments The education system is the part of the social infrastructure that, made to the Committee during its consultations highlighted the after families, has the most sustained opportunity to influence the significance of the transition from primary to secondary school. majority of young people and their parents. It is a large and This transition is critical not just because young people are likely to diverse system (or series of systems) that involves some 2,200 have commenced drug use at this time, but because the schools overseen by the State Government, the Catholic Church opportunity exists to identify vulnerable young people whose and some 200 independent schools. In addition, there are academic, social and behavioural performance indicates they may universities, TAFE colleges and adult education services. There is have significant difficulty through the transition. It is argued that an emphasis across these systems on devolving operational secondary schools require transition arrangements and support responsibility to local management so capacity is maximised to mechanisms that can target these young people and their families. respond to local need. The system’s great strengths are size, Given the level of drug use in the community and among young diversity and localisation, but their strengths also generate people, all primary and secondary schools need to consider significant challenges in achieving system-wide responses to an appropriate welfare, curriculum and policy responses. Even those issue such as drug misuse. schools and communities where there is relatively little use of It is timely that this issue is raised given the systemic reviews into illegal drugs are likely to have problems with alcohol that can be education that have recently been completed. Public Education - just as damaging. Schools can be affected in a number of ways, The Next Generation and the Ministerial Review of Post including: Compulsory Education and Training Pathways in Victoria provide • off-site usage that has implications for the student’s the Government with a broad opportunity to set in place new performance at school; arrangements. In so doing, it can consider the best way for the • off-site usage that has no direct implications but indicates there education system to contribute to reducing drug use and misuse is an issue that the school may assist in tackling; in our community. • drug use by family members that affects student performance 4.2.2 Drug pressures and wellbeing; • drug usage on the school grounds; and Chapter 3 sets out very clearly the prevalence of drug use among • drug dealing on the school grounds. the school population. Based on the 1999 Survey of Over-the- Counter and Illegal Substances Among Victorian Secondary Some schools have been reluctant to provide a coordinated School Students, it is clear that some use of alcohol, tobacco and response to drugs in the belief that it ‘publicly acknowledges the cannabis, particularly by middle to senior secondary students, is school has a drug problem’. In a competitive market, parents may very common.19 Use of illegal substances other than cannabis is also take the view that schools seen to take a ‘tough on drugs’ quite low although increasing, and higher rates of illegal stance, or who promote a ‘drug-free environment’, are better substance use could be expected among school-aged young schools for their children to attend. While understandable, these people not currently in education or employment. responses are unfortunate as they reduce the capacity of the school community to respond appropriately to what is a community-wide problem. This response also means the problems for some become larger than would be the case if a clear, supportive and well-known policy framework were in place. It is the Committee’s view that the community increasingly understands that young people are almost inevitably exposed to drugs, and that the key issue is how the school community responds to it.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 61

Recent key systemic developments in the school system include the: Young people who continue in education and training beyond the • implementation of a Framework for Student Support Services compulsory school age have no guarantee they will find courses in Government Schools to guide the development of healthier and programs that meet their needs. This has led to: school communities and to support students; • university entry becoming a widespread aspiration and goal for • introduction in all government schools and a majority of young people and their parents. While a positive development Catholic and independent schools in Victoria of an Individual for many young people, this has reinforced the academic School Drug Education Strategy (ISDES). This is an agreed focus of the senior secondary curriculum; and outline of action for a specific school community and includes • marginalisation of those young people who do not complete welfare, curriculum, policy and ‘community links’ elements Year 12. The Dusseldorp Skills Forum has developed (currently being reviewed); and performance indicators for the success of young people’s • introduction of the School Focused Youth Service and the transitions. Applying these indicators, their 1999 report found Victorian Secondary School Nursing Program. that 14.5 per cent of 15 to 19 year old Australians are at risk of

23 The efforts of many people in individual schools have substantially not making a successful transition from education to work. enhanced these changes and the Committee commends them. The list of critical transition points above does not include the risk In Victoria, the complexity and length of young people’s transition of moving from education but not into employment. The following from compulsory education to full-time work has increased table identifies the percentage of young people who are neither in dramatically in recent years. The Organisation for Economic education nor employment. This is hardly an unusual situation for Cooperation and Development (OECD) has estimated that this young people. From ages 17 to 19, this group represents at least transition now takes the average young Australian 6.5 years.21 The one in 10 of our young people. transition period is lengthening because more young people than ever are participating in post-compulsory education and training and delaying their entry to the full-time labour market. The number of full-time jobs occupied by teenagers has significantly decreased in the past 20 years, and it is likely that many young people remaining in our schools would rather be working.22

Table 4.1: Young people in Victoria neither in education nor employment by age

15 year olds 16 year olds 17 year olds 18 year olds 19 year olds

3.4% 7.2% 11.1% 13.5% 10.8%

Source: Derived from Department of Education, Employment and Training 2000, Ministerial Review of Post Compulsory Education and Training Pathways in Victoria, Final Report, p. 47.

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Young people in this situation risk losing the connections to 4.3 State welfare services - workplaces, education and other community institutions that research has shown are protective factors against problematic supporting children, young drug use. Participation in education by itself, while important, is people and families almost certainly insufficient in that the best results will be achieved where young people feel they are benefiting from a positive 4.3.1 Overview learning experience and a supportive social environment. Community organisations, the private sector and all levels of While there are clear issues about the operation of the education government provide a range of support services to Victorian system, its capacity to support young people at risk and to families and young people. contribute to the management of those who have commenced The Community Care Division of the Victorian Department of drug use, the group in neither education nor employment is a Human Services manages and funds a number of services greater concern. The recent Review of Post Compulsory designed to provide support and assistance to families and young Education Pathways identified a major flaw in the current system people, some of whom are particularly vulnerable. Increasingly, as the absence of an agency taking responsiblility for these young these services are subject to considerable stress as a result of the people.24 The Committee shares this concern that none of the current drug problem. They have always sought to respond to the formal systems of society has an obligation to engage with and complex needs of some of the most marginalised and vulnerable support these young people at a particularly vulnerable time. children, young people and families in our community. However While it is inappropriate to hold the education system accountable rapidly changing needs of the client base as a result of drugs for supporting all of these young people, it is desirable that there require responses that do not necessarily ‘fit’ with our traditional is an increased focus on meeting their needs. Information shared service paradigms. As a matter of urgency, the pressures that with the Committee during its consultations indicates that drug drugs bring to bear on these services must be considered, and use is one of the key reasons why young people leave school appropriate strategies and service redesign implemented where prematurely or that it contributes to them being excluded by the necessary. system. Services tend to fall into one of three main types: Government action on the two major education reform reports • universal: services available to all Victorians (for example, provides the opportunity for many issues identified in this section maternal and child health services); of the report to be dealt with. The role of the education system • targeted: services available to those experiencing problems or and opportunities to better support it in dealing with drugs are with special needs (for example, family violence and sexual also discussed in chapter 5. assault services); and • statutory: services provided when the law mandates intervention in the lives of children, young people and families (for example, child protection services and juvenile justice). A summary of the services funded by the Community Care Division of the Victorian Department of Human Services is provided in table 4.2.

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Table 4.2:Community Care Division Services

Universal services Secondary services (targeted / streamed) Statutory services

• Child care • Family support services • Child protection services • Preschools • Strengthening families • Juvenile justice • Maternal and child health • Parenting services • Placement and support • Neighbourhood houses • Problem gambling services • Adoption & permanent care services • Telephone counselling • Financial counselling sevices • Early intervention services for families/specialist children’s services • Youth support services • School focused youth services • Family violence and sexual assault services

Source: Derived from Community Care Division, 2000, New Partnerships in Community Care, Discussion Paper, August, Department of Human Services. p. 22

4.3.2 Drug pressures Targeted services are more likely to encounter families where drug Both universal and targeted family and youth services have a key use is a major problem. These programs require additional role to play in responding to drug problems. As universal services support to deal with drug problems as they are one among the are offered to the entire community, they have a wide reach and many problems faced by a growing number of families. are likely to come into contact with families where drug use is a There are also times when the law requires intervention in the lives problem. These families may be more willing to seek assistance of families and young people. When this happens, the child from a universal service than to access drug-specific services. protection and juvenile justice systems are called on to work with For example, the Maternal and Child Health Service is a universal some of the most marginalised and vulnerable young people, service that is accessed by all parents at some stage. It has the children and families in our community. capacity to act as an excellent delivery point for parenting This is particularly apparent in relation to the children of drug programs and more targeted programs without the stigma of a users, who now form a very significant percentage of the young specific stand-alone program. Provided that appropriate skill people in the Community Care client group. In the protective care development opportunities and resources are provided, Maternal system, it is estimated that over 1,000 children are orphaned as a and Child Health Services have the capacity to provide more result of their parents’ suffering a heroin-related overdose.26 It is sustained home visitation and to deliver additional assistance to also seen in the juvenile justice system where up to 80 per cent of targeted families. Olds et al. (1998) found that this approach has young people in custody are estimated to have substance use yielded long-term results in reducing maternal drug use even problems.27 when not followed up with subsequent programs.25 The child protection system is currently coming under increasing The Community Care Division provides a number of services pressure and greater public scrutiny. The effect of drugs on these targeted to families at risk. These services can play a very useful services is significant. The Committee has heard that specific role, particularly in preventing drug misuse. They can also provide factors include: much needed support when one or more family members are • a parent dying as result of an overdose; misusing drugs. For example, Family Support services provide • neglect as a result of parent’s problem drug use; and assistance, counselling and support to families displaying one or • a parent serving a sentence for drug-related offences. more of a range of risk factors. Family Support services target families with significant needs who require support to help them to function well and care for their children. These services aim to promote, maintain and strengthen the wellbeing of those families through family counselling and in-home support (practical advice on parenting and household management are emphasised).

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Child Protection and Placement and Support services aim to The prevalence of drug use among this population implies a provide ‘child-centred, family focused services’28 that protect connection between drug use and illegal activity to maintain a children and young people from the harm they may be exposed drug habit. It is likely that the majority of young people in custody to within the family unit in the future, and to respond to the harm are serving sentences that are in some way drug-related. they have already experienced. Service types include kinship care The Community Care Division works with these young people and (placement with a blood relative or close family friend), foster care children when they are at a critical stage of their development. The (placement with a volunteer family or individual) or residential care reported prevalence of substance use problems should lead (including supported residences). these services to clarify their role in providing clients with Current figures provided to the Committee indicate that 7,183 information and strategies on reducing harm, and managing or children and young people are active clients of protective care in reducing drug use. These services must also stream clients into one form or another.29 drug treatment services if required. Substance use is common among the young people who are The Committee believes that additional resources may be clients of protective services. In 1995, 36 per cent of Child required to meet the needs of young people who are exposed to Protection clients, where intervention proceeded beyond initial drug-related harm. In some instances, this will take the form of assessment, were reported to have problems relating to drugs specialised resources. Such expertise may reside outside and/or alcohol. Over half (56 per cent) of the high-risk adolescents Community Care. Protocols and links are required to assist in Placement and Support Services reported a drug and/or collaboration with other service systems when appropriate. alcohol problem in 1996. The evaluation of the High Risk A comprehensive review of Community Care has recently been Adolescent Service Quality Improvement initiative found that 67 completed.34 The review contains recommendations for a redesign 30 per cent of the sample had substance misuse problems. of the system that includes: A Regional Child Protection Case Practice Quality Audit • planning and service resourcing at the most local level undertaken in February 1999 reported that substance use and possible; family violence were clearly or partially recorded and considered • a focus on building strong communities as an end, not a in 85 per cent of cases involving risk assessment.31 means, of service delivery; Increased referrals to child protection services indicate a growing • better partnerships between services within and beyond the need for the State to intervene in family care situations. Data Community Care system; and systems currently lack the sophistication required to assess the • an increased focus on prevention to reduce the need for extent to which this is a result of increased drug problems. To intensive services in the long term. provide services that best meet their clients’ needs, data The Committee supports the directions articulated in the collection and communication between service sectors must be Community Care Review, which are consistent with the enhanced. The Committee has been advised that the Community Committee’s recommendations for drug policy. Implementation of Care Division is currently investigating strategies to achieve this. the review will need to take full account of the impact of drugs on Juvenile Justice services aim to provide care and supervision to the community care system, and include specialist drug services young offenders in custodial settings and on community-based when developing closer partnerships between Community Care orders. These services provide programs that aim to develop and other service systems. clients’ knowledge and skills generally, and support them to manage their lives effectively without further offending. A key component of this response relates directly to substance use. The profile of young people in juvenile justice facilities has changed significantly in recent years. This change is closely associated with an increase in drug misuse among clients. Ten years ago, a minority of Juvenile Justice clients presented with substance use problems that, at that stage, involved cannabis and alcohol.32 Now, a significant majority of client present with a substance use problem, and the main drugs used are heroin and cannabis. Reports indicate that the majority of those in custody are heroin dependent (65 per cent of 17-year-old males, 80 per cent of 17-year-old females). The rate of Hepatitis C among intravenous drug users in custody is approximately 70 per cent.33

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4.4 Public housing In addition to this profile of the younger user of services, there is consistent anecdotal evidence of increasing drug use among 4.4.1 Overview those in crisis accommodation. One large inner city crisis A prerequisite to stability of lifestyle is access to secure and accommodation service has estimated that 30 per cent of its affordable accommodation that is of an acceptable standard and client group were regular intravenous drug users, and that located conveniently to transport and other services. It is overdose was becoming increasingly commonplace. particularly important to those seeking to rebuild a lifestyle after Those seeking crisis housing assistance often have drug dealing with drug dependency that may have affected job problems, and chaotic street users are more likely to be security, income, health, family relations and future prospects. homeless.39 This group is more likely to inject in public places. Demand for public and community housing remains high. In A consultation paper distributed in July 2000 by the Victorian addition to those seeking housing because of low income, there Homelessness Strategy Unit in the Department of Human are diverse groups with a special case for access. These include Services nominated illegal drug use as one of the five critical the aged, women and their children escaping domestic violence, areas that impact on homelessness. The other four were the more and those suffering chronic physical or mental illness. traditional factors such as labour market changes, family In addition to the long term accommodation options provided breakdown, the private rental market and demographic trends through public housing and community housing programs, the such as aging.40 In addition, the problems with alcohol misuse that State also provides a range of services for those who are have traditionally characterised many in the homeless population homeless. These include crisis services and transitional housing have not disappeared. An estimated 25 per cent have needs designed to provide pathways to long-term, stable linked to alcohol misuse.41 accommodation. This points to a changing set of needs in the homeless A shift in Commonwealth funding policy toward providing rental population. Regardless of whether their illegal drug use causes or assistance for households, and away from capital funding for State is triggered by a housing crisis, or whether a range of factors is acquisition, will have impacts on the growth of public housing. contributing to accommodation and drug problems, to be As at June 2000, there were nearly 41,000 households on the effective the homelessness service sector must now respond to waiting list for public housing.35 At the same time, funds available its clients’ multiple and complex needs. In addition, the needs of in the current year are estimated to enable 1,380 units to be the high proportion of service users with mental health problems purchased or built.36 must be addressed if they are to successfully escape from The Committee also notes that the demand for housing will homelessness. continue to far outstrip the supply, and that there is likely to be an The consultations undertaken by the Committee repeatedly increasing gap between growth rates in housing supply and returned to the issue of housing, particularly when discussing demand. The high per unit cost of housing means even an treatment and law enforcement. Participants frequently made the investment of $12 million in the current year to increase point that for treatment to be effective, it must be combined with accommodation for the homeless can only provide an additional appropriate housing as well as other services to ensure the 70 accommodation units. individual is able to move on from their drug dependency and 4.4.2 Drug pressures build a new life away from drug using. It was also stated that progress made in undergoing detoxification for six days was Twenty years ago, the key agencies providing crisis usually wasted if the individual’s only option was to return to a accommodation to the homeless dealt with older single men as a household where others continued their drug use. key client group. Many of this group had entrenched alcohol dependence and consequently had not been able to hold In the case of the courts, a magistrate’s decision to allow bail employment or stable accommodation. The profile of those using could be influenced by whether the remandee would be going to homeless services today is quite different with an increasing an acceptable form of accommodation. Those offenders with drug proportion of young single people.37 problems leaving prison require secure accommodation, and various levels of appropriate supports, if they are not to quickly The most reliable data to illustrate this relate to the Supported return to the drug-using scene. Accommodation Assistance Program (SAAP). SAAP provides support services to homeless people. The data show that: The above overview reaffirms the point that housing is not only • 59 per cent of SAAP places (measured in support periods) central to an effective drug response but also to the functioning of were utilised by those under 30; and many other parts of the social infrastructure. • single people accounted for 62 per cent of support periods.38

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4.5 The health system Efforts to encourage general practitioners to assume a more active role in alcohol and drug treatment, referral and 4.5.1 Overview management (such as attracting prescribers of methadone) have The great majority of people who suffer ill health effects as a result met with varied success. This can be attributed to general of misuse of substances (particularly alcohol and tobacco) never practitioners’ concerns that: seek help from the specialist drug treatment sector. The specialist • their role does not include asking their patients about their system is more likely to provide services to those whose drug use alcohol or drug use. There may be greater reluctance for some presents complex problems that extend beyond the ill health general practitioners to take on this role in some communities consequences alone. (for example, smaller or rural communities); However, it is highly likely that these people will access primary • those who do take on patients with alcohol and drug needs will health care or acute care in a hospital setting at some point, either be labelled ‘drug and alcohol’ doctors; as a direct result of their drug use or for a non-drug related reason. • clients with alcohol and drug problems will be disruptive to the Increasing the broader health system’s capacity to respond to general practitioners’ practice; those presenting to it is likely to take pressure off the specialist • clients will present with complicated needs that require more drug treatment system, yield better health outcomes, and decrease time than other patients; and the long-term costs of health care provision generally. • paperwork required in relation to methadone clients is seen to This section identifies some elements of the broader health be onerous. system that have a particular role in dealing with drug issues. The Chapter 6 makes recommendations on strategies to assist services considered are: general practitioners to deal more effectively with drug issues and • general practice; these include becoming prescribers of methadone. However, the • community health services; greatest challenge will be to engage general practitioners more • ambulances; fully in responding to the broader needs of their patients with • hospitals; and alcohol and drug problems. • services for people with an acquired brain injury. Community health services Chapter 6 of this report is concerned with the provision of drug The Community Health Program purchases services from a total treatment. It also highlights key aspects of the broader health of 98 community health centres, multi-purpose sites, hospitals system that can have an impact on drug problems. and specialised agencies. In 1998-99, nearly 600,000 episodes of 4.5.2 Drug pressures community health service were delivered in Victoria.45 General practice The Community Health Program aims to ensure primary health It is estimated that in any given year, 80 per cent of people will care services are readily available to all Victorians, and to reduce make a visit to a general practitioner.42 A visit to a general the pressure on the hospital and other specialist institutional practitioner is a relatively ‘normal’ activity and does not carry the services. Community health centres offer a wide range of services stigma of attending a specialised alcohol and drug service, or to their local communities, and with general practitioners, are require people to identify themselves as having a particular often the first point of contact with the health system. problem. General practitioners are in a strong position to Their role in providing advice on drug and alcohol services, positively influence their patients’ substance use behaviour. treating the problems they are equipped to deal with, and referring Reports indicate that even brief discussions about alcohol use those requiring further help to specialist services parallels that of with a general practitioner have the capacity to reduce patients’ independent general practitioners. Many providers of these alcohol consumption significantly.43 community health services have diverse roles that may directly Apart from their capacity to respond to problems of substance involve them with drug issues, such as those services that run misuse, general practitioners are often the first line in the system’s needle and syringe programs. However, they are most able to response to other health problems arising from substance use. have an impact as a first point of contact for people who may have drug and alcohol problems but may not be primarily seeking In terms of drug treatment, general practitioners play a particularly help for these problems. This fits well with the preventative focus important role in relation to methadone. One of the service goals of these services. of the Victorian Government’s community methadone program is the integration of methadone into general practitioners’ normal A major initiative in primary health care has been the development service provision. The general practitioner can also provide of Primary Care Partnerships (PCPs). PCPs are formal alliances of primary care services to their methadone clients. As will be dealt primary care providers that provide services within a geographic with in more detail in chapter 6, this program is currently coming area. This process is in its early stages and shows promise. It will under significant pressure and appears to be reaching capacity. be important that these partnerships and the plans they produce take account of drug issues and include links to specialist drug treatment services.

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Ambulances Ambulances are often the first medical response in the event of a drug overdose or road trauma where alcohol is implicated as a significant factor. Their role in saving lives in this situation is critical. In 1999, the majority of drug-related ambulance attendances involved heroin, followed by other drugs such as benzodiazepines and analgesics, and alcohol. The total number of drug-related ambulance attendances for that year reached 12,802. This represents 6.3 per cent of the total number of ambulance attendances for that year.45

Table 4.3: Drug-related ambulance attendances in Melbourne, June 1998 to December 1999

15 year olds Heroin related Alcohol affected Other drug Total

Number of attendances 7,742 3,636 6,875 18,253

Source: Turning Point Alcohol and Drug Centre, 2000, Victorian Drug Statistics Handbook, Department of Human Services, Victoria, p.11.

In an effort to encourage drug users to call an ambulance in the Accident and emergency departments event of an overdose, the Metropolitan Ambulance Service has Emergency departments are the first or second port of call (after developed clear information for drug users indicating that it is not ambulances) for many people suffering the acute effects of police policy to routinely attend overdose incidents unless there is alcohol and drug use. These range from people injured in alcohol- a clear suspicion of other criminal activity. This may go some way related road accidents, to heroin overdose victims, to people to removing the fear of prosecution, and encourage people recovering from the effects of acute intoxication. present at overdose incidents to call an ambulance without delay. The Victorian Emergency Minimum Dataset collects data on Police policy supports this position. admissions to hospital emergency departments. Based on an As set out in table 4.3, definite heroin-related overdoses (where initial analysis of the dataset, Turning Point Alcohol and Drug there has been a positive response to the administration of Centre has indicated that data quality does not allow for good Narcan) figure prominently in ambulance attendances. In cases of information to be extracted on presentations attributable to alcohol less severe overdose, ambulance officers may need to stay with a and other drug causes. However, one emergency department drug-affected person until they are satisfied the person is not provided information to the Committee that showed 7 per cent of 46 going to lose consciousness. The growing number of drug- its clients had alcohol and other drugs as the primary reason for related ambulance call-outs is having an impact on the system’s presenting, and a further 7 to 10 per cent had alcohol and other capacity to respond to non-drug related emergencies. The drugs as a secondary issue.47 Victorian Government’s policy is to make Narcan more widely St Vincent’s Hospital Emergency Department recently undertook available. In addition to its obvious role in saving lives, it may take an investigation into presentations that were directly related to some pressure off ambulance services. A trial of such an intravenous drug use. The study found that, over a four-month approach could be one component of the research strategy period, 2 per cent of all presentations were related to intravenous proposed in chapter 8. drug use.48 Recent research conducted by the Youth Substance Abuse Service found that doctors and nurses working in accident and emergency departments saw many clients who presented in a drug- or alcohol-affected state as disruptive and at times aggressive, and this made their work more difficult.49

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Inpatient hospital admissions Summary The Victorian Admitted Episode Dataset collates inpatient hospital It is clear that the impacts of alcohol and other drugs on the admissions data. This allows assessment of those inpatient health system are significant and diverse. Various aspects of the hospital admissions that are drug-related. In 1998-99, there were system are involved in directly treating drug- and alcohol related- a total of 61,285 drug-related inpatient hospital admissions. harm, preventing and reducing harmful drug use, dealing with the Tobacco accounted for 40,017 admissions, alcohol for 15,572 and ill health consequences of harmful drug use in the long and short opiates for 2,543.50 terms, and providing their core services to people whose drug Hospitals’ ability to deal with the drug and alcohol issues with and alcohol problems often make them difficult to treat. Many inpatients and outpatients is compromised by: services are recognising the impact of drugs, and a number of • competing demands for staff time; initiatives to improve service delivery to people with drug and • lack of specific alcohol and drug knowledge among staff; alcohol problems have been described above. • a perception that these problems fall outside the role definition In most areas, more needs to be done to integrate the services of staff; and provided to people with drug and alcohol and other health • lack of management support to intervene. problems. Later chapters in this report provide specific To better equip this sector to respond to drug and alcohol recommendations on service improvements and training needs problems, the Premier’s Drug Advisory Council 1996 report noted for various workforces. However, the starting point for any the need for coordinated professional development and the pre- sustained improvement needs to be a recognition that dealing service training for key workforces including general practitioners, with drug issues, in partnership with specialist drug services, is hospital doctors and nurses. Training in these areas needs further now core business for all health services. development and a more systematic response. This is discussed in more detail in chapter 8. 4.6 Mental health services 4.6.1 Overview Acquired brain injury In 1998-99, there were over 50,000 registered clients of Victoria’s There are an estimated 20,000 people in Victoria with a moderate mental health services.53 Services types include: or serious acquired brain injury (ABI) that affects their cognitive, • Child and Adolescent Mental Health Services (for those aged physical, emotional or independent functioning.51 Drug use 0-18 years) which had 10,375 registered clients; (particularly alcohol) is a common cause or contributing factor in • Adult Mental Health Services (for those aged 16-64 years) ABI, and an estimated 30 to 60 per cent of people in ABI which had 31,380 registered clients; treatment programs in Victoria have a history of substance use • Aged Persons Mental Health Services (for those aged 65+ problems.52 years) which had 8,465 registered clients; and People with an ABI and drug and alcohol problems may access • Forensic which had 894 registered clients. government-funded services such as case management, assisted Most services are organised on a regional basis, and more community living packages, neuropsychological assessments, specialist services are provided on a statewide basis. Service rehabilitation, family sensitive counselling, behavioural provision is based on a case management approach. An individual consultancy, carer support services, Home and Community Care, service plan is developed for each client and a case manager is linkages and in-home accommodation support. However, they appointed. The plan outlines the goals and expectations for face considerable difficulties in gaining access to services treatment, the services to be accessed to achieve these goals, and capable of adequately meeting their needs. The Department of the agencies responsible for providing these services.54 Human Services has established the Acquired Brain Injury Strategic Planning Group with membership from a wide range of 4.6.2 Drug pressures government and non-government organisations. It has identified Mental illness and drug use are two well-established co- that improved access to appropriate accommodation services, morbidities. Victorian mental health services that were able to drug treatment and mental health services is essential to better provide data to the Committee on this issue estimated that up to meet this client group’s needs. Other areas for improvement 80 per cent of their clients have substance use problems as well included the development of long-term prevention strategies, and as their mental illness. Of the injecting drug users surveyed in the need to address alcohol and drug issues earlier to minimise Melbourne for the 1999 Illegal Drug Reporting System, 41 per cent longer term problems. had ‘ever taken’ anti-depressants, and 28 per cent had taken them in the previous six months.55

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However, there is no simple link between mental illness and Numerous examples of productive links between providers have substance abuse. The dilemma is seen clearly in the ongoing been supplied to the Committee but the prevalence of these dual debate on cannabis and mental illness. There appears to be an diagnoses requires that each must be regarded as core business association between the two, but it is not clear whether cannabis for both service systems. is the cause of mental illness, hastens the development of mental Valuable work is done by the Early Psychosis Prevention and illness in those who are already susceptible, or is used by people Intervention Centre (EPPIC) that focuses on the early detection 56 with a mental illness to alleviate their symptoms. The same and prompt treatment of psychotic symptoms in young people, arguments are played out in the case of other drugs and particularly in relation to cannabis use. substance use more generally. Whichever is more likely to come That prevention activities aimed at mental health can also have an first, it appears a vicious circle can develop: drugs are used to impact on drug use is supported by the outcomes of the alleviate symptoms of mental illness but actually make them Gatehouse Project.61 This project, which is discussed more fully in worse or prevent action to address them, and therefore lead to chapter 5, aimed to reduce adolescent depression and suicidal heavier drug use designed to medicate these worsened behaviour by intervening at the school level. When the results of symptoms.57 Treatment of each problem is complicated by the the program were evaluated, schools where the program had other, and specialist treatment services can struggle to cope. been implemented were found to have significantly lower levels of The literature on treating people with these dual diagnoses (as use of tobacco, alcohol and marijuana than the control group.62 they are known) suggests integrated treatment models that Indeed, the measurable impact on substance use has been attempt to address both problems as part of a single treatment greater than that on the mental health problems on which the 58 strategy can be successful. The flagship program for integrating project initially focused. This finding reinforces the link between mental health and drug treatment services in Victoria is the mental health and substance use, and suggests preventative or Substance Use Mental Illness Treatment Team (SUMITT) program, early intervention initiatives developed in the mental health field 59 which commenced in 1998. This program operates in the can have impacts on drug use. Western and Northern Metropolitan and the Grampians regions of Chapter 5 considers prevention activities, many of which operate Victoria. Team members are located in, and/or available to, drug on the factors that appear to increase the risk of mental health and alcohol and mental health services in these regions. They and substance use problems. offer a combination of assessment and case management for clients, and training and support for those working in the field. 4.7 Law enforcement and The evaluation of SUMITT indicated that 148 clients had used the service. The evaluation of outcomes focused on a group of 40 who criminal justice had completed 12 months with the service60 and showed positive 4.7.1 Overview results in terms of mental health. There were significant reductions Efforts to reduce the impact of crime in Victoria cover a continuum in hospital admissions for mental health issues, the length of these from crime prevention efforts, through police and courts to the hospital stays, and contacts with mental health services in the corrections system. Taken together, this system represents one of community. On measures of psychiatric morbidity, improvements the major investments made by the State Government. Chapter 7 were noted but fell short of being statistically significant. There provides more detail on these services, examines the impact of were also reductions in the number of criminal justice contacts and drugs on them, and makes recommendations for change. changes of address. On the drug and alcohol side, there was a Some brief statistics give an idea of the overall scope of these significant increase in knowledge of harm minimisation and systems. Victoria Police employed 11,502 people in 1998-99, of reductions in harmful substance use behaviours. whom 9,446 were sworn police members.63 An increase of 800 Use of drug treatment services generally rose, although not members is planned over the next four years.64 In 1999-2000, police significantly. Taken together, these two findings suggest people recorded over 400,000 offences.65 In the Magistrates’ Court where are more likely to present initially with mental health problems, and the majority of drug-related offences and the vast majority of all that one effect of the integrated service model was to allow them cases in Victoria are heard, 108,994 criminal cases were initiated in to address their drug and alcohol problem in a way they had not 1998-99.66 The 15,952 drug offences recorded in Victoria in 1999- previously found possible. 2000 represented 3.7 per cent of all recorded crime in Victoria.67 Programs designed to link mental health and alcohol and drug There are currently around 3,100 prisoners in Victoria, and a further services arise from a recognition that these two services have not, 7,000 offenders on community corrections orders.68 in the past, dealt well with the needs of their overlapping client groups. Some mental health services that provided information to the Committee suggested that a client engaging with the drug treatment system requires a level of organisation and motivation often lacking in people with a mental illness. The Committee has heard that, in some instances, people are denied access to treatment for one problem until the other is addressed.

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4.7.2 Drug pressures Contact with the criminal justice system can represent the sort of The amount of property crime in Victoria that is drug-related is crisis that often prompts drug users to seek treatment. The unknown, but a conservative estimate presented in chapter 3 is available evidence suggests mandated treatment can be as 73 that there are at least 35,000 drug-related break and enter effective as voluntary treatment. It has also been suggested that offences in Victoria annually. Large amounts of other property police action can contribute to users’ desire to seek treatment, 74 crimes are also likely to be drug-related. With property crime although this evidence is mixed. Therefore, all parts of the constituting 82 per cent of all crime in Victoria, it is clear that drug- criminal justice system are well placed to assist users to access related crime is causing a great deal of suffering to its victims, and and succeed in treatment. In this context, the significant advances occupying a large amount of police time. made in implementing harm minimisation principles and diversion programs across the system in the past few years are welcome. In around 8 per cent of cases heard by Victoria’s Magistrates’ Courts, the principal proven offence involves the consumption or The shift from a punitive to a harm minimisation approach to drug supply of illegal drugs.69 Around 6 per cent involve being drunk in use has been a key feature of the Victorian criminal justice system a public place. Again, the percentage of other offences that are in the past four years. Diversion programs have been put in place drug-related is not clear, but the impression of those involved in that significantly reduce the number of drug users progressing the system is that the majority of these are drug-related. Chapter 7 through various stages of the system. These are examined in provides an analysis of sentencing trends in relation to drug more detail in chapter 7. These programs combine to reduce the offences, and the difficulties faced by magistrates in finding likelihood of repeat offending for a significant number of people appropriate sentencing options for drug-dependent offenders. whose criminal activity is solely related to, or driven by, their drug use. Chapter 7 makes recommendations to further reduce the A survey in January 2000 of prisoners serving sentences of less load placed on the criminal justice system by drug-related crime than 12 months found that 75 per cent reported they had a drug and, in particular, identifies the critical need for offenders to be or alcohol problem. This rose to 84 per cent among those who linked to other support services in addition to drug treatment. were not serving their first prison sentence.70 Thirty-eight per cent reported they had committed their offence to support a drug A similar shift is beginning to occur in the prison system. Treatment habit, and this rose to 40 per cent for those who had been in is widely available to prisoners and new initiatives are being prison before. developed to improve its scope and capacity. Drug treatment in prisons is discussed more fully in chapter 7. Key concerns include As referred to earlier in this chapter in the discussion on public the lack of continuity resulting from prisoners being moved housing, increased refusal of bail and imposition of custodial frequently, multiple assessments of prisoners, a reliance on sentences is putting pressure on the prison system. Victoria’s sanctions rather than incentives to get prisoners into treatment, and prison population grew by 27 per cent between June 1996 and the need to recognise the relapsing nature of drug dependency. November 1999. As at 30 June 1999, the system was running at 102 per cent of its capacity.71 This pressure on the prison system Across the criminal justice system, there needs to be increased has resulted in sentenced and remanded prisoners having an recognition that many minor offences relate to offenders’ drug increased length of stay in police holding cells. use, and that providing access to effective treatment will reduce the chances of them re-offending and re-entering the system. Of the 20,000 prisoners on community corrections orders each Effective links to drug treatment need to be seen as a core year, around 70 per cent return positive urinalysis results, and strategy for all parts of the criminal justice system. around 40 per cent test positive for opiates.72 Breach levels for these orders are high, and partly reflect the high workload of As with drugs, crime prevention is an area that is becoming more Community Correctional Services Officers. Given the number of prominent. The Government recently established Crime Prevention minor crimes attracting these sorts of sentences that appear to be Victoria as Victoria’s lead agency on this issue. Nationally, the drug-related, this strain on the community corrections system is National Crime Prevention Program has funded a number of pilot likely to be largely a result of drug-related crime. projects. This focus on prevention, and particularly on working with local communities to address their major crime problems, is Overall, it is clear that drug-related crime is placing a significant welcomed by the Committee and will reap significant benefits in strain on the criminal justice system. This pressure comes partly reducing the impact of drugs in our community. Links between crime from drug offences, but more from crimes that are committed to and drug prevention efforts must be maintained and strengthened. buy drugs, or under the influence of drugs, including alcohol. The research on preventing drug problems supports a strong link between the risk and protective factors for drug problems and crime.75 76 Therefore, crime prevention strategies should have an impact on levels of drug use, and need to be linked to strategies designed to prevent drug problems. Chapter 5 makes recommendations on better coordinating prevention efforts in Victoria.

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4.8 The way forward Each of the service sectors examined in this chapter is having to meet the needs of a more complex client group that is characterised by multiple and often interrelated problems. Drug use and misuse are the most complex problems exerting pressure on the social infrastructure and often result in a need to access multiple services. It is clear that drug use is affecting each sector more and more, to the extent that many are struggling to deliver their core services to people both with and without drug problems. This chapter has focused on some of the State Government-funded services where the greatest impact is being felt. A similar story could be told across the range of community services in Victoria and the corresponding Commonwealth programs. Specific policies and programs on drug issues are important and form the focus of much of this report, but they cannot, by themselves, respond to the broad impact that drugs have across the community. The Committee believes drug issues require the Government to acknowledge that major service redesign, or at least reconsidered service responses, should be implemented across the board if real change is to be effected. This chapter has presented some of the many instances that the Committee has seen where this is already happening, but more needs to be done. Some service providers and sectors have yet to clearly acknowledge the role they have to play in this area. Drug use and drug problems can no longer be regarded as an ‘extra’ issue that affects these programs. These are core issues that affect the core business of many elements of the social infrastructure. Urgent action is now required. The mechanisms for doing this will vary, but in most programs this will require: • service reassement, including program redesign and assessment of staffing requirements to respond effectively; • drug-specific expertise and advice to support these program reassessments; and • improved links between all service sectors so the complex problems that many people have can be met with comprehensive solutions. The effect of inaction on any of these fronts is likely to be increased inability to meet demand for services, increased worsening of mortality and morbidity rates, and escalating costs to all levels of government, individuals and the community.

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Endnotes

1 Australian Bureau of Statistics. (2000) Australian Demographic Statistics: 18 Survey of service providers undertaken by the Drug Policy Expert March Quarter 2000, (Online: www.abs.gov.au. Accessed: 30/10/2000.) Committee. Survey responses indicated that on average 45 per cent of 2 This rate was derived from Teesson, M. (2000) National Comorbidity Project, clients had a substance use problem as a primary problem, with an Comorbidity in Mental Health and Substance Use: Causes, Prevention and average of 13 per cent of clients reported to have a substance use problem Treatment, Background Paper, National Workshop March 6th and 7th 2000, as a secondary problem. p. 4. (Online: 19 Victorian Department of Human Services. (in press) “School Students and http://www.health.gov.au/hfs/pubhlth/nds/new/comorbidity.htm. Accessed: Drug Use; Summary Report 1999 Survey of Over-the-Counter and Illegal 2 November 2000). The rate is 11% and 4.4% for males and females Substances Among Victorian Secondary School Students”, Draft Report, respectively, averaged at 7.8% for the population. DHS: Melbourne. 3 Victorian Department of Human Services (2000) Annual Report 1998/99, 20 Fuller, A. (2000) “Promoting Resilience and Preventing Substance Use as DHS: Melbourne, p. 55. Well as Violence and Suicide”, unpublished paper prepared for the Drug 4 Victorian Department of Human Services (2000) Alcohol and Drug Policy Expert Committee. Information System (Interim ADIS) Annual Report 1998/99, DHS: Melbourne 21 Organisation for Economic Cooperation and Development. (2000) Thematic p. 5. Review of the Transition from Initial Education to Working Life, OECD: Paris, 5 Australian Institute of Health and Welfare. (2000) SAAP National Data p. 205. Collection - Victoria, Annual Report 1998-99, AIHW: Canberra, p. 45. Data 22 Sweet, R. (1998) ‘Youth: The Rhetoric and Reality of the 1990s’, in relates to support periods and may include same client more than once. Dusseldorp Skills Forum. (2000) Australia’s Youth: Reality and Risk, DSF: 6 Derived from estimate that 80 per cent of the population visit a general Canberra, p. 2. practitioner in a given year, contained in Raysmith, H. (1999), Review of 23 Curtain, R. (1999) Young People’s Transition from Education to Work: Primary Health Redevelopment, Department of Human Services: Melbourne, Performance Indicators, Dusseldorp Skills Forum: Canberra, p. 15. p. 5. 24 Kirby, P. (2000) Ministerial Review of Post Compulsory Education and 7 Victorian Admitted Episode Dataset (VAED) total admissions for 1998/99. Training pathways in Victoria: Final Report, Department of Education, Data provided by Acute Health Division, Department of Human Services. Employment and Training: Melbourne, p. 75. VAED includes all hospital admissions excluding elective admissions. 25 Olds, D., Henderson Jnr., C., Cole R., Eckenrode J., Kitzman H. Luckey D., 8 Department of Justice, Victoria. (2000) Statistical Profile - The Victorian Pettitt L., Sidora K., Morris P., Powers J. (1998) ‘Long-term Effects of Nurse Prison System 1995/96 to 1998/99, DoJ: Melbourne, p. 10. Home Visitation on Children’s Criminal and Antisocial Behavior’ Journal of 9 Victorian Department of Human Services (1999) Annual Report 1998/99, the American Medical Association Vol. 280 No. 14 (Online: http://jamaama- DHS: Melbourne, p. 81. assn.org/issues/v280n14/full/joc80422.html. Accessed: 3/8/2000.) 10 Data provided to the Drug Policy Expert Committee by Child Protection, 26 McCauley, J. (2000) personal communication. Community Care Division, Department of Human Services. This figure 27 Veit, F. (2000) “Methadone Maintenance for Heroin Dependent Adolescents relates to current ‘active’ clients as at October 2000. in Custody” , Abstract from Conference Presentation, to be presented 20- 11 Victorian Department of Human Services. (in press) “The Victorian Drug 22 November, 2000 - The Combined APSAD and National Methadone Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria”, Conference, The Sofitel, Melbourne. DHS: Melbourne, p. 11 28 Victorian Department of Human Services. (2000) Working Together Strategy 12 Survey of service providers undertaken by the Drug Policy Expert - Program Description Paper, DHS: Melbourne, p. 3. Committee. Survey responses indicated that on average 26% of clients 29 Data provided to the Drug Policy Expert Committee by Child Protection, had a substance use problem as a primary problem, with an average of Community Care Division, Department of Human Services. This figure 54% of clients reported to have a substance use problem as a secondary relates to current ‘active’ clients as at October 2000. problem. 30 McCauley, J., (2000), personal communication. 13 There are likely to be up to 5 per cent of service users who are families or 31 Ibid. significant others in the lives of people receiving treatment. For the 32 Crundall, I. (1998) A Survey of alcohol and drug use by residents of purposes of this table these have not been excluded given their direct drug Victoria’s Juvenile Justice Centres, Department of Human Services: or alcohol link. Melbourne, cited in Victorian Department of Human Services. (1999) 14 Australian Institute of Health and Welfare. (2000) SAAP National Data Towards Best Practice Drug Services in Juvenile Justice Centres, DHS: Collection - Victoria, Annual Report 1998-99, AIHW: Canberra, p. 45. Melbourne, p. 81. Percentage based on periods involved a support and/or rehabilitation 33 Veit, F. (2000) “Methadone Maintenance for Heroin Dependent Adolescents component that was drug related. in Custody” , Abstract from Conference Presentation, to be presented 20- 15 This percentage represents a direct application of the rate of substance use 22 November, 2000 - The Combined APSAD and National Methadone among the general population derived from Teesson, M. (2000) National Conference, The Sofitel, Melbourne. Comorbidity Project, Comorbidity in Mental Health and Substance Use: 34 Carter, J. (2000), Report of the Community Care Review, Department of Causes, prevention and Treatment, Background Paper, National Workshop Human Services: Melbourne. March 6th and 7th 2000, p. 4. (Online: http://www.health.gov.au/hfs/pubhlth/nds/new/comorbidity.htm. Accessed: 35 Victorian Department of Human Services. (2000) Summary of Housing 2 November 2000). Assistance Programs 1998-99, DHS: Melbourne, p.16 16 Data contained in Department of Justice Submission to the Committee. 36 Data provided to the Drug Policy Expert Committee by the Office of Housing, Department of Human Services. 17 Survey of service providers undertaken by the Drug Policy Expert Committee. Survey responses indicated that on average 45 per cent of 37 Victorian Department of Human Services. (2000) Victorian Homelessness clients had a substance use problem as a primary problem, with an Strategy, Consultation Paper, DHS: Melbourne, p. 2. average of 46 per cent of clients reported to have a substance use problem 38 Australian Institute of Health and Welfare. (2000) SAAP National Data as a secondary problem. Collection - Victoria, Annual Report 1998-99, AIHW: Canberra, pp 26, 34.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 73

39 Hanover welfare services submission to Drug Policy Expert Committee. 65 Victoria Police. (2000) ‘Crime Rate Falls in Victoria’, Media Release, 9 40 Victorian Department of Human Services. (2000) Victorian Homelessness August 2000. Strategy, Consultation Paper, DHS: Melbourne. p.2. 66 Victorian Department of Justice. (2000) Statistics of the Magistrates’ Court of 41 Ibid, p 13. Victoria 1998/99, DoJ: Melbourne, p. viii. 42 Raysmith, H. (1999), Review of Primary Health Redevelopment, Department 67 Victoria Police. (2000) ‘Crime Rate Falls in Victoria’, Media Release, of Human Services, Melbourne, p. 5. 9 August 2000. 43 National Drug Strategy. (1993) An outline for the management of alcohol 68 Data contained in Department of Justice Submission to the Drug Policy problems: quality assurance project, Monograph Series, No. 20, Australian Expert Committee. Government Printing Service: Canberra, pp. 136-138. 69 Victorian Department of Justice. (2000) Statistics of the Magistrates’ Court of 44 Victorian Department of Human Services (1999) Annual Report 1998/99, Victoria 1998/99, DoJ: Melbourne, pp. 60-64. DHS: Melbourne, p. 54. 70 Data contained in Department of Justice Submission to the Committee, 45 Based on data provided to the Drug Policy Expert Committee by unpublished. Metropolitan Ambulance Service 71 Office of the Correctional Services Commissioner. (2000) Statistical Profile: 46 Holgate, F., Ponting, A. and Rogers, N. (2000) The Feasibility of Providing a The Victorian Prison System 1995-96 to 1998-99, OCSC: Melbourne, Table Recovery Service for Young People Post-Overdose, Youth Substance Abuse 1, p. 8. Service: Melbourne, p. 18. 72 Data contained in Department of Justice Submission to the Committee. 47 Estimate contained in survey response (by a major metropolitan Melbourne 73 National Institute of Health. (1999) Principles of Drug Addiction Treatment: A hospital). Survey of service providers conducted by the Drug Policy Expert Research Based Guide, National Institutes of Health Publication No 99- Committee. 4180, NIH: Bethesda, p. 9 (Online: 48 Beltz, A., and Dent, A. (2000) “Emergency Presentations of Intravenous http://athealth.com/practitioner/ceduc/PODAT6.html Accessed: Drug Use”, unpublished paper provided to the Drug Policy Expert 01/11/2000) Committee. 74 Weatherburn, D., and Lind, B.(1995) Drug Law Enforcement Policy and Its 49 Holgate, F., Ponting, A. and Rogers, N., (2000) The Feasibility of Providing a Impact on the Heroin Market, New South Wales Bureau of Crime Statistics Recovery Service for Young People Post-Overdose, Youth Substance Abuse and Research: Sydney, pp. 35-36. Service: Melbourne, p. 18. 75 Fuller, A. (2000) “Promoting Resilience and Preventing Substance Abuse as 50 Victorian Department of Human Services. (in press) “The Victorian Drug Well as Violence and Suicide”, unpublished paper prepared for the Drug Statistics Handbook: Patterns of Drug Use and Related Harm in Victoria”, Policy Expert Committee, p. 5. DHS: Melbourne, p. 11. 76 National Crime Prevention. (1999) Pathways to Prevention: Developmental 51 Victorian Department of Human Services. (1999) ABI/A&D Better Practice and early intervention approaches to crime in Australia, Attorney General’s Project Report, DHS: Melbourne, p. 11. Department: Canberra, p. 29. 52 Fortune, N. and Xing Yan Wen. (1999) The Definition, Incidence and Prevalence of Acquired Brain Injury in Australia Australian Institute of Health and Welfare: Canberra. 53 Victorian Department of Human Services. (1999) Annual Report 1998/99, DHS: Melbourne, p. 55. 54 Victorian Department of Human Services. (2000) The Working Together Strategy: Program Description Paper, Melbourne, p. 34. 55 Dwyer, R. and Rumbold, G. (2000) Victorian Drug Trends 1999: Findings from the Illegal Drug Reporting System (IDRS), Turning Point Alcohol and Drug Centre and National Drug and Alcohol Research Centre: Sydney, p. 43. 56 Hall, W., Solowij, N. and Lemon, J. (1995) The Health and Psychological Consequences of Cannabis Use, National Drug Strategy Monograph Series No. 25: Canberra, pp. 166-179. 57 Muisener, P. (1994) Understanding and Treating Adolescent Substance Abuse, Sage Publications: Thousand Oaks, pp. 71-73. 58 Lindsay, F. and McDermott, F. (2000) ‘Dual Diagnosis or MISUD (Mental Illness and Substance Use Disorder: A Review of Recent Literature’ in Fox, A. (2000) SUMITT Evaluation: Final Report, SUMITT: Melbourne, pp. 69-71. 59 Details on SUMITT are taken from Fox, A. (2000) SUMITT Evaluation: Final Report, SUMITT: Melbourne, pp. 4-9. 60 Ibid, pp. 15-25. 61 Bond, L., Glover, S., and Patton, G. (1999) The Gatehouse Project Interim Report 1999, Centre for Adolescent Health: Melbourne. 62 Ibid, and Patton, G. (2000), personal communication. 63 http://www.police.vic.gov.au/facts/content.htm using information taken from the Victoria Police Annual Report 1998/99. Accessed: 18 October 2000. 64 Haermeyer, A., Minister For Police and Emergency Services. (1999) ‘State Government on Target to Recruit 2000 Police’, press release, 16 December 1999.

Introduction 74

Prevention

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 5 75

5.1 Introduction In this chapter, the Committee will: • consider the role of prevention; Drugs, be they tobacco, alcohol or illegal substances, present a • consider the evidence base; range of problems to individuals and the community as a whole. • propose a framework for future prevention activity; Greater efforts must be made in the area of prevention to stop • look at past and current government effort, and recognise past these problems occurring in the first place, or to lessen their effects. achievements in the prevention area on which future work can While supply reduction and harm reduction have been key focuses be built; of Australia’s harm minimisation approach, attention to demand • propose key areas for action; and reduction measures remain under-developed and largely ad hoc. • indicate those links necessary to build the capacity of the For too long, prevention programs have been short term, have service system. operated in isolation and have not been appropriately linked to other elements of the response to drugs. They have also lacked 5.2 What is prevention? the sustained approach that is necessary to achieve real and long- It is generally accepted that there are three levels of prevention1 term benefits. The Committee believes the only way to reduce although people often refer only to primary prevention. A broadly demand in the long term, and the harm associated with drug use, based prevention framework should accommodate primary, is through a coordinated and sustained prevention strategy. secondary and tertiary prevention elements.

Table 5.1: Levels of prevention

Impact Description Role in prevention framework

Primary • The prevention of uptake of drug use among non-users. Primary prevention programs have an important role to play in a comprehensive prevention framework. While abstaining from certain substances is an achievable aim for many people, we must acknowledge that for some substances (for example, alcohol), use is the norm among the adult population. For this reason, primary prevention strategies must be complemented by secondary prevention strategies that seek to prevent harm from use, particularly in relation to alcohol.

Secondary • Seeking to prevent problematic use and use progressing Despite known dangers of drug use, many people will to dependency (reducing problems among early users). continue to experiment or use drugs for recreation on a regular, although not necessarily habitual, basis. A priority area of Victoria’s prevention framework should be secondary prevention, considering the level of drug use and experimentation described in chapter 3.

Tertiary • Reducing harm amongst problem users and helping There are many people who become dependent and them to reduce or discontinue use (this includes problem users of substances. For example, the National treatment responses). Drug and Alcohol Research Centre estimated that in 1999 there were 19,600 high risk or heroin dependent people in Victoria (74,000 for the whole of Australia)2 There is a real need for additional programs targeted at those currently using substances habitually or at harmful levels. These programs should include information about safer use and treatment. Treatment is important in preventing further harm for individuals and those around them. For the children of drug users, it can be a significant step in decreasing the risk of these children becoming the next generation of problem drug users.

Prevention 76

A factor clouding clear understanding of issues in prevention is 5.3 Types of drug use the different language used in different contexts to describe Australia is a drug-using society. Drug taking is not a new approaches and actions that fall at some point along the phenomenon, nor does Australia alone face the problems associated prevention continuum. In Victoria, the Department of Education, with it. However, as set out in chapter 3, we know substances are Employment and Training currently uses prevention, early becoming increasingly available. In some cases, they are cheaper intervention, intervention and ‘postvention’ (the latter referring to than ever and people are using them at harmful levels. the management within the school of critical incidents and restoring wellbeing).3 In relation to mental health, the Victorian Drugs perform many functions. They have the potential to provide Health Promotion Foundation has identified promotion, great therapeutic benefits and can increase our life expectancy and prevention, early intervention, treatment and rehabilitation. overall enjoyment of life. Some drugs are used for their pleasurable effects alone: they relax, remove inhibitions and can alter perceptual While different definitions are legitimate and highlight the and sensory experience. However, we know drugs also take a huge distinctive approaches taken by various organisations and toll on individuals, the community and the economy. sectors, it is important that there is agreement on common terminology. Government should consider brokering a common It is important to acknowledge that both adults and young people set of terminology, at least across Government. This would assist use substances, often at harmful levels. Therefore, Victoria must the development of complementary approaches and cross- implement a prevention framework that does not focus solely on departmental collaboration that has, in the past, been young people. Different patterns of drug use require different unnecessarily complicated by language differences. responses. Different categories of drug use include: Within these broad categories of prevention outlined above, ABSTINENCE: Non-use of a particular drug. Given the broad programs can also vary in terms of their scope. The following acceptance of alcohol in our society, complete abstinence from all table breaks down the broad scope of programs into universal drugs including alcohol is not the norm among the adult and indicative/selective (also referred to as targeted). population. For example, the 1998 National Drug Household Survey (Victoria Results) found that 75 per cent of the population identify themselves as current drinkers, and 46 per cent identified themselves as weekly drinkers. The same survey found lifetime Table 5.2: Programs - Reach and scope use of tobacco was high at 64 per cent (current smokers were 26 per cent), while lifetime use of cannabis was 34 per cent of the Universal • Programs delivered to the general population.5 population or to an entire EXPERIMENTATION: Many people experiment with drug use. community (for example all people attending schools or mass media Most do not continue to habitually or regularly use these campaigns) substances. Some researchers have indicated that experimentation with certain substances (particularly legal ones) Targeted may be a normal part of adolescent boundary setting.6 7 8 Indicative • Programs delivered to those individuals displaying specific However, the majority of people do not experiment with most characteristics (for example, early illegal substances, or go on to use illegal substances regularly. aggressive behaviour) Targeted RECREATION: People, young and old, use drugs to relax, Selective • Programs delivered to groups of socialise, celebrate and have fun. This is exemplified in the people who are at elevated risk of widespread acceptance of alcohol in many social interactions. problem behaviour (for example, communities suffering social Today’s young people inherit a world where alcohol use, and even exclusion or economic hardship) misuse, is accepted. At the same time, they are keenly aware of the double standards implicit in a ‘just say no’ approach to other drugs. Recreational use of drugs can occur only occasionally, on All programs are required to, and can, work to reinforce and weekends, or more regularly. A particular harm associated with complement each other.4 recreational use is the risk taking that people, both young and old, engage in while intoxicated (for example, driving under the influence of alcohol or other drugs). There is also the risk that regular use of a drug may lead to dependency.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 77

DEPENDENCE: There are some people who are dependent users 5.4.1 Risk and Protective Factors of drugs. Dependence can be psychological, physical or both. Resnick and Blum, Brooks, Jessor, Hawkins and Catalano12 and While there are degrees of dependence, people who are others have investigated the factors that put young people at risk dependent have little or no control over their drug use. Dependent of developing problem behaviour, and those factors that appear to people often have an overwhelming compulsion to use drugs. This be protective. Much of this research aims at developing a set of may have serious effects on their connections to social networks risk factors, protective factors or both for a range of problem and overall health status. For dependent users of illegal drugs, behaviour. there is also the problem of engaging in an illegal activity that often Two key themes emerging from risk and protective factors requires another illegal activity to support their supply of drugs. research are connectedness and resilience. Connectedness refers The notion of gateway drugs is often put forward to provide a to a sense of belonging and having strong and meaningful rationale for the progression of drug taking from experimental or connections to family, school, peers and the community. recreational use to dependence. The idea is that use of ‘hard’ Connectedness is seen as being very important for wellbeing. drugs is preceded by the use of ‘gateway’ drugs, which may be Parental support and assistance in dealing with problems as they alcohol, tobacco and/or marijuana. This is often taken to imply arise are very important to maintaining connectedness. Resilience that preventing or delaying young people’s use of the ‘gateway’ refers to the quality that makes a person able to deal with the drugs will be effective in preventing or reducing their later ‘hard’ problems and demands that may confront them in different social 9 drug misuse. However, we also know that: settings, and to respond well to a range of life events. Being • surveys show the majority of young people will experiment with resilient better enables a person to weather life’s challenges. alcohol and tobacco, and a large number will experiment with Parental support and reassurance can be important in its marijuana; however, the vast majority of these people do not development. go on to use other drugs, let alone to develop problems with In Australia in recent years, there has been an increasing focus on them; a risk and protective factor approach; for example, the work of the • a significant minority of those who do use ‘hard’ drugs have National Crime Prevention Strategy and the Centre for Adolescent not used ‘gateway’ drugs, or began using them after the hard Health’s work for the Department of Human Services (Victoria). drugs; and • one drug preceding another does not establish a causal Factors that protect against risk taking or substance use may also relationship. It seems plausible that the factors contributing to apply to other problems. For example, the recent National Anti drug use are likely to impact on use of more than one drug.10 Crime Strategy report, Pathways to Prevention, Developmental and Early Intervention Approaches to Crime in Australia identified an Rather than focusing on actual drug use and progression of drug exhaustive set of risk and protective factors in relation to crime use, it is more helpful to look at the individual and their motivation prevention. Many of these factors are common to those set out in for using drugs. table 5.3 below and are relevant to substance use. These links are While the reasons why some people misuse drugs and others do further strengthened given the illegal nature of some drug use.13 not are complex, research provides some evidence as to the The Centre for Adolescent Health has recently undertaken antecedents of drug use. important local research for the Community Care Division of the 5.4 Foundations of a framework - Department of Human Services. The report, Improving the Lives of Young Victorians in Our Community, sets out the results of a The evidence base survey of 9,000 young Victorians attending government, Catholic and independent schools. The report measures risk and Internationally, since the 1980s, primary prevention efforts have protective factors in the young people surveyed, and maps results received large-scale funding, particularly in the United States (US). for geographic areas (all metropolitan local government areas and This has included investment in implementation of prevention all Department of Human Services regions). programs and research.11 The report findings are very informative and instructive, as they In broad terms, the Committee has considered research on represent a significant and detailed consideration of risk and factors that affect the individual and the community or whole protection in the Victorian context. The report also identifies that, in populations. The studies that looked at the factors that affect the some circumstances, universal responses are required; for others, individual have examined risk and protective factors and genetic responses must be targeted to different communities and the predisposition. Risk factors can contribute to a person’s risk of particular problems they face. Importantly, the study identifies that developing substance use or other problems. Protective factors targeted interventions focusing on risk factors for high-risk groups appear to provide some armour against the development of later are likely to be effective for substance use. Programs focusing on problems. The Committee has also reviewed current literature that enhancing protective factors in relation to illegal substance use are looks at factors that increase the risks for whole communities, likely to be more effective if they are universal.14 such as ‘social exclusion’. Prevention programs must tackle those factors that add to the risk of drug use for the individual and the community, and enhance those that provide protection.

Prevention 78

The study suggests that patterns of relationships found between with 9,000 Victorian young people. Internationally, Michael Resnick various factors may be useful in identifying the interventions that et al., working in the US, utilised a cross-sectional analysis of may be most effective for a certain geographical region, or a interview data from the National Longitudinal Study of Adolescent particular sub-population of young people. Health. This study involved a total of 12,118 adolescents who Risk and protective factors identified by researchers often reinforce completed 90-minute interviews. These adolescents were drawn concepts and ideas that common sense tells us are important. For from an initial national school survey of over 90,000 students. The example, common sense indicates that having strong connections study identified family, school and individual characteristics 15 to family is a good thing, and that high availability of drugs in a associated with risk behaviour in adolescents. community may increase the risk of drug taking. Examples of risk and protective factors are set out in table 5.3 to Therefore, it is important to note that detailed and rigorous provide an indication of some of the elements that prevention research underpins the identification of risk factors and protective programs may aim to tackle (risk factors) or to enhance factors. At the local level, the Centre for Adolescent Health has (protective factors). used the Community that Cares model as the basis of its research

Table 5.3: Selected risk and protective factors

Level Risk factors Protective factors

Community Availability of drugs Cultures of cooperation Poverty Stability and connectedness

Transitions and mobility Good relationship with an adult outside the family

Low neighbourhood attachment and community Opportunities for meaningful contribution disorganisation

School Detachment from school A sense of belonging and fitting in Academic failure, especially in middle years Positive achievements and evaluations at school

Early and persistent antisocial behaviour Having someone outside your family who believes in you

Low parental interest in education Attendance at preschool

Family History of problematic alcohol and drug use A sense of connectedness to family Inappropriate family management Feeling loved and respected

Family conflict Proactive problem solving and minimal conflict during infancy

Alcohol/drugs interfere with family rituals Maintenance of family rituals

Harsh/coercive or inconsistent parenting Warm relationship with at least one parent

Marital instability or conflict Absence of divorce during adolescence

Favourable parental attitudes toward risk-taking A ‘good fit’ between parents and child behaviours

Individual / peer Constitutional factors, alienation, rebelliousness, Temperament/activity level, social responsivity, hyperactivity, novelty seeking autonomy

Seeing peers taking drugs Developed a special talent and zest for life

Friends engaging in problem behaviour Work success during adolesence

Favourable attitudes toward problem behaviour High intelligence (not paired with sensitive temperament)

Early initiation of the problem behaviour

Adapted from Fuller, A. 2000, Promoting resilience and preventing substance abuse as well as violence and suicide, unpublished paper prepared for the Drug Policy Expert Committee.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 79

The negative effects of risk factors and the shielding effects of identified as a risk factor for a range of problem adolescent protective factors interact and are different for each individual. behaviour. However, it is clear that this may not necessarily be a Caution should be exercised in causally linking risk factors to reflection of academic ability alone. Additional tutoring is not particular problem behaviours. For example, it should not be necessarily the answer for that young person; we need to look implied that poverty is inevitably linked to crime or substance use, further afield to identify ways to enable that student to learn and as this is clearly not the case. thrive in an environment appropriate to their needs. While clear causal links between risk factors, or the compounding In relation to crime prevention, the Pathways to Prevention report effects of risk factors and later engagement in substance use, clearly identifies that: have yet to be conclusively shown, it is certainly possible that prevention programs that target one, two or three risk some risk factors are markers to later substance use problems factors may not have a marked effect, at least in the medium rather than root causes. In some cases, substance use itself can to long term. Several programs operating at several levels be a marker to other problems. This is particularly so for those (such as the family and the school) and at key transition people who, suffering from a mental or physical illness, use legal points may be required to influence a sufficient number of and illegal substances or misuse prescription substances to factors to have an impact.17 relieve the symptoms of their illness.16 On reviewing the research base, the Committee is of the view that Regardless of whether they act as a marker or a cause, risk the same is true in relation to drugs. factors function to tell us there may be a problem in an area of a young person’s life. For example, failure in school is consistently

Risk and protective factors - The study found significant reductions in tobacco and marijuana Practical implementation use when students were followed up at Years 9 and 10.18 It also The research base in relation to risk and protective factors is found that training for community leaders and mass media was substantial and continues to grow. There is also an emerging less effective when not teamed with school-based and parenting evidence base for implementation of interventions that tackle programs. Therefore, the case can be made for the effectiveness particular risk and protective factors. Details of two example of a whole-of-community approach (community mobilisation) that projects from the US that have included whole-of-community aligns to school and parent based approaches. implementation in their program design are set out below: the Project Northland (US) Midwestern Prevention Project and Project Northland. Details are Similarly, Project Northland utilised a multi-component and whole- also provided of a local program, the Gatehouse Project, which of-community approach. This project aimed to reduce alcohol and involved a whole-of-school intervention. other drug use in north-west Minnesota (a mostly rural area rated Midwestern Prevention Project (US) at the top of that state in alcohol-related harm). The Midwestern Prevention Project conducted by Mary Ann Pentz Key elements of Project Northland included: and colleagues examined the effectiveness and replicability of a • a coordinated curriculum program delivered to the same cohort multi-component community-based drug misuse prevention of young people at Years 6, 7 and 8. This program included program (focusing on alcohol, tobacco and cannabis use). The age-relevant information, peer involvement and activities to link study looked at the effectiveness of school drug prevention young people to local decision makers (so-called ‘power’ programs set within the context of broader community groups that included local government officials, parents, law mobilisation strategies. Trial elements included: enforcement personnel, teachers and alcohol retailers); a. a 10-session school program delivered at Grade 6 and 7 that • strategies to involve parents. These included input into emphasised strategies to resist drug use; curriculum development, information fairs and events organised b. a parent involvement program to oversee school prevention by the young people in the program schools, and a series of policy and provide training in positive parent and child newsletters produced by the students for the parents; and communication; • resources. These were provided to support the development of c. training for community leaders in organising local drug community-wide task forces. prevention community taskforces; and This research found that the project appears to have been d. use of the mass media. successful in achieving a statistically significant reduction in The study aimed to measure the program’s effectiveness on alcohol use and tendency to use, a reduction in the combination behavioural, social and demographic risk factors among study of alcohol with tobacco, and a changing of peer norms and peer participants who were followed up at Years 9 and 10. Program influence to use. The study also found a strengthening of parent- 19 schools received all four elements while control schools only child communication about consequences of alcohol use. received elements c and d.

Prevention 80

The Gatehouse Project (Australia) Importantly, there has been a reduction in the rate of smoking in The Gatehouse Project is a school-based program aiming to schools participating in the Gatehouse Project compared to non- reduce the rates of depression and self-harm; two consistently intervention schools. The importance of developing projects to identified risk factors for youth suicide. The project was conducted improve mental health and emotional wellbeing in school with 26 Victorian schools (12 intervention and 14 comparison). It environments, as well as focusing on individuals, cannot be emphasises the importance of positive connectedness between underestimated. teachers and peers. It has identified three priority areas for action: It is too early to demonstrate whether the schools that building a sense of security and trust, enhancing skills and participated in the intervention have exhibited measurable opportunities for good communication; and building a sense of impacts on the explicit program aims, but there has been a positive regard through valued participation in aspects of school small but significant increase in the number of students who life. The project aims to build a healthy environment rather than view the school as a positive part of their lives. concentrating on individuals.

Research case study - Australian Temperament Study

There have been a number of studies undertaken around the world to determine a range of behavioural or temperament characteristics that may indicate a propensity to later problem behaviour development. One of these projects, the Australian Temperament Project, is being conducted by the Australian Institute of Family Studies. Over 2,000 infants were recruited to participate in this study in 1983. The study aims to assess the effect of childhood temperament on the development of problem behaviour. Among the 15 to 16 year olds involved in the study, substance use is common. Among those who use substances, it appears that there may be higher rates of: • showing delinquent or aggressive behaviour, particularly among girls; • having less self-control; • being less shy, more outgoing; • having poorer quality friendships; and • having less attachment to family. In addition, the study identified that behaviour in parents also had a significant impact on their children’s substance use (for example, having parents who smoke and drink). However, none of these characteristics or factors in isolation provides a conclusive link to substance use problems. A number of these findings resonate with the risk and protective factors outlined above. In particular, connections to family are very important.

5.4.2 Genetic predisposition As Dr David Hay, one of Australia’s foremost genetic researchers, Since the 1950s, studies have looked at the influence genes may has stated, genetic factors should be seen as one among many have on an individual’s responses to certain drugs.20 Some factors that include environment, socioeconomic status and 25 specific genetic abnormalities have been identified that link both temperament. with personality disturbance and addictive behaviour,21 but much 5.4.3 Social exclusion - structural issues further work is needed before any particular genetic pattern can British Prime Minister Tony Blair has set up a Social Exclusion Unit be said to account for a strong inherited tendency to addiction. within the Cabinet Office to tackle social exclusion in a Recent studies have suggested that a range of addictive, coordinated way and to develop “joined up solutions to joined up compulsive and impulsive disorders (including tobacco, alcohol problems”.26 and other substance misuse) may have a common genetic Social exclusion occurs when people become disconnected, as a basis.22 There is mounting evidence to suggest that further result of interlinked problems, from the organisations, research in this area may be useful in the future, particularly with communities and structures that make up society. These respect to better matching of pharmacotherapeutic responses to problems include unemployment, poor education, low incomes, dependent heroin users’ individual needs.23 poor housing, high-crime environments, high access to Genetic influences may prove to significantly contribute to drug substances, bad health and family breakdown. dependency but research, including studies of twins, still suggests In Australia, as in the UK, some people are unable to access that environmental factors have the most important influence on basic life chances that should be available to all members of initiation to drug use in adolescence.24 society. Strategies to combat social exclusion aim to identify ways to stop people becoming disconnected from the labour market, family and informal networks.27

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The importance of these networks is profound. For example, • truancy; benefits of participation in paid employment extend far beyond the • homelessness; clearly identifiable monetary rewards. Work can provide • neighbourhood renewal; opportunities for meaningful interaction and friendship, a sense of • teenage pregnancy; and accomplishment and achievement, the possibility of success, and • opportunities for young people not in education, employment a sense of belonging and making a positive contribution to the or training. broader community. It is important to identify the structural factors operating to exclude The nature of work and participation in the workplace continues to people and communities from important social interactions and change. The effect of the increase in participation must be opportunities for connection, and to implement programs to offset considered alongside the casualisation of the workforce. Despite these. an increase in employment rates, some people are still not able to The Committee believes opportunities to reintegrate people into participate while others participate on an unequal footing. education, employment and the community must be a future Without these very important links and connections to other people, priority. social networks and recreational opportunities become increasingly In Victoria, the need for structural reform has been recognised and limited. Involvement in problematic substance use is more likely a number of responses have been implemented. These have 28 when these important opportunities are not available. included the: When people become socially disconnected, they may seek • recent Ministerial Review of Post Compulsory Education and comfort and a sense of security through drug use, and find Training Pathways in Victoria29 that made recommendations to support and ready acceptance from other drug users. It is also improve the accessibility and relevance of post-compulsory important to note that some people become socially education; disconnected as a result of their drug use and find non-using • development of a coordinated homelessness strategy; peers and family are less accepting of them. • recent Public Education, The Next Generation report,30 In the UK, programs to respond to social exclusion have focused proposes greater collaboration between schools that will, in on key points of transition when people are at greatest risk of part, enable better monitoring and tracking of students; and becoming excluded and marginalised. The British Government • recent funding of 38 projects that focus on social and has focused on the following areas for action: economic participation as part of VicHealth’s Mental Health Promotion Plan.

Program case study - Connect Project (Victoria)

The Connect Project is an initiative of the Department of Education, Employment and Training. It aims to support young people at risk of developing lifelong substance use problems. The program’s aim is to retain and reintegrate these young people in educational pathways. Changing Tracks was a pilot program run by the Springvale Community Aid and Advice Bureau for young people (aged 14 to 19 years) from culturally and linguistically diverse backgrounds (particularly Vietnamese and Cambodian) who wanted to stop using heroin and re-enter education, training or employment. The program was run in close cooperation with the Connect Project. The project comprised a series of induction, withdrawal and post-withdrawal elements (including residential camps) in a peer-based framework. The program focused on providing participants with an accurate knowledge of harm-reduction strategies, particularly regarding using practices. One of the explicit aims of the post-withdrawal element was the reintegration of the young people into education or employment. The program evaluation identified that some young people decreased their heroin use or changed their route of administration of heroin while attending the program. All participants subsequently returned to using heroin in doses equivalent to pre-program level within two months. However, in the absence of other programs to support these young people, the program provides a useful addition to our knowledge about what appears promising and what is less successful. The evaluation recommended a number of program refinements. The program further highlights the need to develop culturally appropriate mechanisms for reintegrating particularly marginalised and vulnerable young people into education or employment.

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5.5 Victoria’s prevention framework After considering research findings and consulting with experts and the community, the Committee believes: 5.5.1 Overarching approach • greater priority and investment (in terms of policy development, The Committee believes the Victorian Government should put in time, money and people) must be paid to prevention in all its place a prevention framework that approaches prevention on all forms. Government should now invest in this area with greater fronts: primary, secondary and tertiary (see Chapter 6 for a confidence given the knowledge that is now available and detailed discussion of the treatment service system). The emerging; approach must be flexible so programs implemented are • Victoria should put in place a prevention program that: appropriate for the target group, and for the environment in which - focuses action on preventing uptake of use, stopping use they are delivered. For example, an approach for early becoming dependence, and helping those experiencing adolescents in school would be very different to one for injecting problems from their continued use of drugs; drug users about safe injecting practices that was delivered by - recognises that different strategies are required at different peers. Programs must be delivered at the optimum time to points in the lifecycle; achieve the maximum effect. - acknowledges that different strategies are required in the However, we must be very clear about the difficult task that short, medium and the long term; prevention programs face, particularly given that some of the - aims to include all sectors of the community; factors underlying substance use relate to income, education, - is informed by current best practice; employment and crime. Real progress cannot be achieved - is based on Australian program evaluation and a quickly, nor can it be achieved without adequate investment and strengthened local research base; coordination. - includes a focus on healthy environments as well as healthy The Centre for Adolescent Health in its Evidence-Based individuals; Interventions for Promoting Adolescent Health report to the - pays attention to legal (alcohol, tobacco and prescription Department of Human Services makes a number of and over-the-counter medications) and illegal drugs and recommendations for program purchasing decisions for volatile substances; adolescent health promotion. These include that Government • the drug prevention budget should: should: - allow for the provision of expert advice and support to those • invest in programs that: who will manage or deliver prevention programs, including - advance evidence-based practice; those working in local government and the community; - aim to achieve behavioural outcomes; - emphasise secondary prevention strategies that reduce the - target multiple risk factors; and likelihood of young peoples’ experimentation with • invest in strong implementation and sustained program substances becoming dependent use; and interventions.31 - ensure there is timely, accurate and sustained drug information provided to the community. The Committee is of the view that these are also relevant to the broader population. Figure 5.1 identifies some of the key elements of Victoria’s prevention framework. We now have a good understanding about the antecedents of drug use. This provides confidence about where effort should be placed. The Committee supports the further development of innovative programs that are evaluated to allow for the careful expansion of investments in prevention. This acknowledges that while evidence- based decisions should, as a rule, guide investments, we still need to make room for new approaches and to carefully evaluate them with a view to broader dissemination of promising projects.

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Figure 5.1: Victoria’s prevention framework

Determinants

A complex interaction of Individual risk factors and protective Family factors operate with differing School degrees of emphasis depending on relevant domain Community

Program goals

Primary Secondary Tertiary Preventing use/uptake Preventing use Preventing harm from use among non-users becoming problematic Helping to reduce use (including dependence)

Program scope

Generic Drug specific Programs that respond to common antecedents of problem behaviours or enhance common protective factors

Target audience/domain

Individual Community Family/ parents School Workplace

Short-/medium-term outcomes

Individual Family School Community Increase access to Improved access to Healthy school Improved sense of support and accurate parenting support environments that are capacity to respond information including basic parenting supportive and access to programs and drug- accurate information specific programs

Decreased incidence of substance use and abuse

Long-term benefits

Increased physical Improved Greater amenity Improved quality of and mental health productivity and attachment to life and life expectancy local communities

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Government should implement a mechanism for overseeing all of In considering issues of cultural diversity and substance misuse, its prevention program implementation and planning to assess the socioeconomic status is the most significant factor that effectiveness of prevention programs, achieve coordination and contributes to high-risk behaviour rather than ethnicity itself.35 maximise synergistic effects. Two such mechanisms proposed Sections of Victoria’s population who were born overseas are later in this chapter are a whole-of-government coordinating likely to be particularly disadvantaged, particularly those who do committee and a research forum/clearing house (see section 5.6 not have strong English skills and may have migrated through the below and chapter 8). humanitarian (or refugee) program. Recent Victorian research The Committee again draws the Government’s attention to suggests a range of risk factors may increase problems such as research that points to a range of common antecedents to the drug use in some communities in addition to poverty including: development of later problems such as substance misuse, teen • traumatic refugee experiences; pregnancy, unsafe sex, early school leaving, youth suicide, • inadequate settlement support; depression, crime and delinquency.32 In assessing responses and • acculturation or tension between a migrant’s home culture and approaches, consideration should be given to identifying those that of the host culture (this may be evident in inter- programs and initiatives that are general (that may have positive generational conflict, particularly the parent-child relationship); impacts on a range of problems) and those that need to be more and 36 targeted and drug specific. • isolation that may result from language barriers. The Committee urges Government to invest with confidence in The Committee’s consultations bear this out. These consultations prevention programs that are evidence-based and consistent with have also brought to the fore a number of specific problems the evolving body of knowledge in this area. experienced by culturally diverse communities, such as: • some parents struggle to establish themselves financially in 5.5.2 Specific issues their new country and therefore have little time to spend with Tailoring programs their children; and Research indicates that strategies that are comprehensive • the most recent waves of migration experience acute problems (involving school, community, parents, community organisations when they are also suffering economic hardship. This has and social policy) are more likely to be effective generally than been seen in some sections of the Vietnamese community. single channel programs (for example, school educational The Committee has been advised that there are now significant programs for substance use or mass media advertising) on their issues in a number of Horn of Africa communities and that, in own. Two examples are the Midwestern Prevention Project and future, the latest waves of migrants (such as Afghanis) may Project Northland identified in section 5.4.1 above. The require additional support to that already available. implementation of comprehensive strategies also aligns well with The Committee has heard (in its consultations with representatives the key action areas outlined in the Ottawa Charter (which of diverse communities and those that work with these articulated a need for coordinated activity across program and communities) that producing resources in community languages 33 policy areas). alone is not the answer. Community members have advocated a In terms of targeting young people from diverse cultural and community development approach as the most effective way to linguistic backgrounds, and those who may be at elevated risk of build resilience within culturally diverse groups. Additional support substance use problems, multi-channel programs are more likely to enable communities to mobilise is required. To this end, the to be effective.34 Committee is proposing a comprehensive Community For a multicultural community like Victoria, it is important to Mobilisation strategy that pays special attention to the needs of appreciate the diverse patterns of risk and protection that may diverse communities suffering particular hardships. apply in different cultural groups, especially for the newly arrived. An approach that is based within the community is more likely to yield results by working with, and supporting, cultural identity. There is growing evidence that a strong cultural identity contributes to development of resilience and minimisation of risk factors.37 Current policy acknowledges that shoring up cultural identity while supporting the host culture is central to the concept of multiculturalism. Therefore, the entire Victorian community will benefit from an environment that supports cultural and linguistic differences. This support can be expressed in inclusive programs that respect people’s differences, and programs that service specific cultural groups.

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Substance misuse in Koori communities is a problem that has behaviour (drug use, pregnancy and delinquency) and quietly profound impacts on an already vulnerable part of our community. disturbed behaviour (poor body image, emotional stress and Koori people face specific pressures and structural issues that suicidal ideation or attempts).41 The study found that that boys must be considered in the development of prevention strategies. tended toward acting out behaviours and girls tended toward They also face specific substance use issues. It is essential that quietly disturbed behavior. While the actual factors are the same, Koori people are involved in all stages of program development. their order of importance is different for boys and girls.42 Much of the research concerning indigenous Australians and drug- There are also particular problems faced by gay and lesbian related matters has concentrated on alcohol and tobacco, but communities. A recent report found that among those who there is an increasing need to fully investigate and confront the role identify themselves as gay or lesbian, male respondents in the 20 of illegal drug use, an area that has been relatively neglected.38 As to 29 age group had high rates of alcohol and substance use VIVAIDS, the Victorian drug user group, points out: (alcohol 93.5 per cent, tobacco 34.3 per cent, and marijuana and

43 further marginalisation combined with illegal drug use also ecstasy both 23.9 per cent). Female respondents also reported 44 places them in situations where they are more likely to use in substance use at levels higher than population averages. harmful ways and be at risk of overdose.39 Particular responses are required for these communities which experience high levels of drug-related harm. The apparent links between problematic drug use and the risk and protective factors outlined in this report suggest that services Intervention and transition points concerned with mental health and primary health care within the Research offers some directions about when (in the lifecycle), Koori community must meet the high level of need. This must where (the environment) and for whom (targeted versus universal) include targeted interventions and services that systematically programs should be delivered. confront drug issues. However, expectations of what prevention can achieve must be Many Koori people face deprivation and disadvantage manifested realistic. No single program can address all needs. At the same in family breakdown, crime, violence, and economic time, it is important to invest strongly in a number of strategic disadvantage. For example, we know that Koori people are over- priorities rather than doing a little of everything.

40 represented in correctional settings. These problems are often a Individuals develop through exposure to a range of environments result of, and exacerbated by, problematic drug use. from infancy, through childhood and adolescence, and on to In addition to culture and background, it is also clear that gender adulthood. These environments are known to influence the differences manifest themselves in terms of different forms of individual. No single environment, be it the school, home or the problem behaviour and distinct combinations of risk and community, should be the focus of all prevention efforts. For protective factors. example, messages delivered in the school need to be reinforced The work of Michael Resnick et al. in this area is instructive as it by the broader community standards about use of alcohol and identifies some differences between the patterns of protective other drugs. factors that apply to boys and girls in relation to acting out

Figure 5.2: Intervention/transition points and who can play a key role in effective prevention

Antenatal Postnatal 0–55–11 11–18 14–21 21+

• Parents • Parents • Parents • Parents • School • School • Workplace • Hospitals • Maternal & • Childcare • Teachers • Student • Workplace • Peers • Maternal & • child health • Preschool • Student • welfare teams • TAFE • Professionals • child health • services • Maternal & • Welfare • Teachers • University • (particularly • services • child health • Parents • Peers • GPs) • services • Media • Media • Media • Peers • Educational • Institutions

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Universal approaches and those aimed at providing resources It is clear that we need to build on the work already done. and encouraging the community to play a role must also be However, we also need to be clear about those programs, or included. elements of programs, that do not appear to have worked well Appendix 6 provides examples of some of the programs that and look at what we can learn from them. might be delivered for each of these time points. There are also a number of prevention programs from overseas While a key focus of prevention efforts is on the early part of the that show promise. We are in the fortunate position of being able lifecycle up to and including early adulthood, a broadly based to select the best elements of these programs while avoiding prevention framework should include the needs of adults (with mistakes made by other countries. particular reference to misuse of alcohol and prescription The Centre for Adolescent Health has recently completed its medications). report to the Department of Human Services on Evidence-Based It is understandable that when we think about prevention, our Interventions for Promoting Adolescent Health. This report attention tends to focus on young people. This is because young reviewed evaluated research findings for over 178 research people are particularly vulnerable and adolescence and early articles (of these, 57 related to tobacco use and 39 related to adulthood are times when people tend to experiment and to test alcohol and other drugs). Following a consideration of the boundaries. evidence base, the review authors assigned weightings to signify the confidence with which programs can be implemented. That However, this focus has the potential to create the impression that review has identified a number of strategies that represent the substance use is only a problem for young people, and allows ‘best buys’ for prevention programs.45 These include: adults to leave their own substance use unquestioned and • school-based health education and school organisation and unchallenged. It also denies the reality that there are very many behaviour management; adult Victorians currently experiencing harm from substance use • social marketing; that can be chronic (for example, alcoholism, smoking, abuse of • peer intervention; prescription medications, injecting drug use) or episodic • programs to support parents (including family intervention); and (excessive alcohol consumption). Therefore, we must also look at • community strengthening. prevention opportunities that target Victoria’s adult population. This is important in its own right, and because of the important These programs accord with the new priority areas for action the role modelling function that adults perform for young people. Committee proposes in section 5.8 below. The Committee is proposing a sustained communication strategy With regard to legal substances, levers such as taxation and that will be designed to meet the needs of all Victorians, not legislation can also be effective prevention strategies and should young people alone. In addition, the Committee is proposing a not be discounted. For example, the recent, Tobacco Amendment coordinated strategy to reduce harm for current users that Act 2000 allows for smoke-free dining in restaurants and cafes. primarily focuses on adults. In this section, the Committee reviews the major areas of prevention activity that have been used in Victoria in recent years 5.6 Where we are now - and comments on their effectiveness and the role they have to Past, current and planned activity play in the proposed framework. 5.6.1 Schools As set out in chapter 2, investments in prevention have been modest compared to those in law enforcement and treatment. Schools are well positioned to develop a culture that promotes Less than 5 per cent of the current year drug budget is allocated belonging and fosters a belief in the possibility of success. A to prevention programs. Despite this, a number of programs and focus on the school environment and school connectedness is a initiatives have been put in place. Many of these programs have consistent theme in the research and literature. been moving in the general direction indicated by the emerging Substance use prevention programs have traditionally been research base. equated with a narrow perception of drug education in schools. In recent years, significant efforts have been put into developing a The Committee believes that ‘drug education’ as a term is no coordinated approach to how we deal with drugs in schools. A longer helpful, as it is linked with the notion of providing specific number of other programs have been designed to support the information about drugs and their effects and ignores the broader school environment and inform parents about drug issues. During student welfare, family and social issues involved. this time, various media strategies and peer education programs Providing information about drugs and stimulating debate are have also been delivered. A number of community programs have important components of prevention programs in schools, but must also been implemented, but these require further development be combined with other prevention strategies to achieve results. and support.

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Past Drug Policy Expert Committee (DPEC) comment Prior to the Premier’s Drug Advisory Council report, prevention The Committee welcomes the changes to school prevention programs in schools were: programs in recent years. School prevention programs, when well • primarily provided on an ad hoc and occasional basis; integrated into the life of the school, are an important component • focused on providing information about drugs and their effects; of an overall strategy. Outside presenters should only be involved and when this visit can be integrated into the school’s overall plan and • delivered by presenters invited into the school rather than managed by ongoing classroom teachers. School prevention classroom teachers. programs will be made more effective by supporting: Current • further development of school-based health and welfare support services; Drug prevention programs in schools are now: • cultures that promote resilience; and • increasingly becoming integrated into the broader curriculum • a focus on vulnerable young people. through Individual School Drug Education Strategies (ISDES); • aimed at coordinating curriculum responses, welfare support A consistent theme in this report is that of reintegration. Additional and links to the community, including strategies to involve opportunities must be found to reintegrate or retain young people parents; who have had substance use problems in the school system. • widely implemented, with all Victorian government and 80 per Future directions cent of Catholic and independent schools now having an • There needs to be a sustained focus on wellbeing and life ISDES in place; skills development. • increasingly set within the context of whole-school cultures that • Recent reviews of schooling and post-compulsory education encourage resilience; provide important opportunities to take further steps to • complemented by additional general support services being strengthen the welfare of students and improve long-term life implemented to assist schools to prevent drug-related harm opportunities available to them. (for example, secondary school nurses and expanded student • Additional support in the form of dissemination of research welfare services); and findings and support for evaluating program outcomes should • subjected to national policy coordination with the be priorities. Commonwealth, through the National School Drug Education Strategy actively engaging States and Territories in research, resource development and a series of community summits.

Program case study START (Student Transition & Resilience Training) Program, (Victoria)

A key point of stress for young adolescents is the transition from primary to secondary school. START is a program to support Grade 6 and 7 students in this transition. The program was piloted in over 100 Victorian schools this year. START involves networks of primary and secondary schools working together to reduce the stress associated with transition. The program brings together current thinking about resilience, a focus on the middle years of schooling, social skills development and interpersonal problem-solving skills. Key elements of the program include: • getting Year 6 students to write letters to secondary school and develop ‘passports’ to take with them to secondary school; • inviting secondary school teachers to observe Year 6 programs and teach sessions; • holding informal social functions that include parents; • forming peer involvement teams at secondary school; • scheduling the same teacher(s) to work with groups of Year 7 students rather than having separate subject teachers (to assist with continuity); and • restructuring the physical environment in the secondary school so Year 7 students have a defined ‘territory’. Subject to evaluation findings, the Department of Education, Employment and Training will make the program available to schools generally in 2001.46

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5.6.2 Social marketing Past Social marketing is the use of the mass media and more targeted • Social marketing programs in relation to drugs have communication strategies (for example, ‘narrow cast’ - highly emphasised information services to the community through targeted advertising) to provide information and create a climate advertising, printed material and telephone services. for behavioural change. • Media-based social marketing efforts have tended to be short term and ad hoc. Governments have used social marketing techniques since the 1970s to influence the population regarding issues such as Current energy conservation, HIV/AIDS prevention, reducing transport • Increasing attention has been paid to providing information to accidents, nutrition, and drug and alcohol misuse. current drug users with a view to reducing overdose events. • The Commonwealth Government will launch a major media The use of media to change drug-using behaviour is often campaign on illegal drugs using television and distribution of advocated. The Transport Accident Commission (TAC) material to parents. Little detail of this campaign is available at advertisements target dangerous driving behaviours, including the time of preparing this report. A recent, large-scale drink driving. These are frequently suggested as a model for Commonwealth campaign focused on alcohol misuse among substance use advertisements. The TAC advertisements are young people. The evaluation for the campaign is not yet rightly applauded as a successful strategy in relation to transport available. accidents. However, TAC advertisements are only one part of a comprehensive strategy that includes intensive policing and DPEC comment improving roads. Further, a large part of the impact of these Care needs to be taken to carefully target and structure campaigns concerns the message that high levels of policing communication strategies. Target audiences are sophisticated effort mean there is a strong possibility that drivers committing consumers of information who are adept at filtering out unwanted offences will be caught. This is not the case for drug use, where messages. In recent years, hundreds of items of information have the covert nature of the activity makes apprehension unlikely and been circulated with limited impact. If future campaigns are to be diversion programs are in place for new offenders. useful, careful research (including focus-testing), planning, In relation to tobacco, the National Tobacco Campaign was a monitoring and evaluation are required. Clear goals must be set major social marketing campaign that has also been evaluated as and discretion exercised in developing campaign elements. highly successful. This campaign’s key elements included: Campaigns must target specific age groups and drug use • a sustained program of carefully constructed, tested, branded patterns. Any universal campaign must be very carefully and identifiable messages based on well-researched considered prior to implementation, particularly in terms of information on effects of smoking; potential negative effects. Rigorous evaluation for intended and • a well-coordinated and continuing infrastucture to support unintended effects must be undertaken. Clear linkages must be cessation attempts (Quit); made with other prevention elements, including parenting • a regulatory framework that controls advertising, limits programs and school-based approaches. Any communication distribution (including sales to minors) and prescribes places campaign must be sustained over time. where use is not allowed; and Future directions • taxation levers to make smoking less attractive, particularly to • The Committee believes that an integrated and planned young people. approach to communication on drugs is required. This strategy These efforts and achievements are to be commended. may include the mass media (where appropriate), narrow casting (targeting information for specific populations), direct information provision and community involvement to link together the existing range of activities and build a new and sustained approach.

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Program case study - Speed Catches Up with You (Commonwealth)

From 1993 to 1995, the Commonwealth Government implemented a national and intensive campaign to raise awareness of risks associated with amphetamine use. The rationale for the campaign was based on: • a sharp rise in amphetamine-related deaths (seizures and hospital admissions); • the risk of blood-borne virus transmission through intravenous use; • high levels of availability of amphetamines (due to local production); and • a concern that users did not perceive amphetamine use as dangerous. The campaign involved the use of television, cinema and radio advertisements, brochures and billboards, ‘advertorials’, and sponsorship of a number of youth-oriented and televised media events. A music CD was also produced. This national campaign was implemented in three phases over three years with changing messages over time. A baseline survey was conducted prior to the implementation of the campaign and tracking surveys were conducted following each phase of campaign activity. The evaluation of the program found very high levels of awareness of the key messages in line with communication objectives. It attributed this to the campaign’s multi-channel focus and sustained nature. The campaign was unable to demonstrate behavioural change.47 During this time, changes to the proportion of those who had tried amphetamines did not change significantly.48

5.6.3 Peer education Current activity The complexity of patterns of drug use among different • The Government has supported continuing, although on a communities requires a sophisticated response that is sensitive small scale, work with drug user groups that focuses on and tailored to drug-using cultures. reducing overdose events. Peer education is a method of health promotion that may be DPEC comment particularly useful for substance misuse as it is an effective way to The use of peer education has been shown to be effective access people who otherwise may be difficult to reach. The internationally when used in a targeted and highly structured provision of information from peers is often seen as more credible manner.50 It is particularly useful with groups or subcultures than from other sources (particularly government departments). disconnected from, or mistrustful of, mainstream information and Research indicates that peer education structured around primary communication methods. Current drug users clearly meet this prevention objectives can be effective in the school environment, criterion and should be the target of such a program. The but has been subject to implementation problems, particularly in Committee sees peer interventions as an appropriate strategy to terms of identifying the right ‘peers’ to ensure some students are reduce harm associated with current drug use. not alienated or ‘turned off’.49 Future directions Past activity As part of a coordinated strategy focused on current drug users, • Little systemic effort has been made to use peer education the Committee believes expanded peer education strategies are strategies in this State. required that involve current and former drug users working with • Short-term projects working with school students have been their using peers. The focus should be on: conducted at the local level. The State Government has • providing information; and supported a pilot involving 16 to 20 year olds working at large • facilitating links to health, welfare and rehabilitation services. public events that are likely to attract young people.

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5.6.4 Programs to support parents Current activities Many parents are already very comfortable in their role and ability to • The State and Commonwealth Governments are supporting a raise their children. However, the changing definition of family and range of non school-based programs including expanded altered work practices and demands have meant the traditional telephone support and formal parent education programs. mechanisms of support and advice about parenting, and ‘what to • One major program currently being developed in Victoria, with do’ in different circumstances, are often not readily available. Commonwealth funds, targets parents of Year 7 and 8 children. It focuses on the critical transition from primary to As outlined earlier, research clearly suggests that being connected secondary school. The program is known as ABCD – About to supportive environments is a protective factor. Programs that Better Communication about Drugs for parents of early assist parents in providing such an environment are clearly adolescents. While being made widely available, it will be important. In the past, strategies have focused on providing particularly targeted to socially disadvantaged, culturally and information to parents so they were able to raise the issue and linguistically diverse and Koori parents. This program aims to discuss drug use with their children (for example, programs were concentrate on general parenting skills to assist parents in provided for parents of primary and secondary school students). tackling issues of adolescent substance use. However, research now suggests (and consultations, including DPEC comment those held with young people have affirmed) that what is needed is a ‘habit’ of communication between parent/guardian and child. There is emerging evidence that long-term benefits accrue if This will form a basis for discussion about substance use and parents of children aged 0 to 5 are provided with increased other issues facing young people. assistance. For example, Olds et al. (1997) have found a long- term reduction in antisocial behaviour and emerging substance Past activity use problems in single mothers with low socioeconomic status • A range of generalist parenting programs such as Maternal who received nurse visits during pregnancy and postnatally. and Child Health Services and Family Support have dealt with Program for Parents, an evaluated parenting program for parents drug issues in the course of their normal work, although the of early adolescents, shows promise (see boxed case study). issue of drugs has rarely been seen as a priority or one where staff feel they have particular skills. Future directions • Church and community organisations have developed parenting • Additional effort is required on developing a range of strategies skills programs, some targeted at drugs specifically (for to support parents at different stages as their children grow. example, Focus on the Family’s ‘How to Drug Proof Your Kids’). • Areas of focus include modelling appropriate behaviour for • As noted in the discussion on schools, parent involvement their children, developing a habit of communication, and strategies are an integral part of the Individual School Drug placing a particular emphasis on parents of adolescents. Education Strategies. More than 10,000 parents have • Strategies used should include parent peer support, seminars participated in the last three years, and some programs have and workshops. been provided in languages other than English.

Program case study - Program for Parents (national)

Funded by the Department of Health and Aged Care, Program for Parents was a collaborative project between Parenting Australia, Jesuit Social Services, Anglicare and Centacare. The program was implemented nationally and targeted the most consistent risk factors for adolescent suicide; self-harm, social alienation, depression and substance use. The program demonstrates how an intervention designed to target one poor adolescent health outcome may have positive impacts on a range of other problem behaviour. Program for Parents provided the parent education program, Parenting Adolescents, a Creative Experience (PACE) to parents of students in Year 8. Parents were identified through: • a whole-class approach where all parents of Year 8 students in a target school were offered the program; and • self-selection following advertising in community health centres. The PACE program involved an intensive eight-week course that focused on the development of listening skills, assertiveness and conflict resolution with the aim of developing authoritative parenting styles (confident parenting that is neither authoritarian nor overly permissive). Authoritative parenting has been found to be predictive of reduced levels of substance misuse.52 The evaluation of the program found that while not all parents of students in a particular year participated (in target schools), positive changes were recorded across the school community (through the so-called positive social contagion effect). Parents who participated in the program reported fewer conflicts and a trend for increased parenting confidence.53

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5.6.5 Local community involvement Current activity While much has been achieved at local community level in recent • There is renewed interest among community groups and local years, there is still more work to be done. People at all ages need government in drug issues, and evidence of local strategies opportunities to contribute to their local communities. While the being developed across the State. There is evidence that Government should take a lead role in prevention, the problems business and other organisations are also seeking ways to help. that drugs present to the community require coordinated action • As a result of the Committee’s Stage One report, the five across a range of fronts. The efforts of local communities to municipalities most affected by heavy street drug use are respond to the specific problems they face should be supported, working to develop detailed strategies to tackle the complex and the desire of individuals, groups, service clubs and problems that they face. businesses to become involved must be harnessed. DPEC comment The Committee’s Stage One report was concerned with the effect The Committee strongly believes that community involvement is of drugs on local communities. It recommended systematic fundamental to the implementation of a comprehensive and support for communities responding locally to the problems posed effective drug strategy. There is increasing evidence that resilient by drugs. Key elements of a local response could include: and supportive communities can play a significant role in reducing • improving information provision and linkages between stakeholders; the impact of drugs, and can contribute substantially to the • developing community support strategies; rehabilitation and reintegration of drug users (see chapter 8). • intervening to reduce drug-related harms; Future directions • developing youth-focused prevention and early intervention • Priority should be given to assisting local communities and activities; communities of interest to develop drug strategies and • managing public spaces; and responses, and to collaborate with each other to broaden and • facilitating economic development. strengthen their response to drugs. In recognition of the need to support communities, the • Greater resources and support are required, such as Government has acted on the Committee’s recommendation to information on latest research findings and assistance in embark on a program of community mobilisation. program design. Past activity • There is a need for coordination and a clearing house research • Community groups and organisations, sometimes with the function to be provided to local communities so resources and support of local government, have been active in responding to information about program effectiveness are shared. drug issues for many years. Rarely have these local initiatives, whether about prevention, treatment or rehabilitation been systematically supported. • At a national level, important work has recently taken place in the areas of crime prevention and public space management. Hanging Out, a National Crime Prevention report, identified three key elements that should be considered in a strategy framework: - recognising youth space needs; - planning and development strategies; and - managing public space.54

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Case study - Whittlesea Youth Commitment (Victoria)

A major community initiative that has occurred in the City of Whittlesea links to a number of the key themes already raised in this chapter. The Whittlesea Youth Commitment (WYC) is a program that looks at the pathways of young people after leaving school, and aims to support them in making a successful transition to work or further study. In simple terms, the WYC was formed to respond to the high number of young people leaving school in an unplanned way. These young people encounter a highly competitive job market where those with qualifications are favoured over early school leavers (similar to other areas of the State). The WYC was also formed in recognition of the elevated risk of substance use and other problems for those unable to make a successful transition to work or study. The signatories to the WYC include employers, job networks, regional offices and agencies of State and Commonwealth Government, local government, a university, TAFE campuses, schools and community agencies. The WYC has articulated its aim as contributing to student-centred, high-performance education and training through: • meeting the requirements of all young people in education; • assisting with transition between school and employment; • taking responsibility for the welfare of the regional community’s young people; • improving links between employers and young people; and • committing to measuring progress made to achieve these aims. Key projects auspiced by the WYC in 2000 include: • all students in schools involved in the WYC now complete a common form to identify those exiting without a clear path; • students without a plan are referred to the school’s ‘transition team’ to discuss options; • a transition broker is available for individual referral; • a community team has been established to ensure professional collaboration; and • an employer reference group provides advice on options to improve links between employers, school leavers and jobseekers. In 2000, the WYC has been able to attract funding from diverse sources. It has received funds from a regional assistance grant, the Department of Education, Employment and Training, School Focused Youth Service, Northern Metropolitan Institute of TAFE, the City of Whittlesea, local schools directly and the Dusseldorp Skills Forum. It has also received considerable additional in-kind contributions from commitment signatories.55

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5.7 Commitment to prevention - 5.7.2 Whole-of-government/cross-sectoral prevention coordinating committee The planning process As outlined elsewhere in this chapter, prevention efforts have too The Committee believes the stated need for prevention and the often been hampered by lack of coordination. As our evidence base considered above enable the Government to make understanding of the common antecedents of a range of problem additional investments in prevention with greater confidence. A behaviour improves, it is likely that prevention efforts that aim to minimum of 10 per cent of the total drug budget should be achieve diverse goals (such as tackling youth suicide, depression, committed to prevention programs. body image and substance use) may share a common approach, The Committee considers that an ongoing planning process is themes or elements. required that brings together, coordinates and monitors Victoria’s It is imperative that prevention efforts are appropriately prevention efforts not just as they relate to drugs, but in prevention coordinated. A whole-of-government/cross sectoral prevention programs generally. Key elements include: coordinating committee is proposed to bring together • implementing new priority action area programs identified in representatives from government departments involved in 5.8 below; prevention and key external stakeholders. • continuing to implement existing prevention programs that are Aims working or showing promise; • Better coordinate all prevention efforts. • reviewing achievements based on program evaluation • Remove duplication. (process and outcome evaluation); • Ensure complementary approaches that reinforce each other. • improving surveillance and monitoring and, where appropriate, Core functions community consultation; and • Undertaking a continued monitoring role. • developing a process to identify new program priorities and • Coordinating all government programs designed to prevent make recommendations in relation to recommitting to existing development of problem behaviour. programs following review. • Considering proposed recommendations on new program In support of the planning framework, two new coordinating and proposals as well as recommending continuation of programs unifying functions should be established: that are achieving their aims. • a research clearing house/forum; and • a whole of government/cross-sectoral prevention coordinating 5.8 New priority areas for action committee. While there are many programs that governments can deliver in 5.7.1 Research clearing house/forum prevention, some are immediate priorities and should be When the Committee co-convened a workshop on prevention in implemented without delay. The Committee has determined these July this year, it brought together some of the key researchers, program priorities using the research findings and its consultation academics and program managers working in this area. Modelled process. In implementing these programs, the Government on this approach, more regular meetings of key researchers and should pay particular attention to the needs of Koori communities, people working in the field should be instituted to enhance rural communities, and diverse communities generally. collaboration and improve information flow to policy makers. As already noted, coordination between projects will be very Aims important as strategies that are comprehensive (involving school, • Enhance and develop cooperation and collaboration. community, parents, community organisations and social policy) • Better align funded program activity and research. are more likely to be effective than those that are isolated. • Develop and support local knowledge and research base. The proposed programs are outlined in table 5.4. • Support local government through disseminating best practice program information. Core functions • Disseminating research findings to the Government and others involved in implementing prevention programs. • Identifying priority areas for inclusion on the future research agenda. • Informing policy makers of current best practice. • Reinforcing a commitment to measuring effective program outcomes.

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Table 5.4: Proposed programs

Summary of Program Goals Rationale Key Elements

5.8.1 Community • Support and enhance The Committee’s Stage One Development of local programs mobilisation community connectedness, report placed communities at should be the key consideration. particularly in terms of the centre of Victoria’s response However, coordination of A strategy to support developing locally relevant to drug issues. The importance community-based action is communities to respond to responses to drugs. and potential benefits of imperative if duplication is to be local drug problems and • Provide opportunities for engaging communities, and the avoided, and sharing of translate strategies into actions. involvement and participation enthusiasm of many community program successes maximised. of individuals, groups, local members, have been reinforced The Government’s primary role (See dhapter 8 for further government and business. during the Committee’s Stage 2 should be to provide support discussion of this proposal.) • Identify and support local consultations. Engaging local and guidance. leaders who can champion communities more fully in As a matter of priority, program implementation. responding to drug issues will appropriately detailed resources • Increase opportunities that allow them to address their local should be developed on develop local leaders. drug problems. It will also build different elements of a local • Develop opportunities for stronger communities that can approach so time and money is reintegration, particularly in go on to tackle other issues of not wasted in replicating relation to creating concern. literature searches and educational, training and work A legitimate focus will be on background research. While opportunities. communities of interest allowing for innovation, these including culturally and resources should provide clear linguistically diverse guidelines about project communities. An approach that management and accountability is based within the community is requirements. more likely to yield results by A weighted formula (using social working with, and supporting, disadvantage indices) should be cultural identity. used to guide fund allocation matched with a consideration of the demonstrated willingness of at least one local organisation or consortium to act as project sponsor. Projects that are action-oriented should be preferred to those that aim to develop strategy plans. Practical and continuing support will be provided by the Prevention Resource Team (see section 5.8.7 below). The Committee is aware the Government is embarking on a range of other community strengthening strategies. These should be appropriately coordinated to ensure equitable spread of resources, and to share the lessons learnt through project implementation.

5.8.2 Drug Primary prevention Implementation of an effective Communication programs are communication • Enhance community drug strategy requires a well- required to underpin all the other strategy understanding and ability to be informed and involved community. strategies being proposed. involved in tackling the often Information is important, but it Social marketing is often thought of A strategically designed drug controversial issue of drugs. must be linked to a broader as only use of the mass media. communication program is • Provide a basis to enable strategy to achieve long-term While mass media can play a required that is sustained, better communication between (up to 10-year) goals. legitimate role in a coordinated directed and linked to other parents and children. communication strategy, other elements of the prevention media and non-media responses strategy. should be preferred for more targeted information.

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Summary of Program Goals Rationale Key Elements

5.8.2 Drug Secondary/tertiary prevention Changing community In general, the level of specificity communication • Provide accurate information perceptions about drug use and and detail of the message should strategy about effects of using drug users is a key part of the be low for broadcast messages. substances (in the first process of building more For narrowcast messages. the continued... instance, cannabis). positive engagement that information can be much more • Assist people to make maximises the opportunities for specific and explicit. informed choices about their treatment and reintegration. The communications strategy drug use. Program evaluations and should be linked and coordinated • Provide heroin overdose research identify that great care with other priority areas for action. prevention messages to must be taken in program Mass media injecting drug users. design to ensure desired Programs should be focused on messages are communicated to messages suitable for the whole appropriate audiences. population (and all ages). These Therefore, communication should include strategies that are techniques used will depend on: designed to enhance community • the messages being understanding of broad drug conveyed; and issues (potentially including • different audiences. messages about alcohol and Use of the mass media (within cannabis use as two of the most defined limits) has an important widely used substances). role to play as part of the overall Television, cinema, billboards, strategy and support structure. radio, print and the Internet may be One key priority area in relation considered as vehicles for to drug-specific information messages as appropriate. should be providing clear Narrowcast messages about cannabis as Messages suitable for current drug use of this drug is widespread. users or specific communities. This has fuelled a perception Messages that should be that its use carries no risk. communicated include harm In the case of culturally and reduction strategies such as safe linguistically diverse using practices and responding to communities, the strategy must overdoses. Examples of recognise that different narrowcast advertising include techniques should be employed discrete advertising in venues and that in some cases this may frequented by the target audience, involve community and church messages in fitpacks, magazines leaders in conveying messages. that target a highly specific readership, and sponsorship of relevant events. Non-media Information can also be provided persuasively through personal presentation in workshops and meetings. This includes those elements identified in the Supporting Parents Strategy (see 5.8.3 below), and underlines the importance of coordination with other new priority areas for action. This element should include a ‘services’ component concerned with informing and engaging the alcohol and drug/health/legal/education field by drawing them into the process of communicating their activities.

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Summary of Program Goals Rationale Key Elements

5.8.3 Primary prevention Research points to sound It is important that existing Supporting parents • Support healthy and nurturing parenting and the strategies be linked to ensure home environments. parent/guardian–child relationship duplication can be avoided. A sustained strategy working on • Enhance good as critical to emotional wellbeing. Strategies are required at various a number of fronts to support communication between In addition, the importance of points in the child’s lifecycle. parents (leveraging the benefit parents and children. modelling appropriate behaviour 0-5 from investments made by the • Provide information for cannot be underestimated. Expanded maternal and child Commonwealth and State parents on appropriate However, as society continues to health function, particularly for Governments). substance-using behaviour. change and the definition of vulnerable parents. This focus Secondary prevention family is broadened, traditional should include providing opportunities for passing on Advising, assisting and information on parenting shared knowledge about engaging parents with strategies. adolescents, particularly at an parenting have, to some extent, 5-11 (primary school years) age when drug use commonly dissipated. begins. Given the very important role that Strategies to help, guide and parents play, it is essential that support parents, and to involve they be provided with access to them in school life. These opportunities to develop practical programs should raise awareness skills, information and advice. of the need to provide additional support to their children during the Families commonly face transition period from primary to significant difficulties as children secondary school. make the transition into adolescence. Timely and relevant 11-18 assistance, and the development Developing a program that allows of a habit of communication over parents to come together and time (but particularly throughout share and receive information adolescence), can make a about parenting styles and difference to risk- and drug-taking strategies. A particular emphasis behaviour and the quality of should be on drugs. This should relationships in the family. develop a realistic appreciation for In addition, some families will the problems that they pose and have to deal with the fact that one provide practical responses. of their members is using drugs. The Committee is aware of the These families will require About Better Communication particular advice and assistance. About Drugs program being Culturally and linguistically implemented in Victoria in diverse parents may be under partnership with the particular stress as a result of the Commonwealth. This program is migration process and primarily targeted at parents of acculturation, and therefore vulnerable young people but will require particular assistance. also be offered more widely. The Committee supports this approach. Programs should be delivered in various settings. Community centres, local government and schools are three key areas where these programs should be offered. A program of additional support and advice must be available to parents of children experiencing problematic use of drugs and who have yet to access treatment. This should take the form of telephone counselling for parents, carefully facilitated peer support from other parents, and access to objective and skilled family counselling.

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Summary of Program Goals Rationale Key Elements

5.8.4 Enhancing the Primary prevention A key theme running through Development of a program to school environment • Support students’ prevention research in terms of disseminate research findings and connectedness to the school. evidence about what works is coordinating evaluation of school- Schools should be supported in • Strengthen the student- the importance of building based approaches through the developing strategies to teacher relationship. healthy environments rather than Prevention Resource Team enhance the health of the school only focusing on specific identified in 5.8.6 below. environment. problems. The Committee supports programs The Framework for Student that focus on risk, and protective Support Services clearly factors that are consistently articulates a commitment to this identified in relation to substance concept. The two recent reviews misuse such as the Gatehouse (Post Compulsory Education Project, Centre for Adolescent Review and Public Education, Health). Key elements of such a the Next Generation) both project include: indicate support for the • enhanced social climate framework. Other issues monitoring in schools; identified include clustering of • identification of an independent schools and a greater broker to facilitate clustering of monitoring of the school climate. schools and programs; The Committee is of the view • strategic planning of programs that the commitment to based on locally identified identifiable school drug policies needs; should be retained. • implementation of interventions and professional development; At the time of drafting this report, and the Government is in the • monitoring and review. process of responding to the two recent reviews: • Public Education - The Next Generation • Ministerial Review of Post Compulsory Education and Training Pathways This response includes, among other things, the establishment of a series of targets and contract obligations in relation to such indicators as school retention rates and curriculum standards. In meeting some of these obligations, schools will be clustered to develop local responses and will, by necessity, be required to consider the role of substance use in the school environment.

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Summary of Program Goals Rationale Key Elements

5.8.5 A coordinated Secondary Prevention There are a number of fronts on The two recent reviews in approach for • Reintegration into schools. which Government should act in education support the Framework vulnerable young • Strengthen family bonds and a coordinated way. for Student Support Services. people relationships. Early school leavers As noted elsewhere in this chapter, • Connect with relevant support Prevention programs need to be a particular focus is the A cohesive strategy is required services including housing targeted to those who leave reintegration of young people who to provide additional programs, and income support. school before Year 12. In have left school and who are not in services and support to particular, two areas that should employment or post-compulsory particularly vulnerable young be focused on are education. The Committee Victorians. apprenticeships and TAFE. supports an integrated approach Young people undertaking to vulnerable young people that: further study at TAFE or who are • encourages them to stay at or completing apprenticeships, return to school; often ‘miss out’ on prevention • supports them in their transition programs (young people in to higher education, TAFE, these pathways often find apprenticeships or work; and themselves in adult situations • provides continuing support for where substance use is those affected by parental or accepted). their own drug use Diversity School Focused Youth Services We know that young people are The two core components of this diverse. Some young people service are: can experience rejection or • The development of discrimination from peers, the linkages/coordination between broader school community and youth services, including the community in general on the mapping local services basis of race, sexual orientation, • Brokering (including limited appearance or disability. As part case management) services of the broader information that have been identified as strategy, and articulated with gaps in service availability from curriculum and the student the mapping welfare framework, special The Committee has heard that attention must be paid to these while very promising, this program young people who, research has met with varied success on tells us, can run a greater risk of implementation. The program is developing substance use currently being evaluated (not due problems. A coordinated to be completed until February diversity strategy is required to 2001). In keeping with supporting supplement our prevention evidence-based approaches, efforts. subject to evaluation, further Mental health issues for young consideration of this program may people be warranted. A program of early monitoring of psychosis is required, with particularly reference to young people.

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Summary of Program Goals Rationale Key Elements

5.8.6 Reducing harm Secondary/tertiary prevention The community and the • A program of peer education is for current users • Assist dependent users to individual have much to gain by proposed. Such programs can reduce the harm they do to reducing the harm done through be particularly useful in targeting An integrated strategy for themselves and others. dependent drug use. current substance users as reducing the harm that occurs • Actively link dependent drug The ‘saving lives’ strategy peers are often seen as a highly as a result of dependent drug users to health, welfare and proposed in chapter 2 focuses credible source of information. use. treatment services. on the needs of areas most These should be targeted at affected by high levels of street injecting drug users and those drug use. This proposal attending dance parties. complements that initiative • Training for injecting drug users which includes statewide in responding to overdoses (this services to drug users, their should also be made available families and friends. It is to their families). designed to provide information, • A program focused on safe skills and direct contacts that disposal of injecting equipment. encourage safer practices, and • A consideration of the needs of build relationships that will street sex workers (given that encourage drug users to access reports indicate that up to 90 health welfare and treatment per cent of street sex workers 56 services. are injecting drug users). See also narrowcast advertising messages in 5.8.2 Drug Communication Strategy.

5.8.7 Prevention • Better coordinate diverse In the past, drug prevention The Committee proposes the Resource Team prevention efforts and remove efforts have been hampered by establishment of a flexible team of potential duplication of effort. lack of coordination. They have workers with expertise and A mechanism is required to • Act as an expert resource to often operated in isolation from knowledge in prevention strategies. provide continuing support to disseminate lessons learnt each other, other prevention The team’s particular focus should those involved in delivering from local programs. efforts with complementary aims be on programs that tackle drug prevention programs not just in • Act as a clearing house for (eg, mental health and suicide problems, although this may also government, but in the Victorian information on international response), and the broader involve responding to a range of community and the local evidence-based interventions. elements of the drug response. other problem behaviour with government sector. • Create a sense of sustained With greater efforts in the common antecedents. commitment to supporting prevention area generally, The Prevention Resource Team, the community to tackle drug program areas will require working in partnership with program problems. expert advice and assistance in managers, should: developing drug prevention • provide advice on international strategies. To provide this and local evidence-based best support, the Committee practice; proposes the establishment of a • provide practical assistance in Prevention Resource Team. prevention program development and design, including detailed Three new priority areas for knowledge of other drug action that will particularly prevention strategies and benefit from the expertise of the prevention programs generally Prevention Resource Team are being implemented in Victoria; • 5.8.3 Supporting parents • assist with implementation and • 5.8.4 Enhancing the school delivery planning; environment • ensure appropriate evaluation • 5.8.5 A coordinated approach strategies are put in place to for vulnerable young people. measure results (depending of In addition, communities the project, this should include implementing local responses to both process and outcome the drug problem will benefit evaluation); and from the expertise of the • disseminate lessons learnt from proposed Prevention Resource local program delivery. Team. The Prevention Resource Team should be flexible so it can respond to diverse needs and pressures.

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5.9 Supporting the framework - The development of a commitment to evaluating outcomes is vital if we are to learn from our mistakes and our successes. This Building capacity commitment will assist in future program development. Evaluating There are a number of prerequisites for an effective prevention outcomes will assist in developing local knowledge about what strategy. These building blocks are common to other areas of the works and what is less effective. drug service system and include: 5.9.3 Data collection • evaluation and monitoring; In chapter 3, the Committee identified the need for improved data • development of a skills base; collection. Good monitoring and data collection about current and • community strengthening; emerging drug use trends could also provide an early warning • research; and system for students at risk of leaving school early (among other • development of structures and policies that enhance things). These issues are further discussed in chapter 8. coordination and collaboration. Improved data collection will also be important in tracking These elements are further explored in chapter 8; however, details progress against goals in the longer term. This is particularly of key elements that require particular attention are outlined below. important in the case of prevention efforts, as many benefits are 5.9.1 ‘The voice of youth’ not seen in the short term. There needs to be an acknowledgment We currently do not have good monitoring of youth culture to that some things are possible to achieve in the long term (primary explain the apparent increased use and acceptance of drugs, and prevention), but it is also important to respond to current and the declining age of initiation to drug use. This monitoring is emerging problems (secondary and tertiary prevention). required. Responding to current trends, while of considerable importance, A broadly based capacity is required to ensure young people’s is unlikely to offset challenges and drug problems that may voices are heard. Elements of the strategy should include: emerge in the future. ‘An argument might thus be made for • sustained monitoring of youth culture trends and views, with a sustaining prevention regardless of current drug use trends, so particular emphasis on substance use; that it can help blunt the effects of future epidemics.’57 • identification, from an anthropological perspective, of the 5.9.4 Coordination and links with other prevention reasons why people and groups of people use particular strategies drugs. This is an area of research that should be considered Governments at various levels are engaged in a range of on the future research agenda; prevention strategies that include crime and suicide as well as • school climate surveys that assess students’ views of teachers drug and alcohol prevention. There is a need to coordinate and the overall social environment of the school. These are implementation of these efforts at various levels of government currently voluntary, although strongly recommended. and the community to ensure they reinforce and complement Accordingly, data are not collated. Consideration should be each other. given to making these surveys mandatory; Substance use prevention programs should not be isolated from • data regarding suspensions and expulsions. These are other prevention efforts. collected regionally and are not available on a statewide basis. This should become mandatory and linked to regular reporting 5.10 Conclusion cycles; and As benefits that accrue from supply reduction measures are • opportunities for young people to be heard particularly in increasingly being viewed as securing marginal return, it is only relation to drug issues. These should be expanded through the appropriate that demand reduction efforts are now strengthened. existing Youth Round Table series run by the Victorian Government’s Office for Youth. The Committee has proposed a framework for drug prevention 5.9.2 Evaluation and monitoring programs that aims to bring together all activity in the area of prevention. Based on the emerging evidence base, the In general, Australian prevention programs have not been well Committee believes a commitment to greater investment in evaluated. The evaluations have tended to focus on process (was prevention is now warranted. However, this must be accompanied implementation carried out well?) rather than outcomes (did it by a commitment to evaluating outcomes and how we can make the difference intended?). We know from international continue to improve our response. research that some approaches are more effective in creating real change than others. As set out in section 5.6 above, there are already many programs in place in Victoria; however, they tend to be isolated and fragmented from other prevention efforts. They are also often not connected to other strategies in regard to drug problems (such as treatment and policing programs).

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Endnotes

1 Hando, J., Hall, W., Rutter, S., and Dolan K. (1999) Current State of 20 Crabbe, J.C., and Phillips, T.J. (1998) “Genetics of alcohol and other abused Research on Illicit Drugs in Australia, National Health and Medical Research drugs”, Drug and Alcohol Dependence, Vol. 51, Nos. 1-2, pp. 61-71. Council: Canberra, pp. 45, 49, 53. 21 Comings, D. (1994) “Genetic factors in substance abuse based on studies 2 Hall.,W., Ross., J., Lynskey, M., Law, M., and Degenhardt, L., (2000), How of Tourette Syndrome and ADHD probands and relatives. I. Drug Abuse”, many dependent opioid users are there in Australia, National Drug and Drug and Alcohol Dependence, Vol. 35, pp.1-16. Alcohol Research Council, Monograph no. 44. 22 Blum K., Cull J., Braverman E., Comings, D.(1996) “Reward deficiency 3 Victorian Department of Education, (1998), Framework for Student Support syndrome”, American Scientist, Vol. 84, pp. 132-146. Services in Victorian Government Schools, DOE: Victoria. 23 Hopper, J.L. (1994) “Genetic factors in alcohol use: a genetic epidemiological 4 Roche, A. M. (1999) What’s working in drug and alcohol interventions for perspective”, Drug and Alcohol Review, Vol. 13, No. 4, pp. 375-384. youth in Queensland?, paper presented at the Queensland Drug Summit: 24 Han, C., McGue, M.K., and Iacono, W. (1999) “Lifetime tobacco, alcohol Focus on Youth, 16-17 March 1999. and other substance use in adolescent Minnesota twins: univariate and 5 Victorian Department of Human Services. (in press) “1998 National Drug multivariate behavioural genetic analyses”, Addiction, Vol. 94, No. 7, pp. Strategy Household Survey: Victoria Results”, DHS: Melbourne, pp. 22, 28, 981-93. 34. 25 Dr David Hay (Curtin University). Presentation to Prevention - Developing the 6 Davison, T., Ferraro, L., and Wales, R. (2000) “Review of the antecedents of Framework, a workshop convened by the Drug Policy Expert Committee illicit drug use with particular reference to adolescents”, unpublished paper and La Trobe University, 26-27 July 2000. commissioned by the R.E. Ross Trust. 26 Social Exclusion Unit. (2000) The Social Exclusion Unit Pamphlet, Cabinet 7 Jessor, R. (1991) “Risk behaviour in adolescents: a psychosocial framework Office: London. (Online: http://www.cabinet- for understanding and action”, Journal of Adolescent Health, Vol. 12, p. 598. office.gov.uk/seu/index/march_%202000_%20leaflet.htm Accessed: 8 McAllister, I., Moore, R., and Makkai, T. (1991) Drugs in Australian Society: 02/11/2000.) Patterns, Attitudes and Policies, Longman Cheshire: South Melbourne, p. 11. 27 The Institute of Public Administration Australia (Victoria Division). (2000) 9 Davison, T., Ferraro, L., and Wales, R. (2000) “Review of the antecedents of “Tackling disadvantage; forces for change in the UK”, Going Public, IPAA illicit drug use with particular reference to adolescents”, unpublished paper (Victoria): Melbourne. commissioned by the R.E. Ross Trust, section 3. 28 Morrell, S., Taylor, R., and Ker, C., (1998), “Unemployment and Young 10 Ibid, pp. 6-10. People’s Health: in Medical Journal of Australia, Vol 168, March. pp 236-240 11 Paglia, A., and Room, R. (1998) Preventing Substance-Use Problems 29 Department of Education, Employment and Training, (2000), Ministerial Among Youth: A Literature Review and Recommendations, Addiction Review of Post Compulsory Education and Training Pathways in Victoria, Research Foundation: Ontario, p. 2. Final Report, DEET: Victoria. 12 Resnick, M., Bearman, P., Blum, R., Bauman, K. et al. (1997) “Protecting 30 Victorian Department of Education, Employment and Training (2000), Public adolescents from harm: findings from the National Longitudinal Study on Education, the Next Generation, Report of the Ministerial Working Party, Adolescent Health”, Journal of the American Medical Association, Vol. 278, DEET: Victoria. No. 10 31 Toumbourou, L., Patton, F., Sawyer, S., Olsson, C., et al. (2000) Evidence- Brooks. R., (1994), “Children at Risk: Fostering Resilience and Hope”, in Based Interventions for Promoting Health, Centre for Adolescent Health: American Journal of Othopsychiatry, 64, 4. Melbourne, p. 7. Jessor, R. (1991) “Risk behaviour in adolescents: a psychosocial framework 32 Bond, L., Thomas, L., Toumbourou, J., Patton, G., and Catalano, R. (2000) for understanding and action”, Journal of Adolescent Health, Vol. 12, pp. Improving the Lives of Young Victorians in Our Community: A Survey of Risk 597-605 and Protective Factors, Centre for Adolescent Health: Parkville, p. 6. Hawkins, D., Catalano, R., and Miller, J., (1992), “Risk and Protective 33 Ottawa Charter for Health Promotion, First International Conference on Factors for Alcohol and Other Drug Problems in Adolescence and Early Health Promotion, 17-21 November 1986. (Online: Adulthood: Implications for Substance Abuse Prevention”, in Pyschology http://www.who.dk/policy/ottawa.htm Accessed: 21.08.2000.) Bulletin, Vol. 112, No. 1 pp. 64-105 34 Anderson Johnston, C., Pentz, M.A., et al. (1990) “Relative effectiveness of 13 National Crime Prevention. (1999) Pathways to Prevention: Developmental comprehensive community programming for drug abuse prevention with and Early Intervention Approaches to Crime in Australia, Commonwealth high risk and low risk adolescents”, Journal of Consulting and Clinical Attorney-General’s Department: Canberra, p. 13. Psychology, Vol. 58, No. 4, pp. 447-56. 14 Bond, L., Thomas, L., Toumbourou, J., Patton, G., and Catalano, R. (2000) 35 Macfarlane Burnet Centre for Medical Research in collaboration with North Improving the Lives of Young Victorians in Our Community: A Survey of Risk Richmond Community Health Centre. (1999) “Drugs in a Multicultural and Protective Factors, Centre for Adolescent Health: Parkville, p. 3. Community - An Assessment of Involvement”, draft report for the Department of Human Services, p. ii. 15 Resnick, M., Bearman, P., Blum, R., Bauman, K. et al. (1997) “Protecting adolescents from harm: findings from the National Longitudinal Study on 36 Ibid. Adolescent Health”, Journal of the American Medical Association, Vol. 278, 37 Miller D., and MacIntosh, R. (1990) “Promoting resilience in urban African No. 10, p. 823. American adolescents: racial socialization and identity as protective 16 Muisener, P.P. (1994) Understanding and Treating Adolescent Substance factors”, Social Work Research, Vol. 23, No. 3, pp. 159-69; Brook J., Use, Sage Publications: Thousand Oaks, p. 71. Whiteman M., Balka E., Win P., and Gursen M. (1998) “Drug use among Puerto Ricans: ethnic identity as a protective factor”, Hispanic Journal of 17 National Crime Prevention. (1999) Pathways to Prevention: Developmental Behavioral Sciences, Vol. 20, No. 2, pp. 241-55. and Early Intervention Approaches to Crime in Australia, Attorney-General’s Department: Canberra, p. 29. 38 Meyerhoff G. (2000) Injecting Drug Use in Urban Indigenous Communities: A Literature Review With a Particular Focus on the Darwin Area, Danila Dilba 18 Anderson, C., Pentz, M., Weber, M., Dwyer, J., Baer, N., et al. (1990) Medical Service: Darwin, p. 5. (Online: http://www.daniladilba.org.au. “Relative effectiveness of comprehensive community programming for drug Accessed 20/10/2000) p. 5. abuse prevention with high-risk and low-risk adolescents”, Journal of Consulting and Clinical Psychology, Vol. 58, No. 4, p. 447. 39 Kirsty Morgan, Coordinator, VIVAIDS. Comments made in relation to Saving Lives, unpublished paper provided to the Drug Policy Expert Committee, 11 19 Perry, C., et al. (1996) “Project Northland: outcomes of a communitywide October 2000. alcohol use prevention program during early adolescence”, American Journal of Public Health, Vol. 86, Vo. 7, p. 956. 40 Office of the Correctional Services Commissioner. (2000) Statistical Profile of the Victorian Prison System 1995-96 to 1998-99, State of Victoria: Melbourne, table 6, p. 18.

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41 Resnick, M., Harris, L., and Blum, R., (1993) “The Impact of Caring and 50 Walker, S., Avis, M., (1999), “Common Reasons Why Peer Education Fails”, Connectedness on Adolescent Health and Well-being”, Child Health, Vol. in Journal of Adolescence, 22, pp. 573-7. 29, Supp. 1, p. S5. 51 Olds, D., Henderson Jnr., C., Cole R., Eckenrode J., et al. (1998) “Long- 42 Ibid. term effects of nurse home visitation on children’s criminal and antisocial 43 Murnane, A., Smith, A., Crompton, L., Snow, P., and Munro, G. (2000) behavior”, Journal of the American Medical Association, Vol. 280, No. 14, Beyond Perceptions: A Report on Alcohol and Drug Use Among Gay, (Online: http://jamaama-assn.org/issues/v280n14/full/joc80422.html Lesbian, Bisexual and Queer Communities in Victoria, The ALSO Foundation Accessed: 03/08/2000.) and the Centre for Youth Drug Studies: Melbourne, p. 5. 52 Baumrind, D. (1992) “The influence of parenting style on adolescent 44 Ibid. competence and substance use”, Journal of Early Adolescence, Vol. 11, pp. 56-95. 45 Toumbourou, L., Patton, F., Sawyer, S., Olsson, C., et al. (2000) Evidence- Based Interventions for Promoting Health, Centre for Adolescent Health: 53 Toumbourou, J,. and Gregg, E. (1999) Program for Parents, External Melbourne, pp. 9-10. Evaluation, Centre for Adolescent Health: Parkville, p. 4. 46 Victorian Department of Education, Employment and Training. (2000) 54 National Crime Prevention (1999), Hanging Out: Negotiating Young People’s “START consultation report 2000”, (unpublished paper). Use of Public Space (Summary Volume), Commonwealth Attorney-General’s Department: Canberra, pp. 4-5. 47 Carrol, T., Tayor, J., and Lum, M. (1996) Evaluation of the Drug Offensive ‘Speed Catches up with You’ Amphetamines Campaign 1993-1995, 55 Background documentation, ‘Whittlesea Youth Commitment’, enclosed with Commonwealth Department of Health and Family Services: Canberra, pp. response from City of Whittlesea to Developing a Framework for Preventing 38-39. Drug Problems, An Issues Paper prepared by the Drug Policy Expert Committee. 48 Hando, J., Hall, W., Rutter, S., and Dolan K. (1999) Current State of Research on Illicit Drugs in Australia, National Health and Medical Research 56 Advice provided to the Drug Police Committee Expert Committee by the Council: Canberra, p. 46. City of Port Phillip. 49 Paglia, A., and Room, R. (1998) Preventing Substance-Use Problems 57 Drug Policy Research Centre, RAND. (1999) The benefits and costs of drug Among Youth: A Literature Review and Recommendations, Addiction use prevention (Research Brief) (Online: Research Foundation: Ontario, pp. 17-18. http://www.rand.org/publications/RB/RB6007/ Accessed: 29/08/2000.

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Treatment and Support Services

6 Treatment and support services 104

6.1 Introduction Drug treatment is provided in a variety of settings but the major ones are: Drug treatment and support services are a major component of • the primary health care system (this includes general the State’s drug strategy. Substantial reforms have been practitioners and hospitals); implemented in recent years in the area of drug treatment, and • other health and welfare services where significant drug have resulted in an enhanced and expanded service system. problems might be an important element of the aetiology of the Further to these reforms, the State and Commonwealth individuals’ presenting problems (for example, mental health, Governments have announced a number of new initiatives with child protection and care, housing and homeless services); the aim of providing a more complete service to the community. and The Committee welcomes these. • the specialist drug treatment service system. Further development of the drug treatment service system is Services provided in each of these settings play an important role required to respond to the changing needs of users and in the overall drug treatment response offered to the community, challenges outlined elsewhere in this report. This development is and all of them need to be regarded as key components of the largely about repositioning the specialist drug treatment service drug treatment system. system relative to other service sectors whose clients also often have drug use problems. This repositioning should be structured Key issues dealt with include: to ensure a better response is provided to the changing demands • providing continuity of care for clients; on services, and that clients benefit from improved treatment • enhancing the role of general practitioners in service provision outcomes. It should also enhance the capacity for generic health to clients with drug use problems; and welfare and other specialist services to better manage their • developing ways to better meet demand for services; clients’ alcohol and drug problems. • recognising the impact of harmful drug and alcohol use among the clients of most health and welfare services, and the It is clear to the Committee that the provision of drug treatment necessity for these services to be able to deliver drug-specific can present many challenges to those involved in service delivery. interventions; The organisations and their staff involved in providing drug • seeing the specialist drug treatment service system as an treatment to the community deserve recognition and support for expert consultancy and backup service to drug treatment the valuable work that they do, often in difficult circumstances. being delivered in other sectors; There is no simple definition of drug treatment. Treatment involves • providing service access, particularly for people living in rural interventions that aim to eliminate dependence and/or reduce and regional areas, women with children, and those from substance use to safer levels in a context of the overall culturally and linguistically diverse communities; amelioration of the harms associated with ongoing drug use. The • providing the balance and type of services required for young negative effects of drugs on the lives of those who have people (compared to adults); substance use problems mean that treatment has important • improving service quality through supporting a better qualified physical and mental health and social benefits for the drug user, and trained specialist workforce, agency accreditation, their family, friends and the community. Effective treatment ongoing service evaluations, greater client involvement in represents an important part of the continuum of prevention service planning and development, and ongoing research into outlined in chapter 5. The treatment system needs to be able to the provision of best practice drug treatment services deal with drug problems whether created by tobacco, alcohol, (including trialling new approaches); and illegal drugs or polydrug use, which is increasingly common. • understanding the role of data in service planning and The Getting Lives Back on Track objectives outlined in chapter 2 development. underpin this chapter in that they: • emphasise the link between mainstream service providers (the social infrastructure) and the role of specialist drug treatment services in providing backup consultancy, advice and technical assistance in acute situations; • highlight the need for early intervention and attendance to the general health and welfare needs of drug users rather than just specific drug interventions; • focus on integrated care, not single events; and • point out the need for evidence as the basis for service provision.

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6.2 Drug treatment - Putting it into context 6.2.1 Propositions about drug treatment The objectives, summarised above, are reinforced by a set of propositions about treatment outlined below. These propositions result from research done by the US National Institute of Drug Abuse (NIDA).1 The Committee has reordered them for the purpose of this report. With the objectives, they provide a framework for assessing what needs to be done to develop a fully effective treatment system.

• Drug abuse treatment is as effective as treatments for most other similar chronic conditions. • Clients typically have multiple needs, including medical, psychological, social, vocational and legal. Effective treatment is able to respond to these multiple needs. • Drug withdrawal is an essential first step for many individuals but, as a ‘stand-alone’ intervention, it has little impact on long-term use. • Lapses to drug use during treatment are common and do not indicate that treatment is ineffective. It is critical, however, that lapses can be monitored and addressed during the treatment process. • Recovery from dependence can be a lengthy process and frequently requires multiple and/or prolonged treatment episodes. • No single intervention is appropriate for all individuals. Treatment type must be matched to the individual’s problems. • Treatment must be available and accessible promptly as, typically, clients only present interest in treatment periodically. • Treatment should be planned and reviewed regularly as client’s needs change. • Clients need to remain in treatment long enough for treatment to impact. For most clients, around three months is a significant threshold. Programs should include strategies for engaging and holding clients in treatment. • Counselling and behavioural therapies are critical components of effective programs. • Medication is a critical component for some clients. • Clients with coexisting drug dependence and mental illness should be treated for both conditions in an integrated way. As coexistence is so frequent, clients presenting with one or other disorder should be assessed for the other. • Treatment does not have to be voluntary to be effective. Sanctions and reward from family, the criminal justice system or employers can be effective in motivating a client to enter or remain in treatment.

It is important to note that drug treatment can be, and often is, In addition to these propositions, the Committee believes planned provided in an outpatient community-based setting and does not support for clients leaving the drug treatment system and re- have to include inpatient or residential treatment. Bed-based entering community living is vital to maintaining treatment gains. services have not been proven to be better than non-bed based Safe and secure housing, income support and vocational and services and are therefore not always the best or most training opportunities are particularly important in assisting clients appropriate treatment option for clients.2 These include withdrawal to reintegrate into the community. treatments that contain only an element of drug treatment. The Committee’s investigations have confirmed that there is no “Although detoxification [withdrawal] is an important single best treatment approach that will suit all individuals. Clients component of treatment for addicted drinkers, especially have diverse needs and, to attract as many clients as possible to where the degree of dependence is great, it is not appropriate treatment, the treatment system needs to offer various to consider detoxification as a treatment in its own right. This is approaches and interventions. The drug treatment system must because people who have undergone detoxification programs not only cater for diversity in terms of individual client need, but for are equally as likely to relapse as those who have not.”3 the needs of particular population groups in the community. Client Where appropriate, physical withdrawal from drugs should be diversity refers to a wide range of characteristics including age, followed by further support and interventions, ‘including a link to culture and ethnicity that may impact on the way treatment needs ongoing treatment services or relapse prevention to be delivered. pharmacotherapies’4 that aim to address the psychosocial aspects of drug dependence.

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With increasing numbers of young people commencing drug use, There is considerable agreement among researchers in Australia, and at earlier ages, the Committee has particularly focused on their Canada, the USA and the UK in terms of the appropriate areas to specific treatment needs. Recent research has clearly shown that measure in relation to the effectiveness of treatment for drug young people commonly have very different treatment needs to dependence. The list below describes the variables where adults.5 This point will be discussed in greater detail in section 6.4. consistent agreement is found: Methadone is currently the most effective and least costly of all • reduced substance abuse; the specialist treatments for opiate dependence. It does not suit • reduced high-risk behaviour; everyone, and some clients are reluctant to be involved in • improved physical health; substitute drug treatments. However, it must be seen as the first • improved social functioning; treatment choice when confronting opiate dependence. • improved psychological wellbeing; and • reduced criminal behaviour. The cost of the dispensing of methadone is currently $1,820 per client per year and this is borne by the client. However, the cost These outcomes are often only achieved with the client’s for providing methadone syrup, medical consultations and participation in a number of treatment episodes. Even short-term pathology services based on 7,772 clients (as recorded on 1 improvements in the above indicators are valuable and can October 2000) is approximately $8,220,910 per annum. A number significantly reduce harm. Significant, long-term success requires of assumptions have been made in reaching this figure. These persistence because of the physical, psychological and social include an average dose of 50 mg, that each client will visit their dependence, and lifestyle associated with drug use. Relapse is doctor 16 times per year, that each client undergoes urinalysis 13 common. Most people who were dependent on a drug and no times per year;6 and the consultation is only of standard length. longer use it describe multiple efforts to cease drug use akin to Thus, methadone currently costs the Commonwealth those who give up smoking tobacco. approximately $1057 per client. If total costs of dispensing, Since sustained success will usually be achieved after a number administration, pathology and medical services, and the syrup of treatment efforts, the treatment experience should aim to attract itself are considered, the program cost per annum is $22,365,950 and retain clients. Studies have shown positive relationships for the 7,772 clients, or $2,878 per client. between length of time in treatment and declining levels of drug

7 In comparison, the cost to the State Government for a bed in a use, criminal behaviour and sexual risk taking. Treatment can be residential rehabilitation program is approximately $8,894 for three cumulative within one episode, and over different experiences and months, which is the average length of stay for an episode of time. Thus, it is important to offer treatment to those clients who residential treatment (or $35,576 per bed per year). In 1998-99, have previous treatment experience as well as newcomers. 151 clients received an episode of residential rehabilitation in A number of national, multi-site treatment outcome surveys with Victoria at a total estimated cost to the Government of $1,342,994. large sample sizes have now been conducted internationally. This analysis indicates that for every residential rehabilitation bed Clients were followed up at six and 12-monthly intervals and, in utilised for a year, 12.4 clients could be treated for 12 months on some instances, after longer periods post-treatment. A summary the community methadone program. of these studies is provided in appendix 7. Victoria is participating in a similar study, the Australian Treatment Outcome Study, which 6.2.2 Does drug treatment work? is being initiated in Australia. Some members of the community believe that treatment for drug The overseas treatment outcome studies have consistently shown and alcohol use is not effective. Given the investment made by that drug treatment results in reduced drug use, crime and government in drug treatment services, it is necessary to assess psychosocial dysfunction. Drug treatment is also cost-effective. whether this investment is well placed. One study conducted in the UK estimated that treatment saved Outcomes of drug treatment may include short-term and the criminal justice system 5.2 million pounds per year.8 Treatment intermediate impacts, and those maintained over longer periods does work. of time. Drug use affects the user and those close to them as well as the community. Therefore, measures of success include a reduction in the costs of drug use to the community (through, for example, reduced criminal activity and use of health care services), in addition to outcome measures for the individual drug user.

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The Victorian community would benefit from a better 6.3 The drug treatment system understanding of drug treatment. Currently, there appears to be a difference between what the community calls for (want), what is in Victoria needed (in terms of what might make a difference and be the best The drug treatment system might usefully be thought of as use of resources), what the community can or might be prepared comprising several interdependent components. These include: to pay for, and what is effective. Often the high-profile apparent • The primary healthcare system: ‘cures’ are expensive and not always very effective. The - general practitioners; Committee believes information about drug dependence, - hospitals; treatment services and the drug treatment process should form • The broader service system (supporting the social part of a community information strategy. infrastructure). This includes child and family, mental health, 6.2.3 When and where do clients seek juvenile justice, homeless, ambulance, adult corrections and treatment? other services; and Clients often do not access treatment until some years into their • The specialist drug treatment service system. This includes harmful alcohol or drug-using career. By this time, their methadone prescribers and dispensers, and the various dependence has usually become a major preoccupation and is specialist drug treatment services such as withdrawal, significantly impacting on other parts of their lives.9 According to counselling and support and rehabilitation programs one research study, entry into treatment occurs from six to 10 (residential and non-residential). years after initiation of illegal drug use,10 and this is often longer for The Committee believes improvements can be made within each alcohol dependence. Seeking treatment is then part of a client’s component, and that the effectiveness of their linkages can be crisis management strategy. enhanced. Given the trends in usage outlined in chapter 3, there Attracting clients to treatment at an earlier point would have will be increasing demand for drug treatment in coming years. obvious advantages. This might be achieved by exploring 6.3.1 The primary health care system opportunities with active illegal drug users at points of contact Drug use, mostly relating to alcohol and tobacco, continues to be such as needle and syringe distribution programs and other a major cause of death and hospitalisation in Australia. Some street-based services. Early interventions can also be offered by drug treatment services are delivered via general practice and the general practitioners. Research has shown that general hospital system and they provide vital assistance to people in the practitioners can successfully screen patients for early signs of community with a substance use problem. alcohol-related problems, and that early intervention can be brief and effective.11 It is likely that through the provision of primary General practitioners in the primary health care setting health care, illegal drug users might be attracted to treatment General practitioners are well placed to deliver effective drug earlier too. treatment in the primary health care setting. They represent the We have not previously attempted systematic identification, access point for many drug-affected individuals. Their role in assessment and initiation of drug-specific treatments in the broad detection, assessment and provision of information and referral as health and welfare services throughout the community. Most well as specific drug treatments is paramount. people with drug and alcohol problems are already known in Research shows that up to 80 per cent of Australians will visit their these systems prior to approaches to the specialist drug general practitioner annually.12 Studies have established that treatment services. Therefore, it is sensible to explore initiation of general practitioners are seen as a credible source of information earlier treatment in these sectors. In addition, these broader in the community.13 Research also shows that they can be systems of care are important in post-treatment support to effective in the early and later stage interventions for tobacco maximise treatment outcomes. cessation and treatment of alcohol-related problems and Drug users will often need and seek support and interventions for dependence. They are also vital in providing drug-specific problems related to their drug use, even when they are not treatments, especially through their role in the community seeking to change their drug-using behaviour. When they do want methadone program in Victoria. to reduce or cease drug use, most look to specialist drug The Committee has not been able to access any data to indicate treatment services, general practitioners, self-help groups such as the number of people seeking drug-specific treatment (other than Alcoholics Anonymous or Narcotics Anonymous, or to private methadone) from general practitioners in our community. The role treatment providers. Thus, these drug treatment services are of general practitioners in the provision of pharmacotherapeutic operating in a reactive environment; they respond to clients treatments is discussed in detail in section 6.3.3. seeking specific drug treatment. There may be opportunities for more proactive initiation of drug treatment if these same people were identified during contact with the broader health and welfare services system.

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Hospitals A key focus of the Committee’s work has been an attempt to Hospitals often come into contact with people with drug use obtain details of the proportions of clients in the generic and other problems when their admission may not appear to be related to specialist service sectors who have concurrent drug and alcohol substance use (for example, injuries or trauma associated with a use problems, and of how they attempt to respond to their drug road traffic accident, or a fall). Drug problems are not always treatment needs. A summary of these details is provided in identified or acted upon by hospital staff. Hospitals often have the appendix 8. opportunity to detect and assess tobacco, alcohol and illegal drug As can be seen in appendix 8, it has been difficult to establish use, and to deliver appropriate treatments. precise information about clients in these broad areas who have Tobacco use and harmful patterns of alcohol use are significant concurrent drug and alcohol service needs. It is apparent that all contributors to the overall burden of morbidity among hospital are experiencing a significant impact of drug and alcohol patients. problems among their clients, and all anticipate an increase in this trend. They also indicated that where drugs are identified as being The number of hospital admissions related to illegal drug use is particularly problematic, assessment and referral to specialist drug small; however, there has been a significant increase between treatment agencies are the main planned responses. However, it 1993-94 and 1998-99 due to heroin poisoning (overdose). Over is clear that reliance on specialist drug treatment services to this period, heroin overdoses have increased as a proportion of all respond to all of the drug treatment needs of multi-service users is hospitalisations from .01 per cent to .04 per cent per annum (or not sustainable. 157 patients to 662).14 Drug-using clients will have multiple needs and thereby will This increase in heroin overdose has significant consequences for probably need to access many parts of the service system the Victorian community. Projections made as part of the Victorian simultaneously. When asked to recommend ways in which Burden of Disease study suggested that by 2016, illegal drug use responses to clients with drug and alcohol problems might be (primarily related to heroin) would become the third major cause improved, these broad service areas suggested a mix of of years of life lost (YLL) among men after coronary disease and approaches. These include the use of joint assessments, cross- cancers.15 sectoral education and training, enhanced collaboration and One major hospital’s accident and emergency department information sharing, the development of joint protocols, and estimated that 6.8 per cent of presentations were a result of assertive outreach workers. While these initiatives might assist, the intravenous drug use and/or harmful levels of alcohol use. A Committee believes the development of broad rhetorical further 10 per cent of presentations were estimated to have statements, information sharing, protocols and referral between 16 involved alcohol and other drugs as a secondary issue. the specialist drug treatment service system and these other While it was not fully investigated by the Committee, there is an systems of care will alone be insufficient. impression that a negative consequence of the changes in the With the increasing demand for drug treatment services, and the basis of hospital funding (and possibly other factors) has been a extent of concurrent health and social problems experienced by decrease in some hospitals’ active involvement in providing drug drug users, it is time to enhance the responsiveness of all service treatment. This can be the case even when a substance use systems to appropriately deal with, and deliver treatment to, drug problem is central to the patient’s presenting condition, and there users. A substantial effort is required to reframe thinking in many are reports of a small number of hospitals being reticent to admit areas to ensure drug-affected people are assessed regarding patients wanting to undergo drug withdrawal. In addition, some their drug use and treatment needs. hospitals that had previously developed a commitment to medical The specialist drug treatment services need to be seen more officers’ education and training in drug- and alcohol-specific strategically as providing specialist consultation and expert assessment and treatment (through establishing special backup to the broader service support system, rather than being subgroups or units, or through internal consultancy and support the main providers of all drug treatment in the State. services) have withdrawn from it. The Committee believes that there needs to be a whole-of- 6.3.2 The broader service system (supporting government reassessment as to how the service sectors need to the social infrastructure) interact within a suggested new framework for cross-sectoral Increasing use of legal and illegal drugs in the community has provision of drug treatment. For this reason, a proposed new had a flow-on effect of complicating the client group with which framework for service provision to people with drug use problems every service sector deals. Consultations with government is presented in section 6.5. The framework depends upon representatives and direct client service providers (in the effective cross-sectoral collaboration and cooperation. ambulance service, accident and emergency departments of public hospitals, acquired brain injury services, mental health services, and the juvenile justice and child protection service sectors) indicated that the clients that they now deal with, are very likely to present with a substance use problem.

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Client management Treatment needs to work to attend to this crisis and the underlying Clients with drug use problems usually have multiple needs, and drug use. However, it might be necessary for significantly more will often have to access many services simultaneously and attention to be paid to underlying social and developmental repeatedly. Therefore it is important to determine the most deficits experienced by many drug users, given the young age at appropriate location for management of such clients. which they commenced drug use and the interruption to usual developmental opportunities this sometimes entailed. Secure and The Department of Human Services (DHS) has piloted and safe housing, income support and employment, and training established a number of special projects with the aim of opportunities are fundamental to this process of reintegration. improving service access and outcomes for these clients. They ‘Clients treated in enhanced programs show significantly less include the Primary Care Partnerships, the Multi-Service Clients substance use, fewer physical and mental health problems and Project, the Working Together Strategy, the Dual Diagnosis Pilot better social functioning.’19 Service, the Acquired Brain Injury/A& D Project, Drug Treatment Services/Juvenile Justice initiatives, and the High-Risk Adolescent This is an area that has not been well conceptualised in the past. Quality Improvement Initiative. Details of these initiatives are Some treatment programs have developed their own local provided in appendix 9. The extent to which they are aware of networks and, from time to time, can offer connection to ongoing other sectors’ efforts, and how effectively they are working support and reintegration in the community. However, this is the together to make the best use of available resources to achieve exception rather than the rule. their common goals, is not clear. In addition to linkages with broader treatment and support In addition, the Department of Human Services currently requires systems, there might be opportunities to better utilise local level that case management form part of the service delivered by drug resources. There are people and institutions (including service treatment services. Feedback during consultations indicated that clubs, businesses and the like) who want to assist in building a this case management is often restricted to limited overseeing of local response to the drug problem. This could be considered in clients and their progress through the drug treatment system or, in the context of the proposals presented in the Stage One report of some instances, through a specific service type. This does not the Committee relating to Local Drug Action Plans. attend to their extensive additional needs, or support their access 6.3.3 The specialist drug treatment service to other services. system Many models for facilitating continuity of care for drug-affected Historically, specialist drug treatment services were developed in clients have been developed with the expectation that the response to the needs of those with alcohol dependence, as specialist drug treatment service system would provide the bulk of initially there was little problematic use of illegal substances such drug treatment. The new framework described in section 6.5 may as heroin. Services were provided mainly by religious and charity mean a re-orientation of these models that requires careful, organisations, and by private groups and self-help organisations cooperative development with attention to case management. If such as Alcoholics Anonymous. These were largely based on an the specialist drug treatment system is to fulfil a role in facilitating abstinence model of care. and supporting the broader health and welfare services to provide However, over the past 20 years, there has been a significant drug treatment, then cross-sector strategic planning is required. change in the drug-using habits of our community seen in an There might be various ways of enhancing case management increased use of substances including heroin, cannabis and other from across service networks that maximise the expertise illegal drugs. With this increased use of illegal drugs came a available. There are special groups, such as young people and necessary change in the way governments and the community those from culturally and linguistically diverse backgrounds, who responded. The Government has taken a more active role in require particular attention. These are discussed later in this establishing and funding treatment services. A particularly chapter. significant development has been the establishment of Reintegration after specialist drug treatment pharmacological treatment responses provided through general medical practice. Drug treatment relies on the services and support that other sectors can offer to increase its effect and make the most of its delivery.17 Cross-sectoral support that better provides for clients’ needs when exiting treatment may also increase the overall attractiveness of the treatment experience.18 The traditional understanding of rehabilitation does not quite cover all that is envisaged. Usual rehabilitation models refer to returning the person to the level of functioning prior to the experience of an acute crisis or adverse health event. This assumes that this level of functioning was adequate and appropriate. In the case of drug users, the crisis that propels them into treatment can often be an acute health issue (such as illness) or some social crisis (such as relationship trouble).

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In recent times, due in part to the funding of general practitioners It is envisaged that general practitioners will play a central role in through the Commonwealth-funded Medicare system (as distinct providing newer pharmacotherapies such as buprenorphine, from the State funding of other treatment services), there has LAAM (levomethadyl acetate) and naltrexone (for relapse been a conceptual separation of pharmacotherapy treatments prevention). These drugs are currently being trialled in Victoria as from the broader drug treatment service system. This has part of a nationally coordinated set of treatment trials. Appendix occurred in an environment where clients need continuity of 11 summarises the major trials, progress to date and early services. This separation is compounded by the physical and findings. These studies will report final results in June 2001. functional separation of the area of the Department of Human The near future is likely to see an increase in the importance of Services responsible for overseeing the methadone program pharmacotherapy responses to drug use. Much has been learned (including the Government’s regulatory function), and the area in recent years about the mechanisms the human brain uses to responsible for developing, implementing and monitoring drug sense satisfaction, pleasure and even ecstasy. There is a complex treatment services. While pharmacological treatments are dealt system of neurotransmitters (in what is termed the limbic system) with separately from the rest of the service system below, they are which constitute the brain’s ‘reward pathways’.22 Growth of placed together in this section of the report to assist with the knowledge in this area offers the prospect of new approaches to reconceptualisation of both as components of one specialist drug therapy, as the drugs interact with this pathway. These treatment service system. developments may have a major impact on managing withdrawal Specific smoking cessation programs have developed from drugs, and medication that can modify a dependent independently of drug treatment services but rely, in large part, on person’s craving for a drug. general practitioners. The levels of smoking among those with Development of pharmacotherapies in drug treatment has alcohol and drug dependency problems are significantly higher produced more promise that any other research in this area in the than those of the general population. Therefore, some effort is past 25 years. While some of this work is still experimental (such required to encourage tobacco cessation interventions as a part as exploration of substitute therapy for amphetamine of drug treatment services in the future by taking advantage of the dependence) or developmental and of uncertain ethical increasing range of intervention options. appropriateness (such as vaccination against the effects of Methadone and other pharmacotherapies cocaine), research and trials are under way for many more General practitioners play a key role in providing drug treatment products. This suggests that medications will become even more through prescribing methadone to opiate-dependent clients. important in treating nicotine, alcohol, opiate and amphetamine Methadone is a synthetically produced opioid that dependence. There are a number of new products, or new uses pharmacologically has the action of an agonist. It has been for products already known, on the horizon that might provide available in Australia since 1965. Research has shown methadone treatment options in the future. to be an effective treatment for opiate-dependent people as it It will be important for Victoria to sustain interest and a capacity to reduces heroin use, criminality, needle sharing and spread of assess, trial and implement the provision of such treatments. No blood-borne viruses.20 As Ward, Mattick and Hall argue, one drug is likely to be ‘the answer’ and it is desirable that a range ‘methadone maintenance is as effective as an expensive, of products becomes available to allow for more careful residential treatment, more effective than detoxification alone, and prescribing for specific clients, possibly at different times and leads to significant improvements compared with no treatment at stages of drug treatment. All will need careful assessment and the all’.21 development of clinical guidelines that take into account issues of Some community members, including some general practitioners, safety and efficacy. Cost is also likely to be a factor in determining have concerns relating to the prescription of methadone (a legal which products are used. opioid) as they believe it is a mere substitution for illegal opioids Behavioural and social interventions and supports remain such as heroin. The Committee appreciate the community’s need important. Some drug-using clients will still choose drug-free to better understand substitute pharmacotherapy treatments and, treatment; for others, these psychological and social interventions to this end, has included an appendix that offers a rationale for will be an important corollary to medication. However, for all such treatments, and an explanation of the way they work. (See specialist drug treatment programs, the potential value of appendix 10.) medicated treatments should not be overlooked, and clients of the specialist drug treatment system should be provided with access to these where appropriate.

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Medicated withdrawal can now be offered using different Buprenorphine, one of the drugs currently being considered for medications and supports. This increases the attractiveness of registration in Australia, is an example of a drug that is likely to this component of treatment. Withdrawal can promote entry to enhance the opportunities for targeted treatment for opiate more sustained treatments by providing follow-on medication for dependence. Buprenorphine will need to be ‘scheduled’ in such a maintenance, relapse prevention and opportunities to treat other way as to provide access for as many clients as possible while medical conditions. These treatments emphasise the importance ensuring the drug is prescribed in a safe manner. Early results of the medical profession and, in particular, general practitioners. from national trials of buprenorphine, as well as overseas The Committee recognises the opportunities afforded by this new experience, suggest this drug might be particularly useful in opiate generation of pharmacotherapies. It will be important to monitor dependency treatment as an adjunct and/or alternative to the medications that show promise, and to support appropriate methadone for opiate withdrawal and maintenance. The use of research and trialling of these when necessary. Where trial results buprenorphine in this context will largely depend on whether it is are positive, the introduction of these pharmacotherapies should listed as a drug on the Public Benefits Schedule (a decision made be supported, and access to them provided in the publicly funded by the Commonwealth) and on how it is to be prescribed drug treatment service system. Impatience for new approaches (decisions made by the State). should not supplant careful and rigorous evaluation of efficacy The community methadone program in Victoria and safety of such products for specific uses. The majority of methadone treatment services in Victoria are The Committee is aware that, with the introduction of new delivered via a community model that relies on a general pharmacotherapies, there is a developing entrepreneurial practitioner, a pharmacist and, in some instances, a counsellor. treatment sector nationally and internationally. The Government Some difficult or more complex clients with treatment needs that will need to closely monitor the development of privately funded generally cannot be met by this community-based option are services, and be available as a source of advice to the community referred to a specialist methadone service. These include clients about them. with unstable psychiatric conditions, high-risk patterns of In the context of supporting the evolution of pharmacotherapy substance use, chronic pain disorders and serious medical treatments for drug dependence, trialling the provision of heroin conditions. as a treatment for opiate dependence should remain a priority. On 1 October 2000, 7,772 people in Victoria were dosed with The Committee understands that this is controversial but firmly methadone as registered participants in the methadone program. supports such a trial. The rationale for such action has been Almost all of these are participants in the community-based provided in previous reports.23 The Committee, on reviewing these, methadone program. The program has grown at a rate of affirms this development. approximately 15 per cent per annum since its introduction and There is a lack of detailed information about the extent to which demand continues to be strong. Drug treatment services will need particularly heavy users consume the bulk of heroin used in to establish greater structural linkages to better support the Victoria. We know that this is the case with other products such as projected growth in demand for services delivered by the alcohol, and it is likely to be similar with illegal drugs (that is, a few methadone program. very heavy users consume much of the heroin available in the Methadone is available to drug treatment clients through a State). Thus, it is particularly important to attract this group of very medical practitioner or, in some cases, a specialist doctor who heavy users into treatment. Many clinicians suggest that providing must be registered with the DHS Drugs and Poisons Unit for this heroin is the most likely means of doing this. The community purpose. The doctor reviews a patient’s condition and if assessed generally seems to better understand the potential of heroin as a as appropriate for the program, a permit to prescribe methadone treatment in recent times. will be sought from the Drugs and Poisons Unit for the patient. The Committee believes Victoria should move to prepare for a trial Once administration arrangements are in place and methadone is of heroin to treat opiate dependence so that when it is possible to prescribed, the patient takes the prescription to an approved conduct this work, all the appropriate mechanisms will be in methadone-dispensing pharmacy. The patient attends the place. Such a trial should be carefully introduced with rigorous pharmacy daily to receive their methadone. Guidelines for the evaluation planned to assess the impact and outcome of this provision of methadone are contained in the Victorian Methadone 24 treatment. This should include measures of community impact Program Guidelines for Prescribers. and outcomes, as well as individual user outcomes. The introduction of new pharmacotherapies and a possible corollary increase in client demand for these services will require that more general practitioners become involved in treating substance use problems if the service is to operate successfully.

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Victoria’s methadone program is currently under significant For clients under 18 years of age, meeting weekly payments of pressure due to a lack of sufficient numbers of prescribing $35 can be particularly difficult, especially given the payments this general practitioners and dispensing pharmacists. This problem group receives under social security arrangements. In addition, needs to be urgently addressed considering the recent estimation clients who are under 18 years and on the methadone program that there will be a need for an additional 5,600 places on the have clearly had difficulties with substance use that will have program over the next three years.25 interrupted normal developmental achievements, such as Provision of methadone requires the support of multiple systems. completing school or gaining regular employment. Therefore, this The Commonwealth Government is structurally responsible for group is quite disadvantaged in economic and social terms and providing payment for assessment and ongoing medical support the community would benefit from sustaining their interest in through payment of general practitioners under the Medicare treatment. Given the known effectiveness of methadone treatment, agreement. An outcome of current funding arrangements is that the Committee believes, where methadone treatment is indicated, the client is generally left to pay an additional ‘start-up’ fee (usually the Government should directly support this treatment option for about $80). Many general practitioners request this to cover the heavily dependent opiate users who are under 18 years of age. time and effort needed to conduct a full assessment and Pharmacists also play a very important role in the methadone commence a patient’s methadone treatment. For many clients, this program. Their willingness to be involved enables its continued acts as a sizeable barrier to accessing or staying on the program. operation. As with medical practice, the program’s required Funding for general practitioners’ involvement in assessment, expansion in future years will place pressure on dispensing monitoring, ongoing supportive treatment and prescribing has arrangements. Creative ways to recruit and assist pharmacists will been raised as an issue. It is not clear whether this is a significant also be required. Key stakeholders have noted that increased impediment to recruitment and uptake of methadone provision by access to training, including online training, may encourage more general practitioners; opinions differ. Commonwealth and State pharmacists to be involved in the program. Governments need to discuss these matters in an open manner The Pharmaceutical Society of Australia - Victorian Branch has to overcome some of the difficulties currently encountered by proposed that the State Government should assume responsibility clients in accessing appropriately trained and committed general for the cost of dispensing for the first eight weeks of participation practitioners. on the methadone program. Others have advocated that the total The Commonwealth supplies methadone syrup free of charge to cost to the client over a year of dispensing should be no greater the States; however, clients must pay dispensing fees. The weekly than for any prescriptions under the Pharmaceutical Benefit cost of methadone dispensing (approximately $35) is an Scheme. impediment to many heroin users accessing and sustaining The Committee supports the provision of a subsidy to encourage treatment. This cost is relatively modest compared to the cost of heroin users into treatment, and to provide an incentive to remain maintaining a regular heroin habit, which is estimated to be, on in treatment for a significant period. Table 6.1 provides an average, $140 per day.26 However, this simplistic analysis fails to estimated costing for subsidising the dispensing methadone. take into account other needs someone has at the time of stopping heroin use. People moving into the methadone program are generally trying to establish a non-drug using lifestyle and this usually involves a range of costs that are commonly funded from limited income security payments. The Committee is aware that many alcohol and drug and welfare agencies are trying to fund the cost of methadone for users, sometimes by providing ‘loans’. This is an indication that, for some, the burden of paying for dispensing is onerous.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 113

Table 6.1: Estimated costs of subsidising methadone dispensing

Method of subsidy Methadone dispensing Methadone dispensing Methadone fully subsidised subsidised by Commonwealth subsidised by the State for each year for under (similar to PBS)* Government for first 8 weeks 18 year olds for new clients

New cost to $11,530,558.00 $0.00 $0.00 Commonwealth per annum for all clients

Cost to State Government $0.00 $326,200† $318,500.00 per annum for all clients

Cost to client per annum Health Care Card $1,540.00 for remainder of $0.00 Holders: $171.60 year one Non Health Care Card Holders: $802.80

* This would be the cost if the Commonwealth was to subsidise the cost of dispensing methadone in a way that is similar to the PBS. For example, for Health Care Card Holders, the Commonwealth pays costs in excess of the current Safety Net Threshold. This is $171.60 and $802.80 for Non-Health Care Card Holders. Assuming that 90 per cent of methadone clients are Health Care Card Holders, the annual cost to the Commonwealth will be $11,530,558.00. † This figure is based on growth of the program at 15 per cent with 1,165 new program participants anticipated for the year from 1 October 2000 to 1 October 2001.

The Committee is aware that a number of administrative issues There are different levels of involvement among registered would have to be considered if the State were to introduce methadone prescribers in Victoria ranging from general subsidies for dispensing, particularly the issue of tracking people practitioners with less than five or 10 clients to those with 100 or on the program more. Figure 6.1 demonstrates that 44 per cent of current Options for strengthening the community methadone model methadone prescribers have less than 10 methadone clients each. Between them, they treat only 6.6 per cent of all methadone There is clear evidence of a need to enhance the number of clients. Conversely, the 8 per cent of prescribing general general practitioners who are currently willing, trained, registered practitioners who each have 100 or more clients treat 46 per cent and available to provide treatment to drug-affected patients in of methadone clients. Victoria. There are two reasons for highlighting this. First, there is a shortage of places available among general practitioners to meet the current demand of people seeking treatment, especially methadone supported treatment. Of the 5,31627 general practitioners in Victoria, 304 are registered to prescribe methadone. At this time, 67 general practitioners are not carrying current permits to prescribe, which leaves 237 currently prescribing. This is only 4.5 per cent all current general practitioners in Victoria. Second, general practitioners may have the opportunity to use the emerging new pharmacotherapeutic responses. These can provide symptomatic relief during drug withdrawal as well as in longer term maintenance, and facilitate relapse prevention in the near future. These treatments do, and will, rely on community-based general practioners for prescriptions and community pharmacists for dispensing. The Committee has considered the adequacy and appropriateness of the current model and supports extending the capacity of the community- based system in preference to establishing pharmacotherapy- specific drug treatment services.

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Figure 6.1: Methadone prescribers grouped by number of It has been suggested that disincentives for general practitioner methadone clients treated involvement in drug treatment might include the current funding levels through Medicare for initial assessment and ongoing 50 management. The new schedule opportunities within Medicare % of Doctors able to prescribe introduced approximately one year ago recognise the need for 40 general practitioners to be involved in case management and % of Patients seen planning as well as substantial review for some complex multi-

30 need and service patients. They provide one avenue that might be appropriate for drug-specific clients, but they are still in development at the level of most general practices and it is not Percentage 20 clear that they will significantly help. There do seem to be some difficulties with using these provisions for clients seeking treatment 10 for problematic drug use; however, it might also be that general practice managers are insufficiently experienced in using them. 0 This should be monitored. Some effort could also be made to <10 10 - 29 30 - 49 50 - 99 100 + work with Divisions of General Practice to understand these Number of methadone clients treated provisions and develop protocols that are specific to drug- and Source: Drugs and Poisons Unit, DHS. alcohol-dependent clients. Other reasons for the low uptake of methadone prescribing This means some practices constitute large methadone or drug registration rights among general practitioners include the: treatment specialist practices that manage over 100 clients, • difficulties in accessing training (long distances to travel and sometimes at more than one site. It is generally believed that the few incentives to be involved); prescribers involved in these practices have developed a high • inadequacy of training in recent years; level of expertise and experience over time. • absence of a clear system of support following training to allow for a period of guided mentorship; At the other extreme are general practitioners who manage less • absence of a geographically close specialist methadone than five methadone clients. These general practitioners may be service; committed to patients drawn primarily from a family-based • disruptiveness of these patients in general practice locations; practice. This number may be too few for general practitioners to • absence of local supportive community pharmacies; and be adequately exposed to, and experienced in, providing • poor linkage with other specialist drug treatment services. methadone and other treatments. Other general practitioners work with varying numbers of clients on the methadone program. A There is also some ongoing pessimism about the efficacy of drug more thorough understanding of general practitioner involvement treatments among those with less experience. and the reasons for non-involvement in the prescription of However, it should be noted that a contract has recently been let methadone, is a necessary part of developing the community to a consortium including the Royal Australian College of General methadone system. Practitioners, Monash University and Turning Point Alcohol and Drug Centre to develop and deliver a coordinated training strategy for pharmacotherapy treatment. It is anticipated that this will go some way to better supporting prescribers although much more remains to be done. It is likely that the relatively low level and non-strategic recruitment effort over the most recent years has contributed to the low uptake among general practitioners. However, it is also likely that the residual pool of general practitioners who can be attracted by the mere provision of training has been largely exhausted. Figure 6.2 below demonstrates that the rate of growth in newly registered patients has declined. The Committee believes this is due to low numbers of new general practitioners becoming methadone prescribers, or registered prescribers reducing their client numbers, ceasing to provide the service, or needing to maintain a ceiling on the numbers they accept. Evidence suggests a strong demand for such treatment and significant problems with waiting times for clients wanting to access methadone treatment.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 115

Figure 6.2: Decline in growth in numbers of clients on the • providing facilities that may be outside a general practitioner’s methadone program in Victoria usual clinic location. These would be supported by

10 experienced drug treatment clinical staff to assist in the assessment and case management of clients as well as increase/decrease from previous quarter administrative requirements; and 8 • recruiting actively. Specialist drug treatment services 6 Prior to 1994, drug treatment services were provided by a small number of government and non-government services. These 4 services were largely uncoordinated and there was no systematic planning for their spread across the State. Large government-run

Percentage of increase / decrease Percentage 2 institutions in the Melbourne metropolitan area, established under the Alcoholics and Drug-dependent Persons Act 1968, provided

0 half of these services. 1 Oct 4 Jan 1 July 1 Oct 1 Jan 4 Apr 1 Jul 1 oct 1998 1999 1999 1999 2000 2000 2000 2000 In 1994, redevelopment of the specialist drug treatment services Date of census commenced. This took a more structured approach to the development of treatment and, in particular, attempted to address the uneven geographical spread of services. In 1996, the Source: Drugs and Poisons Unit, DHS. Premier’s Drug Advisory Council (PDAC) made wide-ranging recommendations regarding treatment. Most were taken up and A recent one-day census of the availability of methadone the service network has been substantially revised and expanded. prescribers in each DHS region indicated that, in some areas of There have been significant achievements and Victoria now has a the State, there are generally very few prescribers. It also showed more systematic approach to the provision of comprehensive that of the 237 prescribers in Victoria, only 18 were available to treatment services than other States and Territories. take new clients seeking methadone treatment on that day. In Figure 6.3 depicts the specialist drug treatment services provided 28 three regions, no prescribers were available for new clients. in this State. The services defined as regional are available in all It is clear that the program needs to continue to expand over the regions and, where appropriate, statewide services have regional next few years, and that this will place increasing pressures on the links and outlets. system. A number of innovative suggestions have been proposed There is regular comment in the media and elsewhere suggesting to enhance general practitioner recruitment to drug treatment. there are too few treatment services in the State. The figure These include: demonstrates that there is a range of service types available in • exploring the reasons for general practitioner involvement/non- each region of the State. In 1999-2000, 227 individual services involvement and possible strategies that will increase their were funded and they were delivered by 83 agencies. involvement and effectiveness in providing drug treatments; especially those involving pharmacotherapy; • continually discussing and negotiating with the Commonwealth to ensure general practitioners are available and engage in treating drug-dependent clients. This may include considering current financial incentives/disincentives as well as structural arrangements; • enhancing training in the use of medications in drug treatment and the linkage of a mentoring program. This would enable less experienced or new prescribers to call upon the expertise of another general practitioner or drug treatment service with greater experience in using methadone and other new pharmacotherapies and managing clients;

Treatment and support services 116 Figure 6.3: Victoria’s specialist drug treatment services - The current framework for service delivery

Regional services

Young people General adult

Outreach Residential Withdrawal

Counselling, consultancy & Home-based Withdrawal continuing care Withdrawal Services Outpatient Withdrawal

A & D Supported Accommodation Rural Withdrawal

Peer support Pharmacotherapies (specialist methadone) Aboriginal services Counselling consultancy and continuing care Residential Rehabilitation Statewide services A & D Supported Accommodation

Youth Substance Abuse Service Peer Support Aboriginal Services Ante & post natal support

Specialist clinical services

Family program

Information & support services

Training and research Family Drug Information and Support Telephone Helpline Parent Support Program

Community Offenders Advice and Treatment Service (COATS) Intensive Post Prison Release Drug Treatment Service (STEPOUT) Drug Education for First Offenders (FOCiS) Juvenile Justice Services

Drug Diversion Pilot = New initiatives in 2000

Offenders treatment services Court Bail Diversion (CREDIT)

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While there is a substantial service network, it is clear that more Figure 6.4: Drug treatment services funding 1996-97 needs to be done. Government has recognised the need to to 2002-03 expand the drug treatment services system and has begun to 80 develop additional services. COAG Over the past five years, many process evaluations of specific 70 TTT

service types have been conducted and there has been an overall 60 urning the Tide improvement in the nature, level and geographic spread of Historical

50 TTT=T services across Victoria. Notwithstanding these improvements, and while the Committee 40 has not undertaken a formal review of the specialist drug 30 treatment service system, it is clear that a range of issues are $ millions Funding 20 affecting the service network’s operation. Identifying these issues should be viewed as part of the ongoing evolution of a more 10 responsive and targeted service system. 0 Key issues that need comprehensive service responses include: 1996/97 19997/98 1998/99 1999/00 2000/01 2001/02 2002/03 Year • appropriate framing of the role and systematic linkages of the specialist drug treatment service sector to the broad health The State Government has supported a number of important and welfare service systems, such that the specialist service initiatives designed to create an effective service system for all system provides crucial expertise and support to others who clients including the development of: must deliver a substantial part of the direct treatment • a youth drug treatment service component that did not exist response; prior to 1997; • recognition of the role to be played by general medical • a drug diversion program for those apprehended by police practitioners and community pharmacies; who may derive greater benefit from drug treatment than • service interface with the public, street drug users and those involvement in the criminal justice system; who provide services to them such as needle and syringe • a brokerage service for parolees and offenders referred from programs; the courts who receive community-based order or a Combined • workforce development of the sector; Custody and Treatment Order. The service provides • improvement in flexibility while retaining accountability in assessment, develops an alcohol and drug treatment plan, specification of drug treatment service types and levels of and purchases necessary treatment from community-based funding; alcohol and drug treatment services; and • service quality across locations and treatment service types; • a community-based methadone service complemented by a • development of appropriate service responses to special specialist methadone program. population groups; The Commonwealth makes a significant contribution through the • ongoing evolution of the new model for treating young drug funding of general practice and the methadone program. It has, in users; and recent years, committed some additional funds to expand • effectiveness in meeting the needs of complex clients. specialist drug treatment services. Costs of providing drug treatment services How much specialist drug treatment is needed? Large amounts of government and private funds are invested in There is no blueprint to tell us how many or what sort of treatment drug treatment each year. The State Government currently invests services are needed now or in the future. A number of people are $54.3 million in specialist drug treatment services. This has dealing with their drug and alcohol dependence without ever increased from approximately $23.6 million in 1996-97 and is accessing formal treatment programs, sometimes with the expected to continue to rise up to 2002-03, with additional funding support of self-help groups.29 Others receive treatment in the provided through the Commonwealth’s Council of Australian private treatment system and information about this is scant. Governments (COAG) initiatives and new State funding. Further State funding of approximately $402,000 is allocated to support the community methadone program and undefined amounts are provided in other parts of the service system.

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Table 6.2 compares the estimated number of high-risk/drug-dependent users by each of the major drug categories (projected to 2003), with the number of people who attended specialist drug treatment services in 1998-99. The information in this table indicates that for most drug types, only a small proportion of dependent users are treated within the specialist drug treatment service system.

Table 6.2: Comparison of estimated number of high-risk/drug-dependent users projected to 2003 with the number of people attending specialist drug treatment and other health services

Principal drug of concern Estimated number of high Use of specialist drug Estimated Current usage of risk/dependent users* treatment services (1998–99) percentage of other services high-risk/ dependent users receiving specialist drug treatment

1997-98 2000 2003

Alcohol 226,000 246,700 253,700 6,917 clients 2.8 Unknown number access general practitioners; 15,572 alcohol- related hospital admissions

30 Opiates 19,600 21,400 26,600 5,806 clients 54.0+ 7,772 people were (in1999) dosed with methadone syrup on 1 October 2000. Approx. 160 of these were clients of the specialist methadone program.

Amphetamines & 7,500 8,225 8,460 642 clients 7.8 No evidence of other stimulants substantial use of health services outside drug treatment services.

Benzodiazepines & 15,000 16,450 17,000 703 clients 4.3 Unknown number other tranquillisers may access general practitioners and other private providers

Cannabis 60,000 65,803 67,000 2,905 clients 4.4

* Estimates for 1997/98 are based on data provided in the 1998 Victorian Drug Household Survey. Projections for 2000 and 2003 are based on the current estimated rates of dependence for each drug type 31,32 and population projections provided by the Victorian Department of Infrastructure. + This percentage is estimated from the number of clients attending either a specialist drug treatment service or who are on a methadone program, with some discount for clients who may be attending both.

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In 1998-99, approximately 19,000 drug-dependent people were The implementation of the National Minimum Data Set for Alcohol provided with 36,125 episodes of care within the specialist drug and Other Drug Treatment in July 2000 will allow some treatment service system. By 2003, service capacity will be comparisons with other States. Ongoing improvement in the expanded (through new initiatives funded by the State and reliability of these data is necessary. Recent valuable work being Commonwealth Governments) to provide an estimated 44,060 done by the Department of Human Services includes evaluation episodes of care. This, combined with the information in table 6.2, studies, monitoring of waiting times, and support for upgrading indicates that the size of the pool of people who could potentially the capacity of drug treatment providers to improve data entry. A benefit from drug treatment is far greater than the current capacity national treatment client census should be separately facilitated. of the specialist drug treatment service system. However, many of In recent times, there has been considerable concern about the these dependent people may be accessing treatment through possible displacement of alcohol-dependent clients by illegal drug their general practitioners, private treatment services or other users in the specialist drug treatment field as heroin has now health care facilities. This would reduce the apparently large become the primary problem drug recorded among those number of drug-dependent people who are currently not seeking treatment. As can be seen from figure 6.5, prior to 1998, undergoing drug treatment. the predominant group presenting for treatment were primarily It is important to note that, in the case of opiate dependence, alcohol dependent. In 1997/98 opiates were reported slightly table 6.2 indicates that 54 per cent of dependent/high-risk users more often as the primary problem drug (39 per cent) than was either attended a specialist drug treatment service and/or were alcohol (34 per cent) and in 1998/99 equal numbers of clients (33 being provided with methadone treatment in a one-year period. per cent) reported alcohol and opiates as their primary problem Should the estimated increase of 5,600 additional places on the drug. methadone program by 2003 be achieved, it is possible that approximately 65 per cent of opiate-dependent drug users will be able to receive some form of drug treatment service in 2003. This is a significant proportion of Victoria’s opiate-dependent Figure 6.5: Percentage of clients with alcohol, opiates or population. cannabis* as the primary drug problem Planning and developing a drug treatment service system for the 60 future, needs to be shaped by an understanding of the overall Alcohol Opiates Cannabis likely demand in the context of an assessment of the most 50 effective ways to respond to that demand. Any enhanced responsiveness of the broader service sector might impact on the 40 demand for specialist drug treatment services and expertise 30 required. Percentage

Ongoing efforts are necessary to develop appropriate indicators 20 to assist in forward planning. This will require improvement in, and utilisation of, various data. Sources of information that might be 10 used include: • profiles of current treatment clients and those seeking access 0 (waiting lists); 1991/92 1997/98 1998/99 • data about patterns of drug use (legal as well as illegal); • information about possible new or improved treatments that Source: Alcohol and Drug information System, DHS. might serve to attract a new generation of clients and/or *Data not available for 1991-92. provide for effective and possibly more efficient responses; and • information about drug treatment and responses provided in the generic and other specialist health and welfare services (the social infrastructure, see chapter 4).

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Diversion programs and impact on treatment demand Some further research or exploration regarding waiting times The Committee is impressed with the development of treatment might be warranted. Service providers report that some, if not alternatives for drug users identified through the criminal justice many, of the clients seeking treatment might be better managed system. Victoria leads the rest of the country in this regard. with a separately designated assessment service that could assist in some gate-keeping of the more intense specialist drug The National Drug Diversion Program in Victoria is expected to treatment program resources. significantly increase the numbers of clients in the drug treatment service system. There is some concern that this could produce an Throughout consultations, some agencies described efforts to imbalance in the system such that those apprehended for crime manage waiting clients. These included daily telephone contact who have drug problems might be seen to, or actually receive, (seen by some clients and service providers as punitive and by quicker/preferred access to the drug treatment system over those others as supportive) pre-withdrawal support services including voluntarily seeking these same treatment opportunities. It would daily contact, involvement in groups, individual counselling and be quite unsatisfactory for clients and providers if it were to reach support while waiting for initiation of residential and non-residential a situation where the quickest or only way to access treatment withdrawal. This was suggested as a more efficient use of the was through engaging in some criminal activity to attract police withdrawal service because it screened those likely to benefit from attention and gain a referral. withdrawal, and increased the likelihood of those who had been through this process subsequently completing the withdrawal It is hard to know how many of those being diverted are among treatment. Little research has been done in this area to determine the people who would ordinarily seek voluntary treatment, albeit the most appropriate pathway to care. possibly a little later. The impact of the program is concurrently somewhat dependent on policing practices. As it is known that Regional planning for service provision strategic community level policing can enhance the likelihood of Planning for service provision at the regional level is currently people seeking voluntary treatment,33 there is potential for the net conducted by DHS regional offices based on the 12 key service to be widened, but the outcomes for the treatment service system types shown in Figure 6.3, within the constraints of available are uncertain. funding. Figure 6.6 shows the range of treatment and support It will be important to monitor and assess the impact and utility of services available to a client in each region. these programs that are designed to impact on the criminal justice and drug treatment services systems. Access to treatment and waiting times Waiting times for drug treatment services in Victoria vary widely within and across service types. A survey of waiting times conducted by DHS in June 2000 showed that clients were able to access a drug counselling service from between 0 and 20 working days (the average waiting time was seven working days). Access to a residential withdrawal unit took between two and 20 working days (an average of nine days), and the wait for a residential rehabilitation service was between five and 40 working days (an average of 27 working days).34 The Council of Australian Governments Tough on Drugs in the Community initiatives, announced in August 2000, will establish 16 new residential withdrawal beds (to provide 864 episodes of care each year), 77 residential rehabilitation beds (to provide 229 episodes of care each year) and 120 additional alcohol and drug supported accommodation beds (to provide 192 episodes of care per year). This should help to reduce waiting times in a system that is managing clients diverted from the justice area as well as voluntary clients.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 121

Figure 6.6: Treatment and support services available to each region in the specialist drug treatment service system

Counselling, Peer Youth Dual diagnosis Residential consultancy and support outreach rehabilitation continuing care

Outpatient Alcohol & drug withdrawal supported accommodation Client (User or family member) Rural Community & withdrawal specialist methadone

Home-based Koori community Needle & Parent support Community Withdrawal A&D worker syringe program residential drug & resource service withdrawal

S Source: Drugs and Health Protection Services Branch, DHS. Note: Services in italics are to be established in 2001.

Regional service networks Over the past three years, some different models and practices The Committee believes there is a need to have a ‘critical mass’ have begun to emerge. Some DHS regions are piloting (or have of drug treatment services in each region that functions as an implemented) the establishment of a central organisation around integrated network or system of services. Feedback from service which all regional drug and alcohol treatment services, and providers indicates that compulsory tendering resulted in statewide services, may cluster. These models provide increased competition between services and this sometimes led opportunities for: to areas of fragmentation in the service system. In some • drug treatment service providers to participate in decision instances, this fragmentation has reportedly contributed to a lack making in regard to service planning and provision across the of continuity of care for clients as they attempt to address their region; drug use problems. However, in other localities, it may have • a centralised assessment, referral and pre-service support enhanced geographic access and encouraged increased centre (which may be at one or more locations across the cooperation, particularly between smaller services. Some drug region); treatment services have been so decentralised, it is suggested • improved linkages and cooperation between the drug that the level of drug treatment specific attention and expertise in treatment and other service sectors; and these areas has been reduced. • a locality information service for the community through the establishment of a 1300 telephone line that might supplement the statewide counselling, information and referral service, DirectLine.

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The Committee has not been able to explore this issue in detail. The Committee has not been able to fully investigate these Existing regional network models need to be examined with a view matters and is aware that opinions among service providers vary to determining their limitations and benefits at local levels. These on these subjects. The nature and reliability of data in the area issues need to be considered in light of the need for enhanced continue to improve but are not yet at the point where they can be general practitioner involvement and possible linkage to provide used alone to assess some of these concerns. For example, alternate locations for general practitioners to be involved in some data might contain hints of perverse incentives such as the specialist drug treatment. possibility that services may attempt to meet their episode of care In summary, the Committee believes there is a need for clustered, targets by treating a higher proportion of less complex clients. identifiable specialist drug treatment services to allow for the Current funding arrangements do not differentiate between a congregation of sufficient knowledge, skill and capacity to service complex, multiple-needs, client whose motivation may be direct clients as well as perform the consultancy role locally. There uncertain versus a well-motivated, socially intact client. The unit may be different ways of ensuring such clustering. Different cost for providing treatment to these different clients is models need to maximise options for individual clients to move theoretically equivalent. The Committee heard no evidence of any between treatment types without undue duplication of history systematic exploitation of these aspects of the funding taking and assessment, since such duplication during referral and arrangements. However, there is some concern that this is likely to transfer is consistently reported to reduce the likelihood of increase the desire to treat those requiring least effort or retention in drug treatment. resources at the expense of responding to the group the The drug treatment services funding model community would expect the highly specialised treatment sector to tackle. Specialist drug treatment services are funded on the basis of the following three elements: There are now a significant number of clients attending specialist • a resource allocation mechanism. This is used to determine drug treatment services in Victoria whose primary drug of concern is the regional distribution of drug treatment services funding; cannabis (3,220 (18 per cent) in 1998-99) (see figure 6.5). While it is • episodes of care. These define the basic unit of service for certainly true that there are people with problematic cannabis use which a provider is funded. An episode of care is ‘a completed that requires treatment, and many who will also have trouble with course of treatment undertaken by a client under the care of an other drugs such as alcohol and benzodiazepines, it is not clear that alcohol and drug worker which achieves significant agreed this is the best use of highly specialised drug treatment services. treatment goals’.35 Each service type has a different number of These clients might more appropriately be managed in other parts of episodes that it is expected to achieve within the funding level the health care system. for that type; and Perhaps the greatest concern is the possible lack of flexibility at • unit costs. A standard unit cost has been developed for each the service level in responding to different clients. The mix of service type based on funding required for an Equivalent Full clients needs, and ways of responding to these needs, must be Time position or an occupied bed day, as appropriate. better understood to ensure Victoria’s system is appropriately Through an annual funding and service agreement negotiated accountable, and flexible at the individual client level. with the DHS, funded organisations are contracted to provide a While acknowledging important accountability gains, the sector set number of episodes of care of one or more of the specified consistently articulated a number of concerns throughout the service types. They also agree to meet a number of performance consultation process. These included: indicators negotiated with the DHS. Services are required to report • incomplete or non-specific episodes. Some activities on the achievement of these episodes of care and performance conducted by funded agencies, such as client assessment targets on a quarterly basis. This process has meant improved and service planning, do not necessarily result in a completed accountability for government expenditure and a broader spread episode of care if a client leaves treatment prior to the goals of services over the past six years. being attained. There are variable recording practices in However, the implementation of this new set of arrangements has agency episodes of care counts in this regard; raised a number of concerns throughout consultations. These • travel time in rural areas. Throughout consultations it was have included issues relating to funding levels, and a perceived argued that service providers in rural areas were lack of flexibility to respond to the changing demands and disadvantaged in terms of meeting their targeted episodes differences between clients and in certain locations. because of the distance they were required to travel to meet with clients. It should be noted that the drug treatment services funding formula includes a weighting for rurality based on population density. This issue might need further exploration to gain a better understanding of the service models required to meet the needs of clients in rural areas;

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• client complexity. In addition to the relative effort or resources • inadequacy of operational funding. Prior to the 2000-01 required to respond to a client with multiple needs and financial year, the standard operating cost for drug treatment significant social deficits compared with someone with was set at 10 per cent. The current minimum (1999-2000) is relatively few problems, other differences might need to be 13.5 per cent and most services receive between 13.5 and 20 understood. This includes the difference between seeing one per cent. It can range up to 32.5 per cent for some service client many times for repeated episodes of care compared to types. An adequate level of operational funding is required for taking on many new clients; services to undertake activities that will improve service quality, • formula inflexibility within and across different service types. and maintain appropriate professional capacity to provide While some providers suggested that inflexible formulas were treatment. Operational funding levels need to be subject to impeding appropriate service delivery, others suggested that if annual review and should be a part of the transparent funding the service was large enough, experience within it allowed for formula used to fund services. Work being done in sectors “averaging” and opportunities for individualised care plans such as mental health might provide useful information to within broad program parameters. However, overall, the conduct an initial review of current operational funding levels. implementation and administration of requirements was seen The current funding model for drug treatment services has been in as inflexible, and as impeding honest, shared appraisal of place for three years. Therefore, it is timely that the funding changes in client demand, needs, complexity and the approach be reviewed. Overall, the systematic development of appropriateness of service responses. This varied between service contracts based on descriptions of services received by different agencies. Some were able to approach and negotiate the client, and equivalent funding across locality and service variations, while others took the apparently firm departmental types, have helped to increase accountability and the number of stance as final. services delivered. Service providers are grappling with the balance between The review would aim to determine whether the current model throughput and adequacy of treatment time, and the intensity of needs refining or adjusting, or whether there are other more treatment response, especially as they are in an environment appropriate models that could be used. This review could where the incentives are for throughput. The Committee was examine the needs of complex clients who should be expected to unable to fully explore the nature and appropriateness of require multiple treatment efforts to achieve their stated aims. It is processes for assessing funding levels for episodes of care. It is possible that alternate or additional approaches to funding for possible however, that more information and greater transparency some treatment types, or certain categories of clients, might regarding the construction of funding formulae and defining the usefully be trialled. This could include, for example, a capitation amount of activity expected would assist the future planning and agreement incorporating responsibility for significant case funding in this sector. Any such assessment should be done with management. number and intensity of response in mind. This might mean that Workforce development for the sector funding per episode in some service types needs to be adjusted. This could be accommodated by a change in the number of The specialist drug treatment sector has seen significant episodes to be delivered, or by enhanced capacity through expansion over the past five years. It faces further expansion with increased funding; the development of the National Drug Diversion initiative. • interpretation of the framework. Some service providers If the specialist drug treatment sector is to deliver well-targeted, suggested that their interpretation of the funding agreements evidence-based interventions efficiently and effectively, a critical precluded or hindered their ability and resources to see clients’ mass of well-qualified, competent practitioners is needed. Further, family members or to engage in local community networking if they are to provide the expert support, consultancy and with other services. Some regional Department of Human specialist auxiliary care needed for the broader health and welfare Services personnel also perceived constraints in having to treatment and support sectors, they need to be regarded as purchase only those services specified in the drug treatment credible experts by those who will call upon it. This means services framework because there was little or no additional ensuring a basic level of well-qualified personnel. Current funding flexible funding for locality-specific responses; and administrative arrangements do not necessarily provide for this into the future. Strengthened leadership of senior, experienced clinicians is required within the specialist drug treatment sector.

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Staff qualifications and training In some areas, such as providing valuable group support and Preparation of professionals through tertiary education and ongoing opportunities for peer support, self-help groups training has lagged behind the expansion of services. constitute an important care system that goes beyond usual hours of operation and professional practice. Self-help endeavours of In addition, there are significant disincentives for some this kind generally operate without government or other professionals working in the sector. Medical officers, for example, sponsored funding, and their contribution should be cannot currently receive specialist recognition while remaining in acknowledged and facilitated wherever possible. These are not a this area. Under increasing requirements for postgraduate substitute for professional treatment but rather are an adjunct, or qualifications to sustain ‘billing rights’ through Medicare, doctors an independent care system in some instances. are disadvantaged if they wish to work in the field for a number of years. While some might be willing to work for a period soon after Bridging training graduation, this group requires more experienced senior Due to the shortage of appropriately experienced people to professionals to mentor, train and supervise them. employ, new staff entering the system often require some initial There have been significant changes in the profile of drug training in alcohol and drug service provision. Efforts to fill the treatment clients as well as in the drugs of concern, what is experience gap are being made by providing short training understood as evidence-based practice, and in the overall system courses based on the nationally endorsed competencies from the of health and welfare service delivery. In this environment of Community Services and Health Industry Training Board. Further change and development, a vibrant sector requires well-qualified, attention to providing curriculum input into undergraduate and adaptable staff who value multiple sources of knowledge and postgraduate courses is vital to address the lack of qualified appreciate the place of research evidence. people in the sector. There is also a need for the broader health and welfare sectors to be able to respond to people who have Pre-service training drug and alcohol specific problems. At present, there is no base qualification requirement to practise Postgraduate training as an alcohol and drug counsellor or become a worker in an alcohol and drug service. A recent survey of the qualifications of In the immediate environment, enhancement of postgraduate staff in specialist drug treatment services indicated that 15 per opportunities by supporting programs and scholarships or cent of respondents had not completed secondary school and 25 traineeships to engage in these courses should be considered, per cent had no tertiary qualifications.36 since this group is needed to form the core of a new generation of leaders in this sector. Mere provision of bridging and basic The lack of previous data means it is not possible to compare the courses will not substantially lift the profile, competence or current profile of staff with previous personnel. Anecdotal reports capacity of the sector. from some employers suggest there are too few well-qualified applicants for advertised positions. They also comment on For some professional groups, it will be necessary to establish difficulties in meeting the salary expectations of those who do relevant postgraduate courses or subsections of existing courses apply. They consider there has been a gradual diminution of level at graduate diploma and masters level. While this might usually be of expertise and experience, but this is difficult to verify. What is seen as a Commonwealth government responsibility, some clear is that there needs to be a substantial investment in contribution to this effort from the State is likely to be necessary to improving the current staffing qualification levels. encourage their development. Historically, the numbers enrolling in specialist courses have been small and this has not While it is important to recognise the value of some alcohol and encouraged tertiary education providers to develop resources drug workers who have previous personal experience with drug needed to develop them. Further exploration of opportunities for problems, many of these people can be further trained to expand articulation into already existing courses may be warranted. their value to the sector. Not all workers necessarily need to be highly qualified; however, the level of qualification should be While medical graduates constitute only a fraction of the matched to the nature of the service expected. Secondary professional workforce needed in this sector, they are increasingly consultation roles suggest the need for qualified staff. In important. Substantial progress has been made in recent years in introducing a basic qualification requirement, it will be important to developing an appropriate qualification, and recognising this area allow for a period of time (perhaps five years maximum) for all of work as a medical speciality with the likely development of a personnel to have achieved this level. subspeciality (Addiction Medicine) accredited by the Royal Australasian College of Physicians. If Victoria is to maximise this opportunity to have appropriately qualified medical personnel, it will be necessary to develop a small number of medical traineeships.

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Ongoing professional development While the implementation of these activities to boost service Ongoing training opportunities also need to be provided for drug quality is laudable, further means need to be developed that and alcohol workers. The Committee understands that additional support and encourage drug treatment services to provide high- advanced in-service courses will be offered on working with quality services. The specialist drug treatment service sector will intoxicated clients, managing withdrawal, and working with clients not be in a position to provide secondary consultation and expert with alcohol and drug and mental health issues. Again, these will advice that is credible and backed by evidence without some be based on the national competencies. Other means to provide significant assurance of expertise. An agency accreditation ongoing training need to be explored such as distance education process should be implemented to create a base level of quality or online training modalities. Training scholarships for existing assurance across drug treatment services. While accreditation workers to undertake a tertiary qualification, while currently programs are available in related areas such as community available to a limited extent through regional training funding health, they are reportedly quite resource intensive. Therefore, it is initiatives, need to be further developed and managed more important that government provide resource support to agencies strategically. for this to occur, and that specific drug and alcohol treatment standards be developed and used in the process. This could be Staff supervision and mentoring planned in conjunction with requirements for staff qualifications In addition to professional development, supervision is an (see above). important aspect of a treatment service. It contributes to maintaining and improving the counsellor’s standard practice,37 6.4 Meeting the needs and helps to address the inherently stressful nature of work in the sector. Staff new to the field, and longer-term staff, require various of special population groups levels of supervision. As discussed above, many specialist drug 6.4.1. Youth drug treatment services - engaging treatment services have indicated during consultations that current and treating young people funding levels preclude provision of appropriate supervision for Young people are experimenting with a wider group of drugs, and their staff. at a younger age, than has previously been seen.38 Young people Service quality have particular needs that often mean placing them in a drug The redevelopment and expansion of the specialist drug treatment treatment service targeted at adults can have a detrimental effect service system has emphasised the need for improved service and deter them from seeking out other treatment options. There is quality and service accountability to clients and the Government. also the danger of exposing young people to more entrenched Efforts to improve service quality and accountability have drug use if they are placed in an adult service.39 To avoid this, a included: range of youth-specific services was established to cater for the • the development of draft service standards with individual perceived need for drug treatment among young people. These service guidelines; tend to mirror the models of care established for adults with the • an annual survey of client satisfaction; addition of a youth outreach role. (See figure 6.3.) • the development of service improvement plans that respond to There were few data available to those planning the early models the needs of clients from culturally and linguistically diverse for youth drug treatment services. Since implementation of the backgrounds; Youth Substance Abuse Service (YSAS) in 1998, considerably • the establishment of an expert working group to investigate the more experience and data are available. These data suggest that development of strategies that will improve the continuity of some of the early expectations underestimated the degree of care for clients across the drug treatment sector; and dependence among a significant number of young people. • research and evaluation activities. These have included Since Victoria’s implementation of youth services over the past investigation into the provision of best practice drug treatment three years, other States have seen them as providing innovative, services, studies into treatment service demand and client youth-specific models of practice, and they are being emulated. outcomes, and research into new pharmacotherapies (as The achievement in establishing these services is impressive. described above). However, it is important to recognise that these models need to Some of these measures are more developed and universally continue to evolve in the light of experience while meeting best understood and used than others. practice requirements. The severity of dependence, the Similarly, all drug treatment services are subject to evaluation. involvement of family, and the need for time away from a set of While the current focus is on process evaluations, there is a particular social or geographic settings were commented on in recognised need for effectiveness or outcome evaluations. Staff consultations. In addition, a series of practice issues arise such as training and professional growth should also be further developed. exploring the model for withdrawal services, the role of supported accommodation services, and the appropriate manner of using methadone in treatment.

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There is a need to continue to monitor and review pathways to In light of the early stage of the development of the youth-specific care for young drug users, and to determine the appropriate drug treatment service models, and the changes occurring in drug profile of specialist drug treatment services. This should include use among this population, it is timely to convene a group with the necessary skills and qualifications of staff. Health experience to continue the development of the best model of care professionals rely on the expertise of youth outreach workers to for young problematic substance users, and to help set criteria to access, engage and sustain the interest of young people in be used to assess the services’ relevance to its target group. attending treatment. Youth workers need clinicians’ expertise to 6.4.2 Involving the family in drug treatment respond to the physical and other problems associated with and support persistent drug use. In planning for comprehensive drug treatment, the families of drug Getting the balance right between youth and adult services users need to be considered, as often it is the family that seeks While research indicates that younger people are becoming treatment for the drug user. Families have a role to play in involved in drug use at an earlier age, it is important to note that supporting the drug user to access treatment and sustain their young people are by far the minority of those in the community involvement, as well as supporting post-treatment efforts at who use drugs to a point requiring treatment. In 1998-99, 15 per reintegration. Traditionally, families have only been occasionally cent of specialist drug treatment services were provided to young included in the planning and delivery of specialist drug treatment people aged 12 to 21 years (approximately 3,000 young people).40 services. This represents a rapid enhancement of youth-specific drug Families play a very important role when a family member treatment as would be expected with the initiation of new services. presents for treatment. In a study of the first 100 clients treated in It will be important to monitor the balance between adult and the residential withdrawal service of YSAS, for example, it was youth-specific treatment opportunities. found that 41 per cent of young people were living with either their Managing the service needs of young people wholistically parent/s or siblings prior to admission to the YSAS withdrawal

42 There appears to some client shifting, rather than client sharing, unit. While this might be expected with young people, it should between sectors. There are reports of some young people being be noted that, anecdotally, the belief had been that most of these directed away from the initial service they approached because of young people were detached from family. their drug use. There appears to be an expectation that the Many people presenting for treatment may appear to be specialist youth drug treatment services will manage all of these disconnected from their family of origin. In these instances, further young clients’ needs. Many young people who are using drugs enquiry and exploration can often reveal a network of support that will need other services and might not identify themselves as can include family. In addition, where members have left the family having a drug problem. 41 For some young people, it may be following difficulties caused by drugs, the family often continues to important to keep them outside the drug treatment service suffer. This long-term effect of involvement with a family member system, which can further expose them to drugs and drug-using who has a substance use problem has not been satisfactorily careers. Thus, the proposed model of services to include the considered in the planning and development of drug treatment. broader service sectors is especially appropriate for this group. Snyder and Ooms note that, ‘The primacy of the family should be The role of youth outreach respected; the family should be empowered rather than

43 Currently, the drug treatment sector is one of the few that offers supplanted by treatment’. There is evidence that family 44 street-based youth outreach and, since these workers are involvement contributes to more successful treatment outcomes, accessible, they identify young people with all sorts of problems. and a greater effort to include families in treatment planning is Therefore, outreach workers play an important referral and linkage necessary. It should also be noted that some young people role for young people more generally. Anecdotal reports suggest presenting for treatment may have a poor relationship with their this is one of the major benefits of youth outreach workers. family as a result of behaviours associated with their drug use. Their drug use might also, in part, be related to early childhood The Committee notes that some outreach is performed in other trauma and familial neglect. Thus, careful assessment is required sectors, but these are generally specialised services such as when including family members in treatment planning. mental health youth outreach work performed as part of the Intensive Mental Health Youth Outreach Service rather than Government has supported the conduct of important research generic forms of outreach. The Committee was not able to more that has examined the ways the drug treatment service system fully explore the role and functions of the youth outreach services. can best work with families and/or carers of young people with 45 However, it was felt that in reviewing the model of care for young drug use problems. The project identified the crucial role of people with problematic substance use, consideration needs to families in drug treatment for young people, and the need for be given to the potential role of a more generic youth outreach family-focused support. It has also resulted in the production of a service. This service could link to other government programs workbook entitled Resources for Family-Inclusive Practice that including youth suicide prevention, mental health, crime aims to help drug treatment agencies involve families more prevention, school nurse programs and student welfare roles. If effectively. these roles are to develop and be sustained with such a broad agenda, sources of funding should be explored with an eye to shared arrangements.

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The Committee welcomes the recent announcement of a series of The role of women as carers in society to children and elderly family support initiatives including a family drug information and family members means women contribute enormously in unpaid support service, family drug information and support telephone hours of work to our community. Therefore, treating women with helpline, parent support programs, and family counselling substance use problems who are carers delivers benefits to the programs. These developments are most positive. individual and the community. In addition, it is important that It will be important to monitor the extent to which the family- services should take account of the need for child care during inclusive guidelines have been implemented by drug treatment treatment. Wherever possible, child care should be built into the services, and whether the new initiatives are adequate and costing of drug treatment programs and arrangements made to appropriately respond to the needs of families. allow access to child care for women (and men) while attending treatment. For women who are unable to care for their children 6.4.3 Women while in drug treatment, appropriate other options should be Most drug treatment approaches have historically been based on sought. These could include involving a significant other in the models developed for men. There are clear gender-specific issues child’s life who is trusted by parent and child, and who is willing to for men and women in treatment, and the Committee notes that be responsible for that child for the duration of treatment. enhanced gender-specific elements in some programs (such as 6.4.4 Adult offenders life skills training and anger management targeted at male clients). Significant numbers of people who come into contact with the criminal justice system have histories of problematic substance More men than women use alcohol and other drugs with the use. A discussion of the current and proposed initiatives provided exception of prescription medications such as benzodiazepines, for these offenders, and existing issues relating to these services, which are particularly used by women. Female drug users is provided in Chapter 7. especially are likely to have a long history of abuse and neglect arising from family relationships and, for many, exploitative 6.4.5 The Juvenile Justice Population relationships continue into adolescence and adulthood. Women Elsewhere in this report it has been noted that the needs of many who inject drugs are likely to have been particularly exposed to of those using services in the social infrastructure are becoming numerous health risks. For example, ‘males largely control access increasingly more complex. In chapter 7, discussion of the to illegal drugs and frequently inject their female partners after changing prisoner profile highlights the dramatic increase in those they have used the injecting equipment first. As a result, female coming before the courts, and those entering prison, who have a injecting drug users have less autonomy to make decisions on serious drug problem. This changing pattern is also reflected in their injecting behaviour and are at a higher risk of contracting young people entering the Juvenile Justice system.

46 infectious diseases’. Anecdotal and empirical evidence shows that clients in the The rituals around injecting behaviour, coupled with risks associated Juvenile Justice system are a particularly complex and with street sex work, mean women presenting for drug treatment marginalised group. The case study below illustrates a number of may have greater primary health care needs than other clients. the features that characterise this group of young people and Research over the past 20 years has shown that while men can which are discussed in more detail in this section. benefit from mixed gender treatment groups and programs, many women do better with women-specific programs. The DHS has worked to develop gender-sensitive approaches in drug treatment services; these are essential for men and women. Some women need to be able to access gender-specific drug treatment services. Currently, State and/or Commonwealth funded services for women in Victoria include: • 13 Alcohol and Drug Supported Accommodation Services providing 143 beds; • an antenatal and postnatal support service located at the Royal Women’s Hospital; • a 16-bed residential rehabilitation service for women and their children; and • Woman For Sobriety, a service that provides mutual support groups, counselling and referral, alcohol and drug consultation and community education for women.

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Case study

Cindy has had a long history of involvement with the Department of Human Services, from Placement and Care as a child to being a client of Juvenile Justice as an adolescent. At age 17, she was referred to an agency which provides supported accommodation while she was in custody at the Metropolitan Women’s Correctional Centre and was due to give birth to her first child a few months after release. Whilst still in prison she had a record of aggressive and violent behaviour, much of which was linked to her heroin trafficking activities. On release Cindy joined up with her partner who was also addicted to heroin and benzodiazepines. They were able to get housing as well as parenting support from a community based agency. However, because Cindy and her partner continued to use heroin and pills prior to the birth of their child, they were warned they would lose both housing and support services if they continued this pattern. After the birth of their child Cindy and her partner were told they would not be able to continue with the housing and support program they had been involved with. While Cindy was still in hospital after the birth, in a chemical dependency unit, she resumed using heroin and nursing staff were concerned that she was not bonding with her baby. The child was taken into the protective services and she and her partner were required to submit clean urine tests in order to have access visits. Cindy went on to methadone, however had trouble meeting the dispensing costs of $35 per week out of her social security income of $122 dollars per week. She became depressed and slipped back into heroin use. She and her partner started committing robberies at ATM machines, using heroin and were without any stable accommodation. Protective services refused access visits to her child. She returned to jail within two months of the birth of her first baby.

Typically young people in the Juvenile Justice system are not in this drug use to be an attempt at self-medication in response to schooling, and may in fact have dropped out at a very young age. problems in the young persons life situation. These problems can They may have had little or no work history, with very few be related to past trauma which may be the result of abuse, a employment opportunities. Many will have poor family relationships. response to a sense of abandonment, or psychiatric illness. Females in Juvenile Justice Centres almost all have an illicit drug Using drugs can be an expression of frustration and anger, There problem and many have a history of sexual or physical abuse are, however, some young offenders who are from stable homes or both.47 but whose initial involvement with drugs has been prompted by a desire to go beyond accepted boundaries in search of This group is bearing the brunt of the social exclusion which has excitement, pleasure and acceptance by a new group of peers. been discussed in chapter 5 and which is central to the increasing spread of drug misuse in the community. In short, these young For some, their chaotic lifestyle means that they are more easily people are extremely marginalised and bring with them a greater caught up in a dynamic which includes heavy drug use. For degree of complexity than that seen in many young people those who have had few opportunities to be valued and win outside of the Juvenile Justice sector. acceptance in school and perhaps other networks, involvement in a drug using sub culture may offer an alternative option to belong Ten years ago, a report surveying Juvenile Justice clients reported to a group. Although ultimately destructive for the young person, that a minority of clients had a substance use problem, and for this in the short term it allows them to win acceptance and status minority, cannabis and alcohol were the drugs of choice.48 This among peers whose lives also revolve around using drugs. picture has changed dramatically with the majority of clients presenting with a substance use problem, although reporting alcohol The need to finance drug use once a young person becomes and cannabis as drugs of high usage, now also report heroin as a dependent means that a choice must be made between major drug of choice.49 The Committee has also heard views from exploitation of those who are close, especially family and friends, the Children’s Court which support this pattern, with magistrates property crime and petty theft, prostitution or becoming caught up seeing a great number of young people coming before them who in the pyramid style drug selling network as a low level street dealer. have drug problems, particularly with heroin. If youth training centres and other aspects of the juvenile justice Drug use in this group is often symptomatic of broader problems system are to be changed in ways that benefit young offenders, in a client’s life. Commonly these young people have become such change must be based on a realistic appreciation of the fully or partly disconnected from family, either as a result of pre dynamics and the realities attached to working with chaotic existing family circumstances or because the family relationships disconnected young people. It is critical that any change have not been able to withstand the strain of the young person’s recognises a number of key features about this youth population. behaviour. Their drug taking and the nature of their social networks increase the likelihood of exposure to a lifestyle in which drug use is pivotal as well as being the norm. It is common for

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• Offending patterns are often entrenched, and are therefore not should be encouraged. Such programs are not only valuable in easily or quickly changed. Often this is due to a long history of teaching young offenders how to understand and manage their abuse and neglect in young people’s lives, which means that it own drug problems, but can also offer help with the much-needed is unrealistic to expect positive behavioural change over a preparation for release. In these ways they ease the dangers of short period of time. The drug use and dependence of many the transition period. young people is often of a chaotic nature which means that While in custody, the community has a duty of care to ensure that constant relapse will occur in many young offenders. these young people are not further harmed in an environment • This group may be extremely suspicious of programs and where, despite the best efforts of staff, injecting drug use will individuals who offer help and this suspicion may in turn occur. Some clients are not interested in seeking or receiving jeopardise the development of sound relationships. Again it is treatment for their substance use problem - for this client group, unrealistic to expect the development of trusting relationships harm minimisation strategies should be aimed at protecting both within a short time frame and goals for progress need to be the client and staff from drug related harms. The Committee tailored accordingly. strongly supports any effort to establish a trial of the provision of • Drug treatment services being delivered through a brokerage sterile injecting equipment in these custodial facilities where young system, an arrangement currently being piloted, may interrupt people are being held, as long as this initiative forms part of a positive relationships formed between Juvenile Justice workers comprehensive harm minimisation strategy. Needle and syringe and their clients. There is a need to determine the best way to programs are known to be an effective means of reducing blood ensure continuity of care when effective working relationships borne virus transmission and are available to those young people have been established. in the wider community. The Committee believes that as far as • This group will often have a very poor history in terms of practicable, incarcerated people have a right to the same services succeeding in education, training or employment. Often they for health protection and treatment as those in the general will be the second generation unemployed in their families. community. This is consistent with the United Nations Standard The corollary of this may be lack of confidence in accessing Minimum Rules for the Treatment of Prisoners.50 education training, or employment opportunities and This trial should include consideration of issues of safety for acceptance of the probability of being excluded from the work young people in custody and for staff and consider the best force in the long term. means of distribution and disposal of injecting equipment. • Problems are often multi-faceted, with the young person Experience from other custodial services overseas suggests that having a drug problem in combination with a mental health this can be implemented without increasing danger to either the problem, intellectual disability, general ill health or specific prison population or staff members. It is also likely to reduce health problems. They may also be the victim of abuse and hazardous injecting practices and associated harm.51 have significant history of criminal behaviour. Often relationships with family have been severed, are problematic, The Committee has been made aware that for many young or are not in the best interest of the young person. offenders, the challenges they face on release may be even more significant than the difficulties of being detained in care. For The Juvenile Justice Program has recognised the need to many, dealing with being back in the every day world can be as respond to its more complex client population and now provides hard as the adjustments that needed to be made when they drug services; these can include counselling, methadone entered youth training centres. The Committee appreciates that maintenance, peer education, health services for both withdrawal the demands made on young people post release cannot be and infectious diseases. A post-release treatment service is underestimated and that this period represents a critical point in provided to juvenile justice clients, as is COATS - the Community the young person’s life. At the point of post release, it is critical Offenders Advice and Treatment Service. The Committee believes that the service system be available for young people to draw on that we may need to look beyond the service models that address in a way that suits their needs. This phase offers two distinct adult drug problems and to respond more specifically to the pathways, one into rebuilding prospects for a life away from crime needs of young people. Appointment based counselling, for while the other path way will keep the young person trapped in a example, often fails to engage the young person and can cycle of re-offending and social exclusion. jeopardise successful outcomes for them. Further to the above, the Committee believes that any young The Committee has heard the view that the most valuable input person on a Juvenile Justice Order should be eligible to receive from adults at this crucial point may not necessarily be the fully subsidised methadone for the duration of their order. Such a attention of a drug counsellor per se, but consistency and strategy will increase their chances of moving away from a understanding in those working with the young person. While criminal and drug-related lifestyle. acknowledging this wisdom, and the fact that the relationships formed by the young person at this time are critical, the Committee believes that programs such as “The Edge” at Malmsbury Youth training Centre and the “Community Residential and Outreach Program” at Parkville Youth Residential Centre

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Particular problems the young person can encounter in this post In addition, young offenders who are from diverse cultural release phase are: backgrounds may have particular issues in readjusting post • difficulties in coming to terms with their new found release. In some communities there is likely to be a higher degree independence. It may be a time where structures and active of shame associated with the young person having been through support are required; the Juvenile Justice system. • on release from a Juvenile Justice centre, supports are often The issue of housing has been outlined above as a major difficulty lost after a short time because the client becomes disengaged young people face post release. The Committee believes that from the services that have been offered to them, or they have finding a workable housing arrangement is central to the young found them difficult to access; person’s re-integration. Additional dimensions to the problem go • getting access to a wide range of services particularly given beyond affordability and security of tenure to finding an what may be a disorganised lifestyle; arrangement that is viable. Abstinence-based housing options • the difficulty in finding affordable and reasonable standard have objectives which may contradict some drug treatment accommodation where co-tenants will not influence the young service goals and may prove unhelpful for this client group. If a person to abandon any plan they may have for their own drug young person has few friends or wants to move away from old management; networks which have involved drugs, it may be hard to establish a • multiple relationships, which need to be established because shared housing situation in private rental. Finding the young person deals with a wide range of counselling and accommodation in either public housing or community based support services. At this particularly precarious time for the housing is difficult because of the other demands placed on these young person there is a need for fewer and stronger services. It may also be that the young person requires housing relationships in preference to the young person having to form with support attached. relationships with a wide number of counsellors and others It is for this reason that the Committee believes that a number of offering support, all of whom might cater to a quite specialised public and community housing units must be quarantined for use need; by this group as an ongoing and priority arrangement. • the difficulty in being able to afford methadone. This means that the young person is faced with a choice of either staying 6.4.6 Drug treatment service users on a methadone program and trying to find the funds for this Services need to be responsive to the client group’s needs to while staying crime free, or of reverting to a drug-using and attract and maintain clients in treatment, and to provide the best often criminal lifestyle; possible treatment outcomes. Service users in the context of drug • learning to trust counsellors and invest in those relationships; treatment services may include those with substance use • problems in accessing employment and training. Assistance problems, families, friends and associates of those with far greater than what is currently available is required if young substance use problems. people are going to be provided with the opportunity of having The redevelopment of Victoria’s drug treatment service system a role in the workforce; and recognised the right of clients to accessible, appropriate and • difficulties in trying to reintegrate into the community where the high-quality drug treatment services.52 This is supported by the lack of suitable training options is a major impediment for more recent Government policy on primary health care that aims these clients who are most likely to have had very little work to ‘ensure that ... there will be a primary focus on consumers and experience and minimal exposure to traditional work culture. carers to organise their participation and involvement’. 53 Apart In their efforts to return to community living, many clients will not from VIVAIDS, a peer-based user group, there has been no have the benefit of the wider family supports which can be organisation generally representing drug treatment clients. particularly important upon release. Once these clients are Until recently, service user involvement in the planning, design and paroled, they may be ordered to undergo treatment as part of implementation of drug treatment services has been limited. The their parole conditions. Consultations revealed that many clients implementation of an annual consumer satisfaction survey of drug were reticent to access services purchased from community treatment services provides one vehicle for feedback. The agencies because of a lack of continuity in the relationship Committee notes that user representatives have been involved in between client and counsellor. That is, the counsellor from the a number of departmental reference groups, including the former agency providing the service, needs to attempt to engage the Ministerial Advisory Group on Alcohol and Drugs and several client, whereas an effective relationship may already exist with projects implemented by the Drugs and Health Protection their Juvenile Justice worker. This could lead to a breach of parole Services Branch at DHS. Such involvement is a positive step in and return to custodial care. While protocols do exist between ensuring the relevance of services as they develop, and should be Juvenile Justice and drug treatment services, which aim to encouraged. However, these activities have not been expedite communication between the two, there is clearly a systematically planned across the drug treatment service system. problem in the implementation of these protocols and their usefulness is limited by this.

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The Committee notes that DHS is shortly to fund a project that will This disparity does not arise from CALD communities having establish a client group called the Association of Participating fewer members with drug problems, but rather from lower use of Service Users. The aim of the project, which will receive initial specialist treatment services. It has also been suggested to the funding for two years, is to develop appropriate methods and Committee during consultations that the broader treatment mechanisms for effective client consultation and participation in system, including general practitioners, is not being used in the the development of drug treatment services. way that it could be by those from diverse communities in need of The Committee is of the view that this project needs to be help for their drug problems. carefully monitored and evaluated to ensure it is fulfilling its aim. There are a number of reasons why this is the case, some which 6.4.7 Culturally and linguistically diverse relate to how the specialist treatment service system operates, communities some which originate in the expectations, values and fears of CALD users and some which stem from a lack of responsiveness Culturally and linguistically diverse (CALD) communities have a to drug issues in the parts of the social infrastructure used by problem with drug use in the same way as other communities. In CALD communities. There is no single factor which should be chapter 5 some of the particular factors, which can be associated blamed. Factors from these three areas which constitute barriers with drug problems in those from a CALD community, such as low to getting help for drug problems are discussed below. socio-economic status, traumatic migration history and acculturation, were discussed. Clearly there is the potential for Factors which constrained those from CALD backgrounds from increased problems in communities where there is a high using specialist treatment services include: incidence of these factors. • ignorance and misunderstanding about the complexity of illicit drug use and issues of drug dependence generally.58 59 For The impacts of drug use in diverse communities is evidenced by: some CALD drug users this meant difficulty in admitting they • concern across CALD communities about the impact that had a problem. At the same time there was an increasing drugs were having on their young people. This concern has belief in certain communities that treatment does not work, been voiced to researchers undertaking work in this area,54 as because it had been observed to be unsuccessful on the first well as to the Committee during its consultations around CALD attempt; issues. Those working in and with diverse communities see • a lack of information about the processes involved with this acknowledgement of drug use as a problem as treatment; contrasting with views in most communities four or more years • a perception by some users that their culture meant that they ago when this problem has either denied, played down or not were not a legitimate part of the service’s client group, or that openly discussed; the service would not be welcoming; • the changing patterns of ethnicity in corrections. From 1989 to • fear of lack of confidentiality; 1998, for example, the number of Vietnamese prisoners in • language difficulties, especially for those aged over 35; Victoria increased ten fold from 0.5 to 5.1 per cent.55 Some • a lack of support during the treatment process; but not all of this increase would be due to population • ignorance of the existence of services; increases. Data from 1997-98 show that drug offences were • uncertainty about the legal ramifications; and the main type of offences for this group;56 and • a sense of shame to be seeking help outside the family. • a changing pattern of ethnicity in the juvenile justice population. Data for 1997-98 record 49 per cent of Juvenile A number of issues in relation to the specialist treatment service Justice clients with drug offences as being other than system were identified for the Committee throughout its “Australian”.57 The Committee has also heard anecdotal consultation program: evidence from the Children’s Court of an increasing incidence • services lacked knowledge about diverse users. Recent of young offenders from CALD backgrounds coming before research on this topic has found that drug treatment services that court. were found to have little knowledge of the diversity of people utilising their services and less about the perceptions, However, even though we know that those from CALD expectations and needs of their clients;60 backgrounds also have drug problems, their likelihood of seeking • allied to the issue of lack of cultural awareness is the need to assistance is much lower than for their English speaking fine tune service delivery, so that it is perceived as being counterparts. In 1998-99, 1,743 (9 per cent) of clients of specialist available and willing to assist those from CALD backgrounds. drug treatment services in Victoria were from CALD backgrounds, Interpreting and translating arrangements relevant to user (defined as those people born in countries where English is not needs are critical; and the first language). This compares with 17 per cent of the overall • in addition to creating a culturally responsive service, the Victorian community from CALD backgrounds. service needs to be promoted within relevant communities so that misconceptions about such things as the treatment process and legal ramifications can be countered.

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As well as problems caused by the services and the users There are certain instances in which an ethno specific worker may themselves, part of the low take-up of treatment can be attributed be justified. These include situations of outreach, where the to the agencies that work with CALD communities, particularly worker has the role of forming relationships with drug users from a young people, not doing more to provide accurate information particular CALD group and bringing them to the service. about addiction and treatment and to actively provide links to Research has suggested that outreach is a particularly important services. Such organisations include ethno specific welfare strategy to encourage young women of Cambodian, Laotian and organisations, generalist welfare organisations that play a special Vietnamese origin to access services.61 In such situations the role in working with CALD communities and migrant resource worker would not have to be a part of a treatment service but centres. could be employed by local government or a CALD welfare or The implications of this can be that some families attempt to other agency. An ethno specific worker may also be warranted for devise their own methods of dealing with a child’s drug use a particular community, which has a very significant drug problem, problem. The Committee heard of children being sent back to the if this can coax users into overcoming their reticence to using country of origin in an attempt to remove them from the drug drug treatment services. If those users’ experiences of treatment scene. Such responses are dangerous, particularly in situations are positive, and their expectations are realistic, this may be an where drugs are freely available in the country of origin and effective strategy to provide information and encouragement to injecting or other drug administration practices are hazardous. other drug users in the community to pursue treatment. There have been efforts made in the past to improve treatment In terms of how user distrust and lack of information in relation to access. These have focused on overcoming barriers which exist treatment services can be addressed, the Committee believes that in services and have included an audit of services’ cultural more work should be undertaken to provide clear and accurate responsiveness. The audit appears to have increased awareness information about drug dependency and treatment to CALD and, in some cases, information, but would seem to have been of communities, particularly those that are experiencing low socio- limited value in changing the access of these diverse community economic status and social exclusion. Information needs to be groups to specialist drug treatment services. Other strategies provided according to the communication preferences of the have included ethno specific workers but the Committee has communities concerned. heard criticism of funding for such positions being on a project However the Committee believes that information alone is not rather than a recurrent basis. A bonus and incentive scheme has sufficient to overcome some communities’ reticence to use been applied to encourage increased usage of treatment services treatment and that there is a legitimate case for community by CALD drug users. workers to be located within communities suffering serious drug The Committee believes there is merit in cultural awareness problems. The role of such workers could focus on increasing training, but only where gains made are built on by changed knowledge, linking users and their families with treatment and service practices. This requires incentives, such as the bonus other services and assisting the community to develop its own and incentive scheme, as the Committee believes that depending responses to its drug problems. Such community responses on the commitment of the agency is not enough to effect change could include mechanisms to support drug users and re-integrate in the immediate term. The Committee has also heard from those them into a stable lifestyle. working in the multicultural services field that recruiting staff from The Committee believes that there is no one model for such a relevant communities to work in generic rather than ethno specific community worker role. Where the level of problem is such that service roles, can be an important step in attuning the culture of this level of support for a community is warranted, it must be the the organisation and sending a message of cultural inclusion to community which determines how this resource is applied. potential service users. Local drug strategies also need to consider how best to connect The Committee does not believe, as a general principle, that with their CALD drug using populations. It may be that specific ethno specific alcohol and drug workers based in agencies are initiatives such as ethno specific outreach workers could be used the answer to the problem. In such a multicultural society as but this would be most effective if managed through a partnership Victoria there are far too many CALD communities to make this a between local government, the CALD community and local feasible or affordable option. Furthermore, such a strategy treatment providers. concentrates the agency ability to respond to those in a particular The role of ethno specific and other agencies working with CALD community on one individual. This has a double disadvantage. communities has been referred to above. The Committee Firstly, it makes the service effectiveness for a particular CALD believes that these parts of the social infrastructure are ideally group dependent on the calibre of the individual ethno specific positioned to play an important role in overcoming treatment worker and the quality of relationships they can form. Secondly, it access barriers, particularly as they relate to family knowledge and does not provide incentives for the rest of the service to identify views on treatment, but that they have not taken on this role to any and be responsive to client needs. significant degree. There needs to be a significant effort made with these agencies, to educate them about addiction issues and treatment services, and encourage them to play a greater role with families and drug users in promoting treatment options where these are appropriate.

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Based on a review of current research, and the Committee’s The Committee has noted the role of Koori Community Alcohol consultations, the following strategies warrant consideration as and Drug Workers, and those working in the Koori Community ways in which service access and outcomes for CALD Alcohol and Drug Resource Services. These workers play a vital communities may be improved: role in the provision of culturally appropriate responses to meet • the formation of partnerships and the development of working local Koori community needs. However they are commonly asked protocols between drug treatment services and other health to extend their service beyond that required in the broad and welfare service providers, and ethno specific agencies and community-based drug treatment services. These workers have services working with CALD groups, in order to ensure the advantage of coming from the community they work with, and seamless service to drug users from CALD backgrounds and therefore they usually have a good understanding of its dynamics their families; and and the networks for support. The difficulty for these workers is • implementing a program, across the specialist treatment that this increases the expectations of constant availability. For service sector, to improve services’ understanding of the needs many workers, who often work alone, this expectation has proved of CALD clients ; to be impossible. • the use of incentives for continuous improvement in Koori-specific drug treatment services will continue to be central to management strategies in individual drug treatment services meeting the drug treatment needs of Koori communities. However, which reward increased responsiveness to meet the needs of to improve access to a range of service options for those with clients from CALD backgrounds; substance use problems in Koori communities, efforts need to be • specific inclusion of communities from culturally and applied as a matter of urgency to developing culturally linguistically diverse backgrounds, as a key audience, in the appropriate drug treatment responses in other health and welfare development of the drug information strategy; with particular services. attention to information about treatment. • Koori alcohol and drug services need to be developed within • the use of ethno specific outreach workers to encourage drug the overall drug treatment service system to find the right users from specific communities to start accessing treatment; balance between culturally sensitive and sought after • workers located within specific communities who would treatments, and what is known about effective treatments. This provide information, and link users to services; will help avoid the apparent stigmatisation associated with • work undertaken to enlist the assistance of ethno specific and direct access of a drug treatment service and is also likely to other agencies within the social infrastructure in providing reduce the burden on the Koori-specific drug and alcohol relevant information and linking users and their families to workers. treatment. • To ensure that blood-borne virus infection rates remain as low No one strategy will create the change sought and efforts must be as possible, needle and syringe programs may need to be focused on communities, on treatment services and on other located with other generic services so indigenous intravenous relevant agencies. drug users are more able and likely to access them. 6.4.8 Koori communities • Community education programs that are culturally appropriate and focus on prevention, harm minimisation and service In 1998-1999, 7 per cent of clients of specialist drug treatment access may assist in improving the outcomes for this services self-identified as being of Aboriginal or Torres Strait community. descent. Given that only 0.5 per cent of the Victorian population are of Aboriginal or Torres Strait descent,62 this group is clearly 6.5 Conclusion experiencing a major drug use problem. The threat of HIV and Hepatitis C are also of major concern to indigenous Significant enhancements in drug treatment provision throughout communities.63 Victoria have occurred in the past four years. These have included improvements to previously existing services and the The Committee is also aware that Kooris have problems in implementation of new services. The youth drug treatment gaining access to appropriate services. First, the Koori services and the pilot drug diversion programs are now in the community is comprised of a number of different groups whose process of consolidation and expansion. needs may differ considerably from one another.64 Second, unfavourable and biased media coverage of drug use (particularly Deficits in the drug treatment service system have been identified alcohol and inhalation of volatile substances) has not helped in recent times and announcements of funding for programs such these communities feel confident about addressing drug misuse. as parent support services hold promise. Special groups have Finally, many Koori communities are not close to easily accessible particular needs that will require ongoing attention. treatment services.65 Further barriers include the shame associated with a substance use problem that is also found in other CALD communities, and strong family and peer group links, which may mean a Koori community member returns to that same group upon exiting treatment.66 Recent research evidence indicates that Koori people generally do not use mainstream services as they see them as not culturally relevant.67

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The most striking finding of the Committee in relation to treatment The specialist drug treatment services need to provide secondary is the extent to which problematic drug use now permeates the consultation, expert backup and management of special drug broad health and welfare treatment and support systems in treatment needs in the overall response for some of these clients. At Victoria. All sectors report high and increasing demands to deal the same time, the broad health and welfare systems need to be able with clients with significant drug-related problems. Most feel to recognise and respond directly to drug-related problems among unprepared or lack support to do so. their clients. In this way, many clients could be treated without needing The structural divisions of funding and administrative to directly access specialist drug treatment services. arrangements between service sectors, within DHS, and between Commonwealth and State responsibilities have proven to be dysfunctional in an area which requires systemic planning and Figure 6.7: A framework for future drug treatment service program development. provision Specialist drug treatment provision has slipped behind demand in = Cross- sectoral recent times, especially in the availability of the current most GPs collaboration effective treatment for opiate dependence, methadone provision. -managing The Government must address this urgently and, given its relative clients across sectors cost-effectiveness, should prefer this treatment to making Specialist drug treatment services substantial investments in expanding other more expensive forms of treatment. Establishing an integrated service system Broader treatment and support services The Committee proposes a new framework for the provision of services to people with drug use problems. The framework Reintegration services: depends upon effective cross-sectoral collaboration and housing, income security, cooperation and is presented below (figure 6.7). education, employment With the changes in drug use occurring in the community, and the significantly increased number of clients with drug use problems presenting in the broader health and social support To achieve this systemic approach, it will be necessary to refocus sector, it is not possible for specialist drug treatment services to the specialist drug treatment program structure to enhance the provide all drug treatment in this State. A whole-of-government linkages within the drug treatment service system, and to provide reassessment is required to determine how the service sectors the necessary consultancy role required by the broader treatment need to interact for the cross-sectoral provision of drug response and support service sector by: and treatment services. • including general practitioners (especially in their role as providers of pharmacotherapy treatments); There are opportunities for earlier drug treatment responses, and a • establishing a specialist support and consultancy role in relation need to ensure the support required to sustain treatment gains and to the broader health and welfare services that will often be facilitate reintegration of drug users into the community after delivering drug-specific treatments; treatment. This requires some reframing and more conscious • describing the various pathways to drug treatment including the linkage between service sectors than has previously been in place. place of withdrawal, rehabilitation and other services, and the The role of general practitioners is a key component of the necessary pathways to reintegration services across the framework. They can provide early interventions to their patients community for drug clients with complex social deficits and needs; with drug use problems, and pharmacotherapeutic treatment • determining the relative roles and responsibilities of those options that are likely to expand in the near future. Particular services responding to drug users, especially at ‘street level’; and attention is urgently needed to address the deficits in the current • carefully evolving the diversion programs so that they enhance, system of access to methadone and other medications through rather than replace, current treatment opportunities for drug- general practitioners. dependent people. The development of understanding, willingness, the necessary To support this reframing of the specialist drug treatment system, protocols, knowledge and skill base to implement drug-specific the Government should further explore and review the: assessment and interventions is necessary within acute, primary • nature of service agreements with DHS with a view to enhancing and community health services and other specialist treatment flexibility and responsiveness while retaining accountability; areas. In addition, other social infrastructure support services that • unit costings, including calculations of operational support; already have clients with extensive alcohol and drug problems • arrangements for quality assurance across the service system, need to be supported to respond to the drug use issues of including exploration of agency accreditation; and these clients. • ongoing monitoring of treatment demand. To achieve these changes, it will be necessary to significantly enhance the service personnel capacity through support for education and training.

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Endnotes

1 National Institute on Drug Abuse. (1999) Principles of Drug Addiction 22 Blum, K., Cull, J., Braverman, E. and Comings, D. (1996) “Reward Treatment: A Research Based Guide, National Institutes of Health Deficiency Syndrome” American Scientist Volume 84, pp. 132-146. Publication No 99-4180, NIH: Bethesda, p. 9. (Online: 23 Premier’s Drug Advisory Council. (1996) Drugs and our Community, http://athealth.com/practitioner/ceduc/PODAT.html Accessed: 01/11/2000.) Victorian Government: Melbourne. 2 Dale, A., and Marsh, A. (2000) Evidence Based Practice Indicators for 24 Victorian Department of Human Services. (2000) Methadone Guidelines: Alcohol and Other Drug Interventions: Literature Review, Best Practice in Prescribers and Pharmacists. (Online: Alcohol and Other Drug Interventions Working Group: WA, p. 8. (Online: http://www.dhs.vic.gov.au/phd/0003118/index.htm Accessed: 02/11/2000.) http://www.wa.gov.au/drugwestaus/ Accessed: 28/08/00.) 25 Turning Point Alcohol and Drug Centre. “Trends in Drug Use and Harm in 3 Proudfoot, H., and Teesson, M. (2000) Investing in Drug and Alcohol Victoria: Implications for Treatment”, unpublished report prepared for the Treatment, NDARC Technical Report No. 91, National Drug and Alcohol Drug Policy Expert Committee August 2000, p. 48. Research Centre, University of New South Wales: Sydney, p. 18. 26 Weatherburn, D., Lind, B., and Forsythe, L. (1999) Drug Law Enforcement: 4 Ibid, p.19 Its Effect on Treatment Experience and Injection Practices, NSW Attorney 5 Victorian Department of Human Services. (1998) Young People and Drugs General’s Department: Sydney, p. v. Needs Analysis, State of Victoria: Melbourne, p. 34. 27 Australian Institute of Health and Welfare. (1998) Medical Labour Force 6 Turning Point Alcohol and Drug Centre. (1996) Report on the Evaluation of 1998. (Online: http://www.aihw.gov.au/publications/health/mlf98/index.html the Community Methadone Program in Victoria, Turning Point Alcohol and Accessed: 23/10/2000.) Drug Centre: Fitzroy, p. v. 28 DirectLine, Census of methadone provider availability, 23 October 2000 7 Proudfoot, H and Teesson, M. (2000) Investing in Drug and Alcohol (unpublished data provided to the Drug Policy Expert Committee). Treatment, NDARC Technical Report No. 91, National Drug and Alcohol 29 U’Ren, A., Toumbourou, J., Stevens-Jones, P., and Hamilton, M. (1996) Research Centre, University of NSW: Sydney, p. 69. “Abstract: Social support, self-help participation and drug use”, Australian 8 Gossop, M., Marsen, J., and Stewart, D. (2000) NTORS at One Year, Journal of Psychology, Vol. 48, Supplement, p. 148. Department of Health: London. 30 Hall, W., Ross, J., Lynskey, M., Law, M., and Degenhardt, L. (2000) How 9 Hser, Y., Anglin, D., Grella, C., Chou, C., and Anglin, M. (1998) Many Dependent Opioid Users are there in Australia? National Drug and “Relationships Between Drug Treatment Careers and Outcomes”, Alcohol Research Centre. Monograph 44. Evaluation Review, Vol. 22, pp. 496-519. 31 Hall, W., Teeson, M., Lynskey, M., and Degenhardt, L., (1999). “The 12- 10 Fletcher, B.W., Tims, F., and Brown, B. (1997) “Drug Abuse Outcome Study month prevalence of substance use and ICD10 substance use disorders in (DATOS) Treatment Evaluation Research in the USA”, Psychology of Australian adults: Findings from the National Survey of Mental Health and Addictive Behaviours, Vol. 11, No. 4, pp. 216-229. Well-Being”. Addiction, 94, 1541-1550. 11 National Drug Strategy. (1998) An Outline for the Treatment of Alcohol 32 Turning Point Alcohol and Drug Centre. “Trends in Drug Use and Harm in Problems: Quality Assurance Project, Monograph Series No. 20, Victoria: Implications for Treatment”, unpublished report prepared for the Commonwealth of Australia: Canberra, p. 139. Drug Policy Expert Committee August 2000. 12 Deeble, J. (1991) Medical Services through Medicare, National Health 33 Weatherburn, D., and Lind, B. (1995) Drug Law Enforcement Policy and its Strategy Background Paper No. 2, Department of Health, Housing and Impact on the Heroin Market, New South Wales Bureau of Crime Statistics Community Services: Canberra. and Research: Sydney, p. 36. 13 Turning Point Alcohol and Drug Centre. (1999) Training and Support 34 Communication with the Victorian Department of Human Services, Drugs Services: General Practitioners, Victorian Department of Human Services: and Health Protection Services Branch, Survey of waiting times for drug Melbourne, p. 4. treatment service, June 2000 quarter. 14 Turning Point Alcohol and Drug Centre. “Trends in Drug Use and Harm in 35 Victorian Department of Human Services, Drugs and Health Protection Victoria: Implications for Treatment”, unpublished report prepared for the Services Branch. Submission to the Drug Policy Expert Committee, Drug Policy Expert Committee August 2000, p. 46. December 1999. 15 Ibid. 36 Victorian Department of Human Services. (2000) Drug and Alcohol Training 16 Figures taken from survey of one major city hospital conducted by the Drug Census 2000 (preliminary data, unpublished). Policy Expert Committee and do not form part of an official report. 37 Dale, A., and Marsh, A. (2000) Evidence Based Practice Indicators for 17 Rumbold, G., and Hamilton M. (1998) “Addressing Drug Problems: The Alcohol and Other Drug Interventions: Literature Review, Best Practice in Case for Harm Minimisation” in Hamilton, M., and Kellehear, A. (eds). Drug Alcohol and Other Drug Interventions Working Group: WA, p. 51 (Online: Use in Australia: A Harm Minimisation Approach, Oxford University Press: http://www.wa.gov.au/drugwestaus/ Accessed: 28/08/00.) Melbourne, pp. 140-141. 38 Victorian Department of Human Services. (1998) Young People and Drugs 18 Crofts, N., & Reid, G. (2000) Primary Health Care among the Street Drug- Needs Analysis, State of Victoria: Melbourne, p. 32. using Community in Footscray: A Needs Analysis, The Centre for Harm 39 Ibid, p. 39. Reduction, Macfarlane Burnet Centre for Medical Research: Melbourne, p.26. 40 Communication with the Victorian Department of Human Services ADIS 19 McLennan, A., Hagan, T.A., Levine, M., Gould, F., Meyers, K., Bencivengo, 1998/99. M., and Durrell, J. (1998) Supplemental services impact outcomes in public 41 Victorian Department of Human Services. (1998) Young People and Drugs addiction treatment, cited in Dale, A., and Marsh, A. (2000) Evidence Based Needs Analysis, State of Victoria: Melbourne, p. 58. Practice Indicators for Alcohol and Other Drug Interventions: Literature 42 Youth Substance Abuse Service. (1999) 100% Dependent: The First 100 Review, Best Practice in Alcohol and Other Drug Interventions Working Young People at the YSAS Residential Unit, YSAS: Fitzroy, p. 21. Group: WA, Literature review, p. 2. (Online: http://www.wa.gov.au/drugwestaus/ Accessed: 28/08/00.) 43 Snyder, W., and Ooms, T. (1996) Empowering Families, Helping Adolescents - Family Centred Treatment of Adolescents with Alcohol and Drug Abuse, 20 Mattick, R P., and Hall. W. (1993) A treatment outline for approaches to and Mental Health Problems, US Department of Health and Human opioid dependence, National Drug Strategy Monograph Series No. 21, Services, Public Health Service: Rockland, MD, p. 16. Commonwealth of Australia: Canberra. 44 Victorian Department of Human Services. (2000) Involving Families in 21 Ward, J., Mattick, R.P., & Hall, W. (1994) “The effectiveness of methadone Alcohol and Drug Treatment - Approaches to working with Families, State of maintenance treatment: an overview”, Drug and Alcohol Review, Vol. 13, Victoria: Melbourne, p. v. p. 328. 45 Ibid.

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s

46 Copeland, J. (1993) “A Review of the Literature on Women’s Substance Use, Dependence and Treatment Needs”, report commissioned by the Queensland Department of Health, cited in Connexions Magazine, March/April 1994, p. 9. 47 Victorian Department of Human Services. (1999) Towards Best Practice Drug Services in Juvenile Justice Centres, State of Victoria: Melbourne, p. 81. 48 Crundall, I. (1998) A Survey of Alcohol and Drug Use by Resident’s of Victoria’s Juvenile Justice Centres. Department of Human Services: Melbourne. 49 Victorian Department of Human Services (1999) Towards Best Practice Drug Services in Juvenile Justice Centres. State of Victoria: Melbourne,p. 81. 50 United Nations High Commissioner for Human Rights (2000) Standard Minimum Rules for the Treatment of Prisoners. (Online: http://www.unhchr.ch/html/menu3/b/h_comp34.htm, Accessed 27/10/2000.) 51 Jacob, J., Stover, H. (2000) The transfer of harm-reduction strategies into prisons: needle exchange programmes in two German prisons. International Journal of Drug Policy, Vol. 11, pp. 325-335. 52 Department of Human Services, (1997) Victoria’s Alcohol and Drug Treatment Services - The Framework for Service Delivery, State of Victoria: Melbourne. 53 Victorian Department of Human Services, (2000) Primary Care Partnerships - Going Forward - Primary Care Partnerships State of Victoria: Melbourne, p.1. 54 Victorian Department of Human Services. (2000) Drugs in a Multicultural Community: An Assessment of Involvement, Executive Summary, State of Victoria: Melbourne, p. 12. 55 Ibid, p. 8. 56 Victorian Department of Human Services. (1999) “Drugs in a Multicultural Community: An Assessment of Involvement”, Draft report, p.175. 57 Victorian Department of Human Services. (2000) Drugs in a Multicultural Community: An Assessment of Involvement, Executive Summary, State of Victoria: Melbourne, p. 7. 58 Victorian Department of Human Services. (1998) Report on Cultural and Linguistic Diversity and Drug Treatment Services, State of Victoria: Melbourne, p. viii. 59 Victorian Department of Human Services. (1999) “Drugs in a Multicultural Community: An Assessment of Involvement”, Draft report, p. xii. 60 Ibid p. iii. 61 Victorian Department of Human Services. (1998) Developing Best practice Drug and Alcohol Treatment Service and Support Models for Young People of Cambodian, Lao and Vietnamese Origin , State of Victoria: Melbourne, p. ix. 62 Australian Bureau of Statistics (1996) National Census of Australian Households. 63 Meyerhoff, G. Injecting Drug Use in Urban Indigenous Communities; A Literature Review with a Particular Focus on the Darwin Area, Danila Dilba Medical Service: Darwin. (Online: http://www.daniladilba.org.au) 64 Department of Human Services (1997) Future Koori Alcohol and Other Drug Services - Planning Project, Drug Treatment Services Unit, p. 4. 65 Gracey, M. “Substance misuse in Aboriginal Australians”. Addiction Biology, No. 3. pp. 29-46. 66 Meyerhoff, G. Injecting Drug Use in Urban Indigenous Communities; A Literature Review with a Particular Focus on the Darwin Area, Danila Dilba Medical Service: Darwin. (Online: http://www.daniladilba.org.au) 67 Department of Human Services. (1998) Report on Cultural and Linguistic Diversity and Drug Treatment Services, State of Victoria: Melbourne, p. 32.

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7.1 Introduction In considering developments over the last four years, the Committee notes that significant progress has been made in all The law plays a critical role in embodying many aspects of the areas of law enforcement and criminal justice since the Premier’s community’s attitude to drugs. It also plays a practical role in Drug Advisory Council (PDAC) reported in 1996. Of the changes, supporting drug policy in other ways. The supply reduction most notable are: component of the harm minimisation principles which underpin • developments promoted by the senior management of Victoria drug policy in Victoria and elsewhere, for example, requires an Police that are designed to translate harm minimisation adequate law enforcement effort to be maintained. As it has principles into operational practice. These include the stressed earlier, the Committee believes an effective drug strategy Cannabis Cautioning and Drug Diversion schemes (now being requires an appropriate investment mix across different areas. It is adopted as the model for a national scheme), harm vital that expenditure across the areas of prevention, treatment minimisation training to provide a clearer understanding of and law enforcement represents the best possible investment mix drug issues and appropriate responses, the Victoria Police in terms of responding to the drug issue. Drug Guide, and the development of policies such as the Traditionally, law enforcement has received a large proportion of Police Attendance at Incidents of Drug Overdose policy, and the funding used to tackle the drug problem. The Committee the Management of Drug and Alcohol Affected Persons in acknowledges that the overall amount of funds spent in this area Custody policy; is unlikely to change significantly. This chapter has therefore • a positive and proactive stance by the courts in relation to focused on issues of effectiveness, and looks at the functioning of harm minimisation generally, and a number of initiatives, such the criminal justice system as it relates to drug offenders, and as CREDIT, which have been developed specifically to respond comments on how effectively the police, courts and corrections to offenders with drug problems; and are responding to the problem. • a commitment by the correctional services system to confront The terms of reference the Committee is addressing in this report drug problems in their offender populations, to critically do not require it to comprehensively review the adequacy of the appraise the impact of current strategies, and to develop new current legislation in relation to drug offences. The Committee strategies. has, however, made a specific recommendation regarding repeal Appendix 12 outlines the range of current diversion and of Section 75 of the Drugs, Poisons and Controlled Substances sentencing options for drug and drug-related offences. Act 1981. In addition the Committee believes there is considerable Despite such progress, the Committee believes there are ways in public interest in a number of law reform issues. The last section which our criminal justice system can become better attuned to of this chapter outlines some of the arguments pertaining to current and emerging issues. A number of these issues and legislative issues. In detailing these, the Committee has drawn on trends impact on multiple aspects of the law enforcement system, the views of a range of stakeholders, including those participating and include: in its consultation program. The Committee hopes this summary • the dilemma of how a criminal justice system can and should of the various views will aid further debate on these issues. respond appropriately to drug dependency, which is now Although the areas of police, courts and corrections are dealt with widely seen as a health issue; separately in this chapter, the Committee acknowledges the extent • a changing profile of drug offenders, which inevitably places to which policies and practices in any one area of criminal justice more demands on the system. Police, courts and the can impact on the demands placed on others. There are also correctional system are now seeing more frequent offenders significant implications for other areas of the social infrastructure with more serious drug problems and more needs in terms of as well, most notably for the treatment service system following health and welfare services. Many have mental health initiatives such as police diversion and the CREDIT scheme in the problems. Discussions with key personnel from the Children’s Magistrates’ Court. (The issue of specific treatment requirements Court have found these trends to be also mirrored in the profile for young offenders within the juvenile justice system has been of young offenders. Drug problems have worsened among dealt with in chapter 6.) young offenders, and the Committee has noted the view that Further, the interdependence of the criminal justice and the social heroin use has increased while relatively lesser drug misuse infrastructure systems cannot be overestimated, as an effectively practices, such as chroming, have decreased. There is an functioning enforcement system depends on offenders accessing increase in those from culturally diverse backgrounds among appropriate housing and other services if they are not to be both adult and young offenders, especially from the more trapped in a vicious cycle of re-offending. newly arrived communities which are facing particular socioeconomic disadvantage;

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• heightened demands on the system as a result of: The Cannabis Cautioning Policy (1998), now implemented across - Victoria having the highest arrest rate for heroin offences the State, enables police to caution adults caught using, or in the (consumption and supply) in Australia, with arrests per possession of, small amounts of cannabis (50 grams or less). The 100,000 of population in 1998-99 at 173.8 compared with caution notice includes information about the health and legal NSW’s 72.9;1 consequences of cannabis use and a confidential drug information and helpline number. The program is limited to those - a growth in the number of Victorians in prison. Despite who have no criminal history of drug offences, and who admit Victoria having the lowest imprisonment and offender rates their offence and agree to a caution. Two cautions only can be of all Australian jurisdictions, total prisoner numbers have given to any individual offender. Victoria Police estimates the grown significantly in recent years. According to the number of offenders who will be given cautions each year at 1,728 Department of Justice, the prison population has grown by adults and 250 under-18 year olds. During the six-month pilot 27 per cent since 1996, and the prison population had project for the program, of 97 offenders cautioned, only eight were reached over 3,000 by November 1999.2 The growth is detected for further drug offences. 5 attributed to more offenders being sentenced to prison, and serious offences receiving longer sentence lengths. The Drug Diversion Program (2000), based on a 1998 pilot, deals Consequently, prison occupancy increased to 101.7 per with low-level users of illegal drugs other than cannabis, and cent of prison capacity by June 1999;3 provides an early intervention assessment and treatment strategy. - more prisoners presenting with drug problems. A significant Victoria Police views the Cannabis Cautioning Program as proportion of offenders report having a drug use problem providing ‘the balance between enforcing the law whilst at the 6 prior to imprisonment. Sixty-three per cent of male and 68 same time addressing issues of harm minimisation’. The per cent of female first time prisoners report drug problems Committee would support that view and its application to the other prior to imprisonment. This rises to 84 per cent of males diversion initiatives. and 92 per cent of females who are serving a second or The Committee wishes to make the following comments in relation subsequent sentence; 4 to a number of other initiatives and policing practices. • the potential for positive offender outcomes, in terms of 7.2.2 Local Priority Policing reduced recidivism and changed life course, being seriously The Committee commends the initiative taken by the Chief affected by other aspects of the social infrastructure. For Commissioner in implementing a system designed to bring police example, lack of access to affordable and appropriate long- and community closer together in determining enforcement priorities. term housing has consistently been raised as an issue that increases people’s chances of falling into the criminal justice The objective of Local Priority Policing is to ‘deliver effective 7 system, and significantly reduces the likelihood of their policing services that satisfy community needs and expectations’. successfully moving out of it. A key part of this new approach is the establishment of Local Safety Committees. Designed to be the keys to a statewide Responding to these and other issues identified later in this network of partnerships with relevant government, non-government chapter must be a priority. and community agencies, the committees are part of Victoria 7.2 Policing Police’s community consultation and partnerships strategy. 7.2.1 Current initiatives Local Safety Committees’ objectives include identifying and analysing key community safety issues, developing strategies to The Committee is generally impressed by the range of address community safety problems, developing Community developments aimed at sensitising members of Victoria Police to Safety Plans, and providing a forum for community groups to refer drug-related issues, whether in training domains, or in the day-to- issues for consideration and action.8 A performance review, based day provision of policing services. Victoria Police initiatives range on process and achievement outcomes and evaluation, has been from formal programs to policies addressing the exercise of police built into the Local Priority Policing strategy. discretion. In its Stage One report, the Committee emphasised the The Police Attendance at Incidents of Drug Overdose Policy importance of local communities in determining and delivering (1998) gives police members attending non-fatal drug overdoses appropriate drug responses. It also recommended that police, as discretion as to whether to prosecute minor use and possession well as other key stakeholders, work with local government to drug offences. The aim of the policy is to encourage those develop local drug strategies. The Committee is concerned to present at an overdose to call an ambulance immediately without ensure that the Local Safety Committees being formed in each risk of being arrested themselves. local district are as open as possible to a wide range of community, local stakeholder and service provider concerns, and thus able to develop creative solutions to drug-related issues in areas where that is a particular safety priority.

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There will still be a need for an ongoing local forum in addition to A further consideration concerns the regional coordination of Local the Local Safety Committees to monitor the impacts of drug use Priority Policing across municipalities; local responsiveness should specifically, and develop strategies in response. Police would play not be gained at the expense of statewide and cross-district a vital part in any such forum. The Committee notes that forums coordination. For example, it is important that police activity dealing with drug issues in some way already exist in a number of planned in one area should not be undertaken without considering local government areas. Local safety and crime prevention the impact on other areas. An example of this is discussed in the committees, many initiated as part of the Safer Cities and Shires following section. Program, are one example, and the round tables formed in a 7.2.3 Intensive policing activity in response to number of areas in response to the recommendations of the drug problems Committee’s Stage One report are another. Forums unique to a The Committee has noted the implementation of a number of particular area, such as the Yarra Drug and Health Forum and the intensive policing campaigns targeting particular areas in which North Melbourne/Flemington/Kensington Drug and Health Forum, there has been a high level of street-based drug activity. Such provide other models. An initiative such as the Collaboration, Care campaigns are not a new strategy, but since the Committee was and Innovation (CCI) project in the City of Yarra, while focusing on convened in November 1999, they have been conducted in a local service liaison to offenders at the point of release from number of the so-called ‘hot spot’ street markets custody, also acts as an informal meeting point for police and (Fitzroy/Collingwood, Footscray, Springvale/Dandenong and local service providers. Melbourne CBD). It is important that police are active participants in these forums as The advantages and disadvantages of such a strategy need to be well as in Local Safety Committees. Building on recommendations carefully weighed in the light of agreed harm minimisation in its Stage One report, the Committee recommends that, in those principles. areas where such forums do not currently exist, local governments establish one as part of their local drug strategy. Advocates of intensive policing have suggested to the Committee that there are a number of advantages in such a strategy: In discussing local consultation and liaison, it is important for us • pressure is exerted on drug users to seek treatment as a result all, including police, to remember that drug users are also of difficulties in obtaining heroin through their usual supply or, a members of the community. They will have a unique and valuable more likely outcome, those apprehended are diverted to contribution to make to a community discussion about drug treatment either by Victoria Police or through the court system. issues, whether in the setting of a drug-specific forum, or in formal As discussed in chapter 6, there appears to be no difference in discussions about local safety matters. The Committee the success rate of treatment that is mandated and that which encourages police and local government to take steps to ensure is voluntary,10 so accelerating access into treatment as a result they are able to benefit from such a perspective. of such intensive policing practices may be beneficial to It may now also be appropriate for a formal liaison process between individual drug users; police and drug users to be developed; the creation of illegal drug • markets are significantly disrupted, thus achieving supply 9 user liaison officers in police services has been suggested and reduction goals; may be a useful initiative for Victoria Police to consider. • individuals may be deterred from taking up recreational drug use; It is also important that issues of governance in relation to Local • the tension that can build up where there is street-based drug Priority Policing structures and Local Safety Committees are given trafficking can be diffused. Those experiencing such tension adequate attention. The Committee believes there is a potential and aggression include users, traders, local employees and for confusion over the roles of police and other players in these residents; structures, with the attendant risk that partnership goals might be • police meet the expectations and preferences of some local compromised. Police have established the committees and have traders, businesses and residents and ensure these an acknowledged key role in safety concerns. Care will need to be stakeholders retain their confidence in the police; taken to ensure that committee membership is broad and fully • increases in price are triggered by reduced availability and lead representative of the particular area. All Safety Committee to lower consumer demand; and members need to be confident they have an equal say in what is • other crime in the area is reduced. discussed and what strategies are supported. Those critical of the value of intensive policing strategies argue that The Committee is encouraged by the stated objective that the role impacts go beyond what may be simply assumed as the of chairing the Local Safety Committees be shared with non- immediate consequences, such as reduced drug trafficking. They police committee members once the initial phase of the concept suggest that the full range of impacts is complex and multi- is completed, and that Safety Committee decision making is to be dimensional, that serious health consequences can be triggered, based on consensus (with District Inspectors retaining and that even crime reduction goals may not be achieved. responsibility for managing police resources). The Committee Specifically, they cite the following disadvantages: would encourage Victoria Police to be vigilant about such governance matters, and ensure they are examined independently and closely during the review process.

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• such policing practices do not have any lasting effect; as soon There are several possible reasons why seizures of drugs seem to as the effort is reduced, the trafficking activity increases to have a minimal impact on prices at street level: levels previously experienced; • traffickers may simply assume they will lose a certain amount • such practices merely displace activity from the targeted locale of drugs to seizures and factor this into their pricing and to another street market. The Committee has heard reports that operations. Unless the overall percentage of drugs seized is the crackdown earlier this year in Footscray (Operation Reform) dramatically increased, individual seizures will not change was followed by a surge in trafficking activity in the Melbourne these calculations; CBD (as well as some increased activity in St Albans). • traffickers may stockpile drugs. This would enable them to Although the Committee does not venture a view on the validity weather minor interruptions to supply without affecting their of the alleged link in events in this particular instance, it does ability to deliver drugs to their customers;17 believe, in general, that the so-called ‘displacement process’ • there are many suppliers of most drugs, and more are poised operates in instances of police crackdowns. A study of to enter the market, so even ‘knocking out’ a major supplier intensive police Operation JUVA in Collingwood, for example, may only have a small or temporary effect on availability. As showed an apparent geographic displacement of drug users long as the drug trade remains profitable, there will be new as a result of the operation;11 suppliers keen to fill any temporary gaps in the market; and • there are serious public and individual health impacts of • there may simply be oversupply in the market, meaning prices, intensive policing that include hazardous handling and purity and availability are only minimally affected by seizures.18 administration of drugs. Such practices include storing drugs Despite the detrimental impacts of crackdowns, not just on the in the mouth or nose, swallowing large amounts of heroin in an drug user but also on the community, there appears to be a thrust attempt at concealment, high-risk injecting practices, and within Victoria Police toward aggressive policing measures aimed 12 discarding syringes in public places. Effects can include at driving drug dealing and use ‘underground’. serious infection, the increased spread of disease and The Committee recognises that police have a legitimate role in increased risk of overdose; maintaining public order and confidence, and in reducing supply • there can also be unanticipated consequences on crime by targeting commercial drug traffickers, and that there is patterns where users who frequently traffick in drugs to support significant pressure to ‘clean up’ street drug market areas. their own habits need to find an alternate income when selling However, the Committee believes intensive policing responses to drugs becomes too risky. As noted in a Sydney study, this can the problem are, in the main, counterproductive, and that costs result in users resorting to other forms of crime, including measured in crime, harm minimisation and public health terms do property crime, to make money to buy drugs;13 and not justify the temporary benefits that may be experienced in the • disincentives are created for users to approach and utilise immediate location. pubic health and related services, such as needle and syringe exchanges. The study of Operation JUVA in Collingwood The Committee believes it is very important that the local forums it showed reduced use of the local needle and syringe exchange has recommended be established, as well as the Local Safety facility as a consequence of the operation.14 Committees, facilitate the very necessary police consultation and discussion with the community on drug problems and solutions. The Committee has noted important research in Sydney and This must include drug users themselves, as a recent discussion Melbourne that attempted to gauge the impact of intensive paper notes,19 and local agencies. One study on this issue policing. A comprehensive 1995 NSW study looked at the concluded that police need to work more closely with health influence of heroin seizures and arrests for use or possession of authorities in minimising the risk their activities pose to public heroin on the large and active heroin market in Cabramatta.15 The health.20 Such consultations and discussions, particularly with research examined whether these law enforcement actions health care and drug treatment agencies, would help to inform affected the price, purity and availability of heroin, and the rate at police actions on public order issues and on the possible use of which users enrolled in a methadone program. The study found intensive policing. Any future proposed intensive operations would that variations in the quantity of heroin seized Australia-wide and need to be responsive to the needs of a particular area, the number of arrests in Cabramatta appeared to have no conducted with an awareness of health and other implications, influence on the heroin market. The authors concluded that law and not used or regarded as a general solution to the problem of enforcement is effective in ensuring the price of heroin does not public drug use. drop significantly, and may be a factor in encouraging users to seek treatment. However, the goal of cutting off supply and significantly increasing the price of heroin would appear to be unrealistic. In any event, higher prices may be offset by higher rates of income-producing property crime.16

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7.2.4 Evaluation • ensuring information about the particular situations and needs Victoria Police has acknowledged the need for, and the value of, of drug users from culturally and linguistically diverse evidence about the effect of its operational policies, including backgrounds, and how best to manage them from a policing intensive policing. The independent analysis undertaken on the perspective, is included in police training. Police working in impact of advertisements designed to reduce road trauma areas with large numbers of people from a particular was offered to the Committee as one example of a valuable community will be familiar with their special needs and evaluation tool. problems in relation to drug issues. However, all police members need appropriate information and ongoing training, The Committee believes decisions and community discussions particularly on how such needs and problems might affect the about police policies and operations must also be based on reliable way in which police operations are conducted; and information about their effects, intended and otherwise. It would • better documentation and dissemination of good practice. The encourage the police to pursue links with independent research Committee believes, in some cases, certain regions may have units to determine the short- and long-term effects, in both law- already identified problems but are looking for advice on enforcement and harm minimisation term, of decisions concerning appropriate and effective responses. One example of this is drug issues. The Strategic Partnerships project, for example, was the development of liquor licensing accords, which were begun in 1997 and involves the Department of Justice, Victoria established in one area and then taken up in others. Another is Police and the University of Melbourne in examining the the Community Drug Information Service (CDIS) developed in characteristics of drug offenders and policing of local drug markets. Morwell in response to a perceived lack of information sharing The Committee considers this an encouraging step. between police, the ambulance service, the hospital, alcohol A recent study has outlined possible performance indicators and drug services, government agencies, and local youth (outcome and output), specifically related to drug law workers. The CDIS enables information about many aspects of enforcement, to provide a means to assess police performance in drug use (including drug-related deaths, overdoses, changes minimising the harm associated with heroin, and a means of in use or user patterns) to be distributed quickly via fax 21 gauging what police are doing to achieve their objectives. The throughout the network, and allows its members to develop Committee would encourage Victoria Police to pursue the coordinated responses.23 The Committee believes more effort development of tools such as these so it can be confident that should be put into documenting and disseminating examples harm minimisation principles are being put into practice. of good police practice in harm minimisation terms as well as 7.2.5 Training in terms of initiatives that have been effective in responding to The Committee has noted Victoria Police’s significant efforts over drug issues. the past four years to provide training based on harm To obtain maximum benefit from the documentation of good minimisation principles to its sworn members. A number of the practice and from training delivered by regional training officers, specific elements of Victoria Police’s training packages have been these should be combined. designated noteworthy in a National Drug Strategy review of drug As the Committee has made clear in previous chapters of this 22 harm minimisation education for police in Australia. report, program evaluation is an essential resource for planning. However, that report also noted the need to ensure harm Evaluation, which includes monitoring and appraisal of those who minimisation principles are translated into practice at the have undertaken the program in question, needs to be built into operational level. The Committee believes that in Victoria, as in program design and adequately resourced. The Committee is of other States, there is a need to ensure knowledge acquired in the view that police training would similarly benefit from monitoring training courses does not dissipate when police are faced with the of its impact (including appraisal of members following training), pressures inherent in operational policing. The Committee and recommends this be implemented as soon as possible. In considers there are several important ways in which gains already this regard, it is encouraged by the introduction this year of the made could be maintained, and a more responsive police culture Performance Enhancement Program for senior members of the engendered. These include: service that is designed to develop performance accountability • ensuring drug and alcohol training, which includes practical through individual performance charters. The Committee would information as well as explanation of harm minimisation encourage its application to all police members and would principles, is part of an ongoing program of professional recommend that, where relevant, harm minimisation principles development. The Committee notes the introduction of regional and their application be included in such charters. training officers to conduct training in regions and believes this provides an excellent vehicle for drug and alcohol training;

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7.2.6 Conclusion Each year, the Magistrates’ Court hears around 6,000 cases in Police perform critical tasks in preventing drug use and linking which the principal proven offence directly involves the drug users with treatment, and in meeting the community’s consumption (which includes use or possession) or supply of 25 expectations regarding order, safety and justice. Gains made over illegal drugs. These cases comprise approximately 8 per cent of recent years in the operation and coordination of these systems all offences heard by the Magistrates’ Court. Of these, just over need to be strengthened. half (57 per cent) are cases in which a consumption offence is the principal proven offence. Victoria Police has been strongly committed to harm minimisation, local and State partnerships, and to continued vigilance in tackling It is not possible to obtain accurate figures for the number of other commercial and serious trafficking while actively diverting drug offences that are committed for the purpose of obtaining drugs. users from the system. The development of the drug diversion Nevertheless, the Department of Justice has been able to estimate 26 initiative is a major achievement that will be critical in assisting that around 81 per cent of all prisoners have a drug problem. It is drug users, and in reducing the load on courts and corrections therefore safe to estimate that a significant proportion of burglary, system in the future. The Committee hopes the commitment to robbery and prostitution offences are drug-related. diversion will lead to a decrease in Victoria’s comparatively high These statistics indicate that many metropolitan and regional arrest rate for heroin offences.24 This initiative, and others taken by Magistrates’ Courts in Victoria have become ‘drug courts’ in the Victoria Police, will require additional collaboration with health, sense that a substantial proportion of the cases coming before education and local government agencies at the local and senior them are drug-related. policy making level to reach their full potential. At the start of this chapter, a number of issues were identified as The advent of Local Priority Policing and local government drug having serious impacts on the functioning of law enforcement and initiatives offer an opportunity for constructive liaison between the criminal justice system as a whole. The Committee’s police and local agencies concerned with drug issues. As noted consultations with key players across the criminal justice system, earlier, such liaison has the capacity to give police information including those operating in community-based organisations, has about the nature of the community and the impacts of its policies confirmed the relevance of these issues and, in particular, the and practices, which should then inform police operational problems offenders face in accessing different parts of the social decisions and priorities. This is important in relation to the infrastructure. A large number of offenders’ criminal behaviour is identified harmful public health impacts of intensive policing attributable to drug dependency in combination with other factors operations in the open street drug market. such as homelessness, unemployment, intellectual disability or Such liaison should also take place at a senior policy making personality disorders. Many of these offenders have strong level. As the Committee has stated earlier, cross-sectoral prospects for reintegration into the community if they receive understanding, relationships and coordination are absolutely appropriate services to address these underlying problems; critical to an effective drug strategy. Drug law enforcement however, many appear to be unable to access such services. currently lacks a forum in which perspectives and expertise from A number of problems concerning the dominance of drug across disciplines and portfolios can come together to consider offences in the Magistrates’ Court are outlined in this section. particular strategies and approaches, and overall police drug Underpinning these is the fundamental problem confronting the strategy. The Committee believes such a reference group would court: how to respond effectively to a health issue, and offenders’ be of considerable value to Victoria Police, and would related welfare needs, through a criminal justice system. The complement its community consultation and partnerships chronic relapsing nature of drug dependency makes this strategy. particularly difficult. Conventional sentencing practices can lead to an escalating cycle of arrest, imposition of a conditional non- 7.3 Courts and sentencing custodial order, breach of the order, re-arrest, re-sentencing, 7.3.1 Introduction further breach and, ultimately, imprisonment. While higher courts deal with more serious illegal drug trafficking The following case study illustrates this cycle and a number of the offences, the Magistrates’ Court hears the overwhelming majority more specific problems involved. (The name and some details of offences that directly or indirectly involve legal and illegal drugs. have been changed to ensure confidentiality.) The role alcohol plays in a number of offences coming before the court, such as assault and public nuisance, cannot easily be quantified. The main illegal drug offences dealt with by the Magistrates’ Court relate to cannabis and heroin. In view of the extent of repeat offending and health-related harms resulting from heroin use, the discussion in this section focuses principally on the impact of that particular drug.

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Case study

Mark is 23 years old. He has been using heroin for six years and, for the last two, has been heavily dependent. His heroin addiction costs him around $500 per week. He is unemployed and obtains money to buy heroin by stealing from cars and street-level drug trafficking. He is homeless and usually sleeps in squats and, occasionally, sleeps rough or in a boarding house. He has been in trouble with the police on several occasions and has been to court once. On that occasion, he was found guilty of theft and received a 12-month good behaviour bond. Six months later, Mark was arrested while stealing a mobile phone from a car. He was carrying a bag containing a stolen wallet and two caps of heroin. He was released on bail. He pleaded guilty in the Magistrates’ Court to charges of theft, possession of stolen goods and possession of a drug of dependence. Although Mark was in breach of his good behaviour bond, the magistrate decided to impose a 12-month community-based order. The order included conditions that he undergo drug treatment and perform three hours of community service each week. He spent two nights in a residential rehabilitation facility but was discharged for drug use. He returned to living in squats and, four months later, was picked up by police for being in possession of heroin and was fined $100 (to be paid in instalments). His arrest prompted him to re-enter drug treatment, and this time he successfully completed a residential rehabilitation program. He left the program but was unable to find employment or stable housing and, after two months, he again relapsed. His heroin use rapidly escalated and he was soon arrested selling heroin at a suburban shopping centre and charged with drug trafficking. The seriousness of this offence meant Mark faced more obstacles to being granted bail than he did before. The nature of the offence, combined with the fact that he had no fixed address, was drug dependent and had a prior history of breaching orders resulted in him being unable to ‘show cause’, as the law requires, as to why he should be released. Bail was refused. He was held in various police cells for two weeks before his court appearance, at which he pleaded guilty to trafficking. While the court found that the offence was committed to support his drug habit, the magistrate considered Mark’s history of breaching non-custodial orders left no option but to sentence him to five months imprisonment.

The available statistics indicate that the pattern of events in Mark’s 7.3.2 Bail story, including the escalating cycle of sentences and his need for Bail is increasingly likely to be refused to those coming before the better access to services, is common to the drug-using offender Magistrates’ Court for drug-related offences. Magistrates’ Court group. statistics show that between 1995-96 and 1998-99, the proportion The dilemma of trying to respond to a health and welfare issue in of offenders refused bail for drug offences increased markedly a criminal justice context is the overarching problem to be from 2.8 to 9 per cent. When drug offences are divided into addressed. It gives rise to a number of specific issues: consumption offences (use or possession) and supply offences • the difficulties offenders with drug problems may face in being (trafficking, manufacturing, cultivating), a further pattern emerges. granted bail; Between 1995-96 and 1998-99, the proportion of offenders • the suitability of sentencing options available to magistrates for refused bail for consumption offences rose from 1.9 to 3.5 per an offender population that increasingly has significant drug cent. On the face of it, such an outcome would seem problems; and inappropriate given the nature of the alleged offence, although the • the need for offenders to be able to access appropriate increase in the number of refused applications (26) is sufficiently treatment services, and to be linked to a range of services from small that this is not of immediate concern. However, over the within the social infrastructure. same period, the proportion refused bail for supply offences These issues are discussed in more detail below, and they inform increased from 4.1 to 15.2 per cent. This is an increase of 267 the Committee’s views on the type of enhanced drug response applications being refused. A person charged with a drug supply needed from the court system. offence was over three times more likely to be refused bail in 1998-99 than in 1995-96.

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Table 7.1: Bail applications granted and refused27 in the case of drug charges, 1995-96 to 1998-99

Offence 1995-96 1996-97 1997-98 1998-99

Granted Refused Granted Refused Granted Refused Granted Refused Consumption 3,295 65 2,874 60 2,774 88 2,482 91 (98.1%) (1.9%) (97.9%) (2.1%) (96.9%) (3.1%) (96.5%) (3.5%)

Supply 1,973 84 1,943 115 2,377 239 1,967 351 (95.9%) (4.1%) (94.4%) (5.6%) (90.9%) (9.1%) (84.8%) (15.2%)

To t a l 5,268 149 4,817 175 5,151 327 4,449 442 (97.2%) (2.8%) (96.5%) (3.5%) (94.0%) (6.0%) (91.0%) (9.0%)

Source: Department of Justice. (2000) Statistics of the Magistrates’ Court of Victoria 1998/99, Department of Justice: Melbourne, table CR4.6H.

Some magistrates have stated that those who appear to be The limited time that the scheme had been in operation meant the dependent on drugs often face considerable difficulty in obtaining evaluation was subject to a number of constraints. Although the bail because of the risk that, if they are released back into the process of implementation could be evaluated, further work is still community, they will fail to re-appear for court hearings or will required to determine, in greater detail, the outcomes of the commit further offences. It has been suggested that scheme, particularly for the system’s clients in the longer term. homelessness or lack of adequate, safe housing can also affect a The Committee believes a rigorous outcome evaluation focusing magistrate’s decision. on immediate and longer term impacts for those using CREDIT As a result of these problems, the Magistrates’ Court launched the should be a priority after the program has run for a suitable length Court Referral and Evaluation for Drug Intervention and Treatment of time. (CREDIT) pilot program in 1998. CREDIT uses the bail hearing If offenders fail to get bail, they are remanded in custody pending process to link defendants with drug treatment services by making the finalisation of their case. This can take several weeks in the treatment a condition of bail. Magistrates’ Court. While on remand, they will typically be held in a The CREDIT pilot was subject to a review after its first nine months police holding cell, or in the cells at the Melbourne Magistrates’ of operation, during which time 199 offenders used the scheme. Court, due to current overcrowding in correctional facilities. People The review found that there was little difference in the re-offending on remand for an extended period are commonly held in Port Phillip rates of those who used CREDIT and those who chose not to use Prison. The significant difficulties for prisoners being held in police it.28 Forty-six per cent of those who used the CREDIT scheme re- custody rather than in the corrections system, especially those offended between November 1998 and July 1999. Thirty per cent of undergoing drug withdrawal, are discussed later in this chapter. the re-offending occurred within seven days of bail being set.

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CREDIT: An initiative of the Magistrates’ Court

The Court Referral and Evaluation for Drug Intervention and Treatment (CREDIT) pilot program was launched in the Melbourne Magistrates’ Court in November 1998. The rationale of the program was that if appropriate drug treatment services could be arranged for the defendant and made a condition of bail, and if the court monitored the defendant’s progress in drug treatment, the risk of re- offending would be reduced and the defendant could be released on bail. Under the program, subject to certain eligibility requirements, if a drug-dependent person applies for bail, a drug clinician employed by the court assesses the person’s drug treatment needs. When the person is then brought before the court at the bail hearing, the court is in a position to know: • the extent of the person’s drug problem; • the availability of appropriate services for the person; and • the likelihood of the person successfully undergoing drug treatment if the person is released on bail with a drug treatment condition. Under the CREDIT program, drug treatment services for those released on bail are organised and paid for through a service broker. The CREDIT program presently operates only at the Melbourne Magistrates’ Court. However, funding of $3.3 million has recently been made available through the Council of Australian Governments to assist with its expansion to 13 courts over the next three years. A version of CREDIT is also planned for the Children’s Court and the model will be adapted to meet its different needs. The Commonwealth Government will provide funding for drug treatment in both the Magistrates’ and Children’s Courts as part of its National Illicit Drugs Strategy Diversion Initiative under its Tough on Drugs strategy. The State Government will provide funding for drug clinicians in the Magistrates’ Courts (through the Department of Justice) and in the Children’s Court (through the Department of Human Services).

7.3.3 Sentencing options Changes in the profile of offenders coming before the Magistrates’ Court are largely driven by the increased prevalence of drug problems. However, the Committee believes that these have not yet been adequately matched by changes in the sentencing options and in the Court’s capacity to respond. The Committee believes the CREDIT initiative is an important step forward, and a good example of court practices adjusting to changed offender situations. Sentencing trends over the five years to 1998-99 are set out in table 7.2 below.

Table 7. 2: Sentencing outcomes for drug charges heard in the Magistrates’ Court

Possess/use a drug of dependence

Fine (%) Bond*†(%) Community Imprisonment Discharge Suspended Combined Intensive Based (%) (%) Sentence (%) Custody & Correction Order (%) Treatment Order (%) Order CCTO (%)

1994 - 95 41.5 36.1 9.5 5.2 3.7 2.3 0.8 0.7 1998 - 99 36.9 23.7 14.4 11.3 5.3 4.9 0.8 2.6

Traffick/cultivate a drug of dependence

Fine (%) Imprisonment Community Bond (%) Suspended Intensive Discharge Combined (%) Based Sentence (%) Correction (%) Custody & Order (%) Order (%) Treatment Order CCTO (%)

1994 - 95 33.6 8.5 13.3 28.6 10.5 1.8 3.0 0.6 1998 - 99 22.6 20.2 19.1 14.9 13.7 5.9 2.4 1.1

Source: Derived from COURTLINK data supplied to the Committee. The figures are based on the number of charges that result in a finding of guilt. * Adjourned undertaking.

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As the sentencing statistics illustrate, possession and use Imprisonment offences are resulting in a changing pattern of outcomes for an The Committee has noted earlier that imprisonment rates for offender. The less serious sentences of fines and bonds have consumption offences have more than doubled in the five years to decreased, and the latter has shown a very marked drop from 1998-99. The rates for those convicted of trafficking and 36.1 to 23.7 per cent of all sentencing outcomes. Community manufacture offences have also more than doubled over the Based Orders have increased from 9.5 to 14.4 per cent. However, same period. The most recent Magistrates’ Court statistics the most alarming change is the increase in imprisonment. This available (1997-98) indicate that the length of imprisonment for sentence outcome has more than doubled over the five year drug possession (the most common ‘consumption’ offence) period, and has risen from 5.2 to 11.3 per cent of the total. ranged from less than one day to 18 months; one month was the Trafficking and cultivation offences have also resulted in a median period as well as the most common. The length of changed pattern of sentencing outcomes. Fines and bonds were imprisonment for trafficking (the most common ‘supply’ offence) the two most common sentences at the start of the five-year ranged from three days to two-and-a-half years,29 with four months period, but the proportions of both decreased significantly by the median period and six months the most common. 1997-98 (from 33.6 to 22.6 per cent in the case of fines, and from It is important to make the distinction that many of those charged 28.6 to 14.8 per cent in the case of bonds). The most dramatic with trafficking and manufacture offences are not the high-level increase was in sentences of imprisonment. These rose from 8.5 commercial dealers motivated simply by profit. As the case study to 20.2 per cent over the five years. above illustrates, a number of those sentenced to terms of These data refute the claims of those who have suggested the imprisonment for these offences are actually users involved in low- Magistrates’ Court is taking a more lenient stand in relation to level dealing to support their drug habit. The Sentencing Act drug offenders. The Committee believes it is important that the incorporates the principle that a court must not impose a community is aware of the way in which offenders are actually sentence that involves the confinement of an offender unless it dealt with in the criminal justice system. considers that the purpose(s) for which the sentence is imposed

30 Fines cannot be achieved by any other sentencing order. The increasing proportion of drug-related offenders who are receiving The Magistrates’ Court statistics indicate that, despite a decrease custodial sentences indicates that options such as Community in its imposition for drug offences between 1994-95 and 1998-99, Based Orders and Intensive Correction Orders are not working as a fine is still the most common sanction for offences of drug use effectively as they could. In this respect, the Committee welcomes or possession. the work being done by the Office of the Correctional Services The most recent statistics published (1997-98) show that fines for Commissioner to review the effectiveness of Community the offence of possession of a drug of dependence (the most Correctional Services, and comments on it in the next section of common drug consumption offence) range from $10 to $8,000; this chapter. $250 is the median fine and $100 is the most common. The Committee believes, in most cases, imprisonment for those The Committee believes the imposition of fines on drug offenders, with drug consumption and minor trafficking/consumption particularly those with low or precarious income and no stable offences is likely to be an inappropriate outcome. It has heard the accommodation, reflects the limited sentencing options available views of certain members in the community who believe to the court. It has been suggested to the Committee that although imprisonment of such offenders is justified by the need to protect imposing fines may achieve little in the way of deterrence, our community. However, the protection of the community is short protection of the community or fostering rehabilitation and re- lived if the offender’s drug problem is not addressed while in integration (listed as sentencing purposes in section 5 of the custody. Moreover, imprisonment has very little deterrent value. Sentencing Act 1991), it is preferable to imprisonment and may, in The Committee has noted a recent rise in the recidivism rates of a number of cases, be the only option other than imposing a prisoners. The number returning to prison increased from 35 to 43 prison term. However, the fact remains that statutory sentencing per cent in the four years to 1999-2000.31 aims are not being met by fines. Their imposition on offenders The Committee is concerned that the effect of imprisonment on without adequate income may be actively counterproductive if it many of the more minor drug offenders is counterproductive as it results in these offenders committing further offences to pay the can jeopardise their prospects of rehabilitation and reintegration. fines, or in a more serious penalty if they default. Magistrates informed the Committee that decisions to impose An enhanced community corrections system, with significantly custodial sentences could be influenced by the lack of other improved breach rates and a better record of linking offenders with options for repeat offenders who have consistently breached less the many services they need, represents a far superior option in the serious non-custodial orders. Some magistrates suggested the Committee’s view. It is anticipated that the improvement of availability of drug treatment programs in correctional settings, community-based sentences discussed in section 7.4.3 below would when compared to the difficulty in accessing these services alleviate the need to resort to fines in relation to such offenders. outside the prison system, may also be a factor in determining sentencing outcomes in some cases. Such considerations clearly do not apply when the sentences are short, as they effectively preclude the prisoner from engaging in a treatment program in any meaningful way, if at all.

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There is evidence to suggest that the reasons for the increase in The Committee believes the Government, particularly in the sentences of imprisonment for trafficking/manufacture and context of the current review of the Sentencing Act, should property-related crimes are similar to those leading to more examine the viability of providing for a suspended term of imprisonment for those convicted of drug consumption charges. imprisonment that is conditional upon undergoing drug treatment. As the case study above demonstrates, the escalating cycle of Any re-introduced suspended sentencing option should have offending, receiving a non-custodial order, re-offending, receiving goals for the offender that relate to treatment, managing any drug a more severe non-custodial order, re-offending and, ultimately, use so it does not undermine the chances of reintegration, and receiving a sentence of imprisonment is one that traps many drug remaining clear of any criminal activity. If provision were to be users and small-time dealers. made for such an order, care should be taken to ensure the The Committee is disturbed by these trends. A concerted and consequences of breaching the order (particularly where the integrated effort is urgently required to break this cycle, and breach relates to a failure to comply with the drug treatment prevent others starting on it, if we are to help those caught up in condition) are sufficiently flexible to take account of the nature of drug use and the related criminal lifestyle. The Committee believes drug dependency. the way forward is to build upon the encouraging recent changes It has been noted that a major issue for the Magistrates’ Court is in the court’s approach to dealing with these offenders, and to the limited number of sentencing options available, especially develop new strategies in the corrections system. given the growth in the number of offenders with serious drug The alternative is to accept a more rapid growth in the prison problems. The Committee believes the reintroduction of a population. This will result in more prisons being built, and modified suspended sentencing option, as outlined above, may Victoria’s strong record of low incarceration rates being eroded. offer magistrates a further alternative to imprisonment for such offenders. Suspended sentences of imprisonment Deferred sentencing As shown in table 7.2 above, the suspended sentence is a significant sentencing option in the case of those charged with One further option is deferred sentencing. This allows magistrates trafficking and cultivation offences. Under this option, there are no to defer imposing a sentence for a period of time during which conditions attached to the suspended sentence other than the offenders have the opportunity to get help with their drug offender must not re-offend or the sentence will take effect. problems and get their life in order, which may, in turn, affect the However, until recently, suspended sentences were available with nature of the sentence to be imposed. The Committee believes specific additional conditions attached. the deferred sentence, when combined with arrangements related to accessing treatment and support services, could offer This option was contained in section 28 of the Sentencing Act. It important incentives to offenders to address their drug problems enabled courts to impose a sentence of imprisonment, and then and commence the process of reintegration into a stable lifestyle. suspend the sentence on the condition that the offender: Currently, the deferred sentence is only applicable to offenders • undergo treatment for a period of between six months and two aged between 17 and 25. The Committee understands this years; restriction is due to the limited availability of treatment and other • abstain from drugs; and resources. The Committee’s view is that the Government should • submit to drug testing. consider the value of extending the availability of deferred The section was repealed in 1997 after a consultation process sentences to all those aged over 25. undertaken by the Department of Justice. The Committee 7.3.4 Linking defendants to services understands that there was general dissatisfaction with its operation and, in particular, because orders were inadequately Treatment services supervised and enforced, they did not have the confidence of Coming into contact with the criminal justice system can magistrates, judges or the community. significantly motivate some people who have serious drug A number of the stakeholders consulted by the Committee sought problems to address the issues underlying their criminal the re-introduction of this form of suspended sentence. behaviour. It has been noted that treatment does not have to be voluntary to be effective.32 Furthermore, local practitioners from the In the Committee’s opinion, appropriate funding and reform of the specialist drug treatment service sector have stated in community corrections sector, including guaranteed access to consultations that success rates of voluntary and mandated treatment services where necessary, would resolve the concerns treatment are similar. The Premier’s Drug Advisory Committee that led to the repeal of section 28. However, the Committee (PDAC) noted the importance of capitalising on this motivation in considers that simply re-introducing the section as originally 1996.33 drafted is not desirable. The nature of drug dependency as a chronic relapsing condition means abstinence goals and drug testing are neither appropriate nor viable features of any suspended sentencing option, and will inevitably mean many offenders will be set up to fail.

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A court needs to make the most of its opportunity to intervene in The Committee believes such advice is critical for magistrates, the life of an offender with drug problems. Therefore, courts need and that mechanisms must be developed for specialist health adequate advice, support and access to services to deal with the advice to be brought to bear on the criminal justice decision- offender’s health and welfare needs. In a criminal justice context, making process. the authority of the court will, in many cases, provide an important In addition to better advice about treatment appropriate to incentive for the offender to persevere with treatment and other individual offender’s needs, access to treatment services must be efforts to reintegrate into mainstream society. maintained. The Committee believes a number of important elements of a Other parts of the social infrastructure system that could provide such incentives are already in place. Significant improvement needs to be made in dealing with Since 1996, important steps have been taken to link defendants offenders who have a range of other problems in addition to drug with appropriate drug treatment services. One significant initiative dependency. Chapter 4 has made the point that those with drug is the Community Offenders Advice and Treatment Service problems usually have multiple service needs. The courts are (COATS), which was established in response to a specific PDAC routinely faced with defendants whose alleged criminal behaviour recommendation. PDAC noted the lack of an independent is attributable to factors such as homelessness, intellectual specialist drug advice service to assist the courts, and suggested disability, personality disorder and unemployment in combination such a service could enable community-based sentencing orders with drug dependency. to be better targeted, and appropriate offenders to be diverted from prison.34 The formal evaluation of the CREDIT program concluded that lack of accommodation meant many clients were not able to utilise The functions of COATS are to: their treatment as effectively as possible because their housing • provide independent pre-sentence advice to courts regarding needs were far more significant.37 Non-CREDIT offenders with drug treatment; drug issues also face such problems. • assess offenders who are given community-based sentencing orders with a drug treatment condition, and to purchase It is clear that, if they are not addressed, such service needs will services for those offenders; and continue to present a major obstacle to offenders learning to • assess offenders who are released on parole with a drug manage their drug problems and reintegrate into the community. treatment condition, and to purchase services for those In response to these difficulties, the Magistrates’ Court has offenders.35 employed a range of officers (including a disabilities services The COATS program is currently delivered by the Australian coordinator, forensic psychiatry nurses and diversion coordinators) Community Support Organisation (ACSO). to assist in linking defendants with appropriate services. Although providing an important function in relation to linking While these individual initiatives are beneficial, the Committee offenders to drug treatment services, the Committee believes considers that a more systemic approach is required to identify there are ways in which incentives for offenders in relation to offenders’ broader needs and link them to services. It believes a treatment can be improved. Intensive Correction Orders (ICOs), formalised assessment and brokerage system, along the lines of which can include treatment requirements in the reporting the models created for drug treatment services though CREDIT 38 conditions to be met by an offender, represent one case in point. and COATS, should be developed to link offenders to a broader In 1998-99, ICOs made up only 2.6 per cent of sentencing range of services, such as mental health services and housing. outcomes for consumption offences, and 5.9 per cent for There are several aspects of the current system that could be built trafficking/cultivation offences. An issues paper prepared as part on to provide this enhanced service linkage. Court-based drug of the Community Correctional Services Review has highlighted clinicians already assess offenders’ treatment needs under the the court’s lack of authority to impose treatment conditions in CREDIT scheme. An expanded COATS drug advice function, or a ICOs, and suggested the judiciary should have the authority to new court-based function, could assess treatment and other impose and vary conditions.36 service needs and either undertake that service-linking role For the court to take an increased role in determining treatment directly, or commission a separate body to organise referrals and requirements when passing sentence, it would need specialist purchasing of services. It is not appropriate for the Committee to advice about client needs and appropriate treatment in the same suggest the operational details of such a scheme, but it does way that court drug clinicians provide this advice to magistrates believe two key principles should be incorporated into an involved in CREDIT. Although COATS’s goals, as outlined above, enhanced service linkage response: include the provision of pre-sentence advice to courts, in practice, its • the Court’s authority should be used as an incentive for efforts have been chiefly focused on brokering treatment services. reintegration; and • the number of people the offender comes into contact with through the assessment, referral and service delivery process should be kept to a minimum. This is likely to require a case management approach for those with complex needs.

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Clearly, any improvements in linking offenders with services can The Committee agrees these goals are central to efforts being only be effective if adequate services are available. In this regard, made to stem the escalating rates of drug-related crime, the discussion of the social infrastructure in chapter 4 of this imprisonment and recidivism. However, it believes these goals can report is crucial. be achieved by a more broadly based series of changes to the way The drug court model and enhanced court responses in which the Magistrates’ Court operates, rather than through to drugs establishing a specialist court. While it agrees with the Department of Justice as to the urgency of the need to respond to the problems Specialist drug courts are being tested in a number of jurisdictions identified above, the Committee does not support the introduction to better respond to offenders with drug problems. There are of a drug court, as outlined above, for the following reasons: numerous models in the USA, and there are drug court pilots • the sheer volume of drug-related cases means every under way in NSW, Queensland and South Australia. The magistrate must have the necessary expertise and resources Committee notes that the Department of Justice’s submission to to deal appropriately with drug-dependent offenders. The the Committee has indicated its support for a drug court, and Committee is concerned by the potential for courts not recommended that pilot projects be established in six designated as drug courts to revert to practices focused on Magistrates’ Courts. criminal justice outcomes that do not reflect best practice in Given the variation across models, it is important to clarify the key harm minimisation terms, and are less likely to produce features of a drug court as understood in the current debate. beneficial outcomes in terms of minimising future offending. It These are: is also concerned that focusing attention on designated drug • offenders must be drug dependant and plead guilty, but can courts may have deleterious effects on the resourcing of the be before the court for an offence other than a drug offence. courts that will continue to deal with the large majority of Those using drug courts would typically be the repeat offenders with drug-related problems; offenders who are in the escalating cycle referred to above, • drug courts compartmentalise the court’s response and deal and who are likely to end up being sentenced to a relatively with the most difficult end of the offender spectrum, whereas short term of imprisonment; what is required is an overall court system that is flexible and • there is an initial process for determining who are eligible to responsive to the varying needs of the broad range of have their cases heard by the drug court (this will often exclude offenders with drug problems. The Committee is of the view those with sexual or violent offences); that rather than focusing on a relatively small group of • offenders are usually brought before the drug court quickly; offenders, it is more critical that attention be directed to • a drug clinician assesses offenders’ drug-dependence improving, widening and better resourcing the array of services problems; and facilities that the existing courts rely upon to render their • there is a team approach to handling an offender’s situation, sentencing practices effective in harm minimisation terms; and incorporating the relevant magistrate and health professionals, • offenders’ situations should not have to escalate for them to rather than the usual adversarial approach; become eligible for the expanded opportunities offered by a • the offender can be linked with relevant treatment options drug court; rather, they should be eligible for assistance with using existing service arrangements, and with other services their drug problem earlier in their offending history. The needed; Committee shares the view expressed by many practitioners in • there is intense supervision, and the magistrate retains a role in the field, and a number of magistrates, that at least as many overseeing the progress of the offender, who returns to court at resources should be available during the early stages of regular intervals; and offending when the impact of interventions appears most likely • sentencing is either suspended (as in the NSW and Queensland to be beneficial. models) or deferred (as in the South Australian pilot). The Committee believes the expansion of CREDIT will go some The Committee understands that those who make the case for way to addressing the needs of drug offenders, but that additional specialist drug courts believe they will provide opportunities to: responses still need to be put in place. To improve the Court’s • provide more options than currently exist at the sentencing ability to respond to those offenders with drug problems, there stage; needs to be a way of combining the imperatives of the criminal • ensure a drug-dependent offender is sentenced as soon as justice system (such as a magistrate’s ability to determine possible after apprehension and on entering a guilty plea, and conditions associated with sentencing), with treatment service is provided with drug treatment and rehabilitation services as provision and access to other services. soon as possible; • provide continuity of supervision of an offender’s drug treatment and rehabilitation programs; • avoid imprisonment and sentence escalation for an offender; and • enable productive working relationships to develop between those from the justice, health and welfare sectors.

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Such an enhanced court response will require: 7.4 Corrections • an understanding, across the magistracy of drug issues in 7.4.1 Introduction relation to patterns of use and impacts. The Committee believes this can be achieved over time with a comprehensive The Committee is impressed by the distance travelled by judicial education program. The need for such a program, in government and non-government agencies in this field since the light of the changing profile of offenders and the nature of the PDAC report in 1996, particularly in the face of a growing offender drug problem, has been raised as an issue that needs to be population. It has also been encouraged by the approach taken implemented as a priority, irrespective of all other decisions in by the Office of the Correctional Services Commissioner (OCSC) relation to a court drug response. Such education must deal and the Department of Justice in accepting drug use as a with the specific issues which arise in relation to drug use in problem area that challenges all parties and must not be particular cultural and linguistically diverse communities; marginalised. The key initiatives proposed as part of the Draft • a means by which magistrates can obtain sound assessment Corrections Drug Strategy for 2001-2003 (outlined below) offer an of the treatment and other needs of offenders coming before important way forward in dealing with this difficult problem. them, as well as advice on the most appropriate treatment Nevertheless, the Committee would wish to draw the options; Government’s attention to certain matters. • a greater range of sentencing options to be available to 7.4.2 Management of drug and alcohol affected magistrates. Suspended sentencing (where the magistrate can persons in police custody determine conditions to apply to the offender), and deferred Holding cells sentencing for those aged over 25, are options that enable the As noted earlier, Victoria’s prisons are currently overcrowded. magistrate’s authority to be effectively applied. The Committee According to the OCSC, the lack of beds has resulted in prisoners believes these options warrant serious consideration as part of being held for longer periods than normal in the Melbourne the sentencing review that has recently been commissioned by Assessment Prison while awaiting transfer to other prisons. This, the Government; in turn, has meant that prisoners, remanded and sentenced, are • an improvement in community corrections services to increase spending longer than usual in police holding cells while awaiting the effectiveness of orders and reduce the rates of breach so transfer to correctional facilities. magistrates can have confidence in this sentencing option. The Committee notes that this issue has already been identified by The Committee has been advised that the average ‘long stay’ in a the Government and that a review of Community Correctional holding cell is presently two weeks. Some remanded or recently Services is to be completed shortly; sentenced prisoners have remained in holding cells for up to a • the maintenance of arrangements for prompt access to month, and occasionally prisoners may remain for up to eight treatment, such as those organised under the CREDIT weeks. It is clear that this is far from ideal for all concerned: police scheme; and cells are not designed for long-term stays, nor are members of the • the facility for the offender’s other needs to be assessed police service correctional officers. concurrently so other services can be accessed or referrals Concerns have been expressed to the Committee about the effect made as required. of this situation on many prisoners who are alcohol or drug In chapter 2, the Committee outlined criminal justice objectives in affected, or have associated drug problems. The Committee has relation to drug problems . These included the goals of: been advised of the following drug-related health problems • imposing sanctions with treatment conditions, where resulting from the current accommodation situation: appropriate, on offenders; and • detoxification occurring outside the context of an ongoing • maximising the treatment and rehabilitation of offenders while treatment management plan; under sentence. • delay in starting long-term therapeutic interventions; • stress caused to nicotine-addicted prisoners unable to smoke The Committee believes a court response which incorporates the in holding cells, as would be permitted in a prison; elements outlined above represents the best possible way to • heightened health management risks resulting from: achieve these two crucial goals. Such elements will also go a long - prisoners being housed in both ‘A’ and ‘B’ category holding way toward achieving the successful reintegration of offenders cells, the latter having fewer facilities and less experienced into the community, which is clearly in the best interests of all. staff; - lack of continuity of prisoners’ medical records between Victoria Police and correctional services; and - lack of effective infection control.

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Women prisoners face particular problems. The Committee was The Government has recognised there is a crisis in prison advised that women faced social isolation and limited access to accommodation and has responded by committing funds for an exercise space because there are usually comparatively few extra 357 beds across the system; however, this will only relieve women prisoners, and they need to be separated from male current overcrowding. Future projections of Victoria’s prison prisoners. In an attempt to alleviate this problem, certain police population commissioned by the OCSC indicate the prison holding cells have been nominated as ‘women only’ so women population will increase by 17 per cent by 2005. Nonetheless, prisoners’ needs in terms of staffing and management can be more rapid movement through the system is required to: better met. • reduce the number of prisoners held for long periods in police Concern was also expressed by criminal justice professionals that holding cells; drug-dependent people appeared in the Magistrates’ Court • reduce the resulting physical and mental stress on police and suffering the effects of detoxification and related physical frailty. prisoners; and There was disquiet that this might potentially compromise these • enable appropriate post-detoxification and drug treatment prisoners’ ability to fully understand the gravity of their offence, regimes to commence earlier for those prisoners with drug and give satisfactory instructions to counsel. problems. The Custodial Medicine Unit (CMU), based in the General Policing The Committee considers the expansion of diversion programs Department of Victoria Police, is responsible for providing clinical discussed earlier in the chapter will provide an important services to those in police custody. The unit includes the Custodial opportunity to reduce the number of drug-dependent people Nursing Service. The CMU advised the Committee that its clinical entering the criminal justice and corrections system, and to divert focus is on immediate health needs, patient safety and symptom them to pathways of treatment and rehabilitation. Other pilot management. This is because the CMU has limited time to spend programs, such as home detention, may also reduce the number with patients, has little control over prisoner movements, and of offenders being sent to prison. because the doctor-patient relationship is quite different to any The Committee wishes to take this opportunity to sound a note of normal clinical relationship. As a result, setting long-term warning about the possibility of home detention as an option for management goals for prisoners’ health and establishing new those convicted of drug-related offences. Having the chance to regimes was felt to be unrealistic and inappropriate. The CMU maintain a stable home life and a job can obviously benefit provides police with a medical checklist to screen for health prisoners, and family support for those undergoing drug treatment problems before people are placed in custody. The police is important. However, the implications for a family living with themselves are governed in their prisoner management by someone trying to manage a drug use problem must be given chapters 10 and 12 of the Police Procedures Manual. careful consideration during the pilot stage of the program. It may Detoxification while in police custody be that although there are advantages to the offender, these come at the cost of severe distress or upheaval to family members. The Committee was advised by the CMU that involuntary detoxification of opiate-dependent prisoners in police custody In addition, given the significant number of offenders who are rarely led to serious or life-threatening health consequences homeless or have no family, caution is advised with respect to the unless other conditions were involved. In contrast, alcohol- possibly discriminatory implications of such interventions. As well, dependent prisoners usually faced much more serious health the temptation to regard home detention as a more cost-effective problems as a result of involuntary withdrawal. The CMU advised alternative to imprisonment may result in sentencing decisions that anyone with an acute health problem (such as alcohol that are not in the best interests of the offender, the community or withdrawal), or who was experiencing opiate detoxification the family. alongside other conditions (such as hepatitis), or who had a high A further, longer term initiative that may contribute to improved health risk (such as a pregnant prisoner on a methadone prisoner care is the establishment of a single electronic file for program), would be moved to a hospital, the Melbourne each person in the criminal justice system from entry to exit. As Assessment Prison or the Melbourne Custodial Centre. part of the Department of Justice’s Criminal Justice Enhancement It was clear that CMU policy is that irrespective of whether a Program and planned for roll-out toward the end of 2001, the person who is undergoing alcohol withdrawal or opiate Accused Management Project is designed to enable consistent detoxification in prison rather than elsewhere, clinical care should and timely health, critical care and other prisoner information to be not be compromised. This includes appropriate symptom collected, shared and acted upon. This should enable better management and relief. continuity of medical record-keeping between police and Corrections, which was identified to the Committee as a current problem affecting the management of prisoners’ health.

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However in the meantime, attention must be given to ensuring 7.4.3 Community corrections there is continuity of care for offenders across the criminal justice Community corrections sentencing options should offer offenders system, particularly when offenders are transferred from police an opportunity to repay their debt to society in a manner that custody to the correctional system. The Committee believes, as a benefits both themselves and the community, and to receive the priority, steps should now be taken to establish a system to support they need to be able to return to a stable and law-abiding enable health records to travel with prisoners to ensure continuity life. Given the chaotic lifestyle of many offenders with drug-related of record-keeping and care. problems, community corrections orders also present a serious The Committee would also encourage the development of challenge to those who must ensure the orders are carried out. creative clinical initiatives such as a possible trial of nicotine Community orders replacement therapies for prisoners in police custody, outlined by Structural problems, such as insufficient funding, high turnover of the CMU. Community Correctional Services (CCS) staff and their heavy The Committee would like to comment on a proposal, put to it workload (approximately 25 to 40 cases for each officer, with during its consultation program, to create a secure detoxification some having up to 60 cases) inhibit proper case management of facility that would house drug-dependent remand prisoners for up offenders undertaking community orders and increase the to 21 days. It was suggested that such a facility would provide post- likelihood that they will breach their orders. The breach rate for withdrawal treatment, counselling and advice that are currently Intensive Correction Orders (ICOs) was 38 per cent in 1999-2000, unavailable in the police cells and at other remand facilities. and the breach rate for Fine Default Orders and Community The Committee appreciates the concerns that have prompted Based Orders (CBOs) (community work only order) was 23 per such a proposal; however, it is mindful that ways to meet the cent.39 CCS officers have a degree of discretion in handling health needs of opiate-dependent prisoners must be weighed breaches.40 Nevertheless, if an offender who is subject to an ICO against the resource implications of various options. In preference breaches the order by committing a further offence (even if of a to the creation of any particular facility, the Committee is of the relatively trivial nature), the breach will result in imprisonment view that there should be concentrated efforts put in to ensuring: unless there are exceptional circumstances. • standards of care set by the CMU and that police policies are Breach of a CBO will not necessarily result in imprisonment; scrupulously adhered to; however, the courts have made it clear that, in many cases, the • prisoners are moved out of holding cells as quickly as breach of the order will point to the conclusion that ‘the original possible; and leniency was not justified in the circumstances’.41 Courts have • there is an increased examination of the health and support frequently emphasised the need to maintain the legitimacy of non- needs of drug-affected prisoners in holding cells and the custodial orders in the public mind by dealing with breaches Melbourne Custodial Centre. swiftly and severely. In summary, the Committee is concerned to ensure that such The Committee has serious concerns that the imposition of a non- prisoners generally, and those going through opiate and alcohol custodial order with onerous conditions, but limited support or withdrawal specifically, are cared for by those responsible for supervision, on a chaotic, drug-dependent offender with a history them. The Committee recognises the work being done by the of prior offences is simply setting the offender up to fail and, CMU and supports its current proposal for staffing increases ultimately, end up in prison. during those times of high demand for its services. The day-to- Such problems are currently being examined as part of a review day responsibility for many drug- and alcohol-affected people of Community Correctional Services commissioned by the currently rests with the police, and however uncomfortably this Department of Justice. A paper was prepared in September 2000 responsibility sits, it must be diligently discharged. Implementation that raised the following issues: of the relevant sections of the Police Procedures Manual • the CCS workforce may need to become more mobile and concerning the care and treatment of prisoners, and scrutiny of more offender-focused, and have its skill levels, qualifications that implementation, is critical. The Committee is encouraged by and experience enhanced through personnel audits, the advice that audit teams are used to ensure implementation of professional development, and the development of a targeted the policy, but continued monitoring of health standards in recruitment strategy and the availability of career paths; prisoners’ accommodation is required to ensure that satisfactory services are being provided.

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• reductions in breaches and improvements in offender Current situation management may require: Currently, the issue of drugs in prison is managed through the - a more accurate assessment tool for offenders to determine Victorian Prison Drug Strategy developed in 1992. Its key needs and risk of re-offending; objectives are to reduce the: - enhanced case management, including more intensive • demand for drugs through deterrence programs and treatment management of high-risk offenders; initiatives; and - better liaison between CCS officers and prison officers to • supply of drugs through effective detection processes. improve case planning and transition; Identified drug user (IDU) status is imposed on prisoners found - improved ratios of case managers to offenders; guilty of committing a prison drug offence (including use of - satisfactory matches to be made between offenders and alcohol or a drug of dependence in prison), possessing support programs; instruments to use, presenting a positive urinalysis, or refusing or - performance management and evaluation of services; interfering with a urinalysis test. The process is a three-tiered one • some stakeholders identified a need for greater discretion on with increasing levels of punishment that include loss of contact breach management, with the possible establishment of a visits. IDU prisoners are required to complete certain treatment Breach Review Tribunal to determine whether a particular programs and undergo regular urinalysis to clear their status. breach justifies a return to court; and • anecdotal evidence suggested offenders with alcohol and drug A range of drug treatment programs is provided within prisons. problems may struggle more to cope with order conditions. These include drug awareness, drug education, relapse prevention, alternate therapies, intensive residential treatment (at The paper also put forward a range of possible alternative Fulham Correctional Centre, Bendigo Prison and the Metropolitan sentencing options for discussion. Women’s Correctional Centre) and individually tailored programs Community corrections has become the principal field of that are equivalent to intensive treatment for prisoners otherwise correctional justice. For many offenders with drug-related without access to these programs.42 problems, it presents a major opportunity for constructive Issues interventions. A successful and dynamic community corrections sector would have a major impact on the quality of outcomes for A number of problems have been identified with the Prison Drug people who have become involved in the criminal justice system. Strategy and it is currently under review by the OCSC. However, on the basis of consistent reports in the Committee’s One problem brought to the Committee’s attention is the consultations, it appears that resource limitations are so great that considerable disruption faced by prisoners during their sentences little is being done that is effective. CCS officers are able to do due to serial relocation within and between institutions. The little more than keep in touch with offenders, let alone provide Committee recognises this occurs for a variety of prison and drug-related monitoring, counselling, service and referral. prisoner management reasons, especially those associated with Accordingly, the Committee urges that, as a matter of priority, classifications of prisoners. resourcing of the Community Correctional Services be attended to However, the Committee notes that: with special reference to the skills needed by staff to meet the • it is a particularly counterproductive experience for offenders supervisory, counselling and supportive needs of offenders with who lead chaotic lifestyles while in the community, and for drug-related problems. whom the prison environment offers the potential for 7.4.4 Prison experiencing a more settled and orderly existence; • it interferes with treatment. Often prisoners do not complete While prison is the last resort of the justice system, and should programs, or repeat them in another location, or cannot retain that status, it nevertheless represents an opportunity for complete programs begun in one location because they are treatment and training, especially for offenders resistant to other not offered in another. Any stable relationships established modes of intervention. Consequently, the Committee is concerned between offenders and treatment providers are also inevitably to ensure that satisfactory treatment, rehabilitative and disrupted; reintegration programs are made available to prisoners, and that • prisoners’ records do not travel consistently around the system any obstacles to achieving that goal are identified and removed. with them. This results in problems for continuity of care and treatment; and • prisoners often are assessed many times within a relatively short period. This has counterproductive effects on their attitude to treatment and is, consequently, a waste of resources.

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Other problems involve: The housing, welfare, mental health, child protection and drug • restriction of types of treatment currently available (in particular, treatment services sectors working together in a formalised post- lack of initiation of and ongoing maintenance of existing release setting would greatly enhance the recently released methadone treatment programs); person’s chances of maintaining treatment gains made while in • the lack of differentiation between drugs in terms of sanctions the correction setting. Such services also need to be sensitive to applied. For example, cannabis can be detected in the body prisoner needs. Some prisoners may not want have anything to for a much longer period than opiates, and prisoners have do with services that have a prison or corrections flavour, so reportedly switched to harder drugs to minimise the risk of programs will need to be flexible and prepared to work to earn the detection; trust of former offenders. • shared and improvised drug-taking equipment. Without access Initiatives to clean equipment, prisoners resort to making their own The Committee is encouraged by the moves made by the rudimentary, and dangerous, injecting equipment. The Government and the OCSC toward remedying the problems difficulties in securing this equipment mean it is shared among identified above. It is now government policy for the current prisoners, thus increasing the risk of the spread of infectious methadone program to be expanded to ensure all prisoners have disease; the option to start, or to continue, a methadone program once in • a lack of recognition of, and allowance for, the chronic and prison or prior to release. The Correctional Services Commissioner relapsing nature of drug dependency, despite relapse being a has approved this initiative, and full implementation across all common occurrence during rehabilitation. For example, a facilities should occur by the end of 2002. positive test when completing one of the special treatment programs can result in being removed from the program; The Government has also now announced funding for a suite of • a lack of evaluation of the effectiveness of prison treatment pre- and post-release support programs. These include the New programs, and the need to follow up prisoners after their Horizons Program for male prisoners aged under 30 with major release to determine the value of programs for different types drug misuse problems; programs targeting women, young of prisoners; offenders, Vietnamese and Cambodian offenders, and older • heavy reliance on sanctions with few incentives with the result offenders with long-term drug abuse and imprisonment histories; that, for some prisoners, there is little incentive not to use and residential community-based pre-release facilities. drugs. In addition, treatment programs can be stigmatised and The Committee applauds these moves. provide less incentive for those without IDU status to undertake The OCSC has now proposed a number of other major initiatives. them; and These are designed to deal with the problems already raised by the • removal of contact visits, which can form an important part of Committee and others identified in the OCSC review. They include: the rehabilitation process, and may result in the severing of • development and implementation of an actuarial based important links that would help the prisoner’s transition back risk/needs assessment tool to help target high- to medium-risk into the community. offender, and to help develop appropriate treatment plans; The Committee is also concerned about the current lack of • improved information transmission between drug and health adequate post-release support options. The transition from prison services, and sentencing and classification authorities, to bring to the community is a time of potential danger for released about enhanced case-planning and management. Proposals prisoners who have undergone treatment for drug-related include standardised treatment plans and discharge problems, or who still have problems. The phenomenon of summaries, moves to information technology-based treatment prisoners overdosing in the immediate post-release phase, case plans and monitoring processes, and the development of whether through the desire to ‘celebrate’ their release or because treatment and post-release outcome indicators; they feel they have no other options but to return to their previous • harm reduction strategies (for those who do not wish to cease way of living, is alarming. The Committee has learnt it is a use of drugs in prison but are considering using those drugs particular risk for women. more safely in prison and after release) to reduce the The need for linkages with, and support from, a range of other transmission of blood-borne disease and the risk of overdose; service sectors is important for those leaving prison. These also • treatment services specifically designed for young prisoners need to be coupled with post-release plans. Parole provides some (aged 18-25); and level of supervised entry back into the community. However, with • development of a research agenda and evaluation framework only 11 per cent of prisoners being paroled on leaving custody, (10 to 20 per cent of correctional drug services budget to be there are support gaps that urgently need to be filled. A return to allocated) to enable systematic evaluation of programs and an unstable accommodation environment, coupled with other evidence-driven policy development. problems such as income and family instability, can lead to the loss of treatment gains.

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The OCSC proposals also call for an increase in the capacity of 7.5 Law reform intensive drug treatment services to meet anticipated demand, 7.5.1 Repeal of section 75 of the Drugs Poisons and for development of a more substantial leadership and and Controlled Substances Act 1981 management capacity.43 The Committee is conscious of the fact that the safe disposal of In addition, the OCSC has also raised the need to balance needles and syringes is a matter of significant community prevention and treatment in prison in line with harm minimisation concern. In addressing this, it must be borne in mind that, while principles and practices and public health considerations, and to there are up to 6 million needles and syringes sold or distributed recognise the implications of drug-induced psychosis in an in Victoria each year, most of these are disposed of safely. offender population with high levels of mental illness. A study by the Department of Human Services in 1996 revealed The Committee strongly supports the proposals made by the that 95 per cent of respondents usually disposed of their needles OCSC. A new approach to drug strategy in prisons is clearly and syringes safely in accordance with recommended methods. needed, and the Committee is encouraged that not just programs The most common method of disposal was to return the used but the evaluation of programs and individual outcomes are now equipment to a needle and syringe outlet. This method being proposed. The Committee also supports the following accounted for almost half of all needles and syringes distributed. principles as those that must underpin any such strategy: Other commonly used methods included placing the needle in a • treatment and harm minimisation practices should be of the disposal container or a public disposal unit.44 same quality on either side of the prison wall; • transition from prison to the community is a particularly critical A more recent study, carried out on behalf of the City of point in a drug-using offender’s life and should be prepared for Melbourne, indicates that used syringes found lying on the ground and phased in appropriately; and that were collected as part of the community syringe disposal • there must be evaluation of the long-term impacts of prison program represent a small proportion of the syringes distributed in 45 drug treatment for offenders post-release. the city. Combined Custody and Treatment Orders Nevertheless, even though only a small proportion of all syringes distributed in Victoria are disposed of unsafely, the proportion A Combined Custody and Treatment Order (CCTO) may be which are disposed of in this way, remains a significant matter imposed if a custodial sentence of no more than 12 months is of concern. warranted for an alcohol- or drug-related offence. A minimum six- 46 47 month term must be served in custody and up to six months in the Studies of drug users in Victoria and New South Wales indicate community on the conditions specified. It is clear that court officers that many drug users dispose of their needles and syringes as do not favour this option. The principal problem appears to be the quickly as possibly after injecting (rather than taking time to length of the sentence which must be served in custody prior to dispose of them safely) because they are afraid that, if they are becoming eligible for drug treatment. The Committee supports the intercepted by police while carrying a needle or syringe, they proposals raised in the issues paper (referred to above) that would could be searched, questioned and possibly charged with use of decrease the offender’s time in prison, extend the amount of time a drug of dependence. in the community and on the order, and thereby make treatment From a community perspective, this fear would be desirable if it available at an earlier point in the sentence. had the effect of deterring drug use and encouraging drug users 7.4.5 Juvenile Justice to seek treatment. The Committee is aware of little evidence that strongly supports this hypothesis. Indeed, the available evidence The key treatment issues for clients of the Juvenile Justice system suggests the rate of arrest for heroin use or possession exerts have been dealt with in chapter 6. The Committee would wish to little, if any, effect on the rate at which heroin users seek add here that the Government should ensure that the principles treatment.48 (outlined above), that it believes must underpin the new and proposed initiatives in the adult corrections system, are also Moreover, the benefit of any such deterrent effect must be applied to the youth corrections system. Too often Juvenile Justice balanced against other detrimental effects of the fear of being clients become adult prisoners. A commitment to such principles, charged with use of a drug of dependence. Two key detrimental and action based upon them, may offer a significant way to effects are the possibility that: prevent that tragic graduation. • used needles and syringes will be discarded unsafely. This places members of the community at risk of needle-stick injury; and • drug overdoses will not be reported. For instance, if several drug users are injecting together and one suffers an overdose, the fear of being searched, questioned or arrested can make the others reluctant to call for assistance.

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Under existing Victorian law, if a person obtains an illegal drug for While the policy prevents people entering or leaving needle and personal use and he or she is apprehended by the police while in syringe outlets from being targeted by police, it does not directly possession of the drug but before using it, he or she can be address the issue of the disposal of needles and syringes questioned, arrested and searched. The drug can be seized and immediately after use. the person charged with possession. The seized drug would Overdoses provide evidence to support the charge. Under the policy on overdoses adopted by Victoria Police, when If the person is apprehended at the time of or after using a drug, members of the service attend a non-fatal overdose, before the police can question, arrest and search the person if his or her pursuing any investigation for offences of use or possession, they behaviour leads the police to reasonably believe that the person are required to consider whether such action is in the best has used a drug. The police observations regarding the person’s interests of the community. In doing so, they are required to demeanour and behaviour would provide direct evidence of the consider each incident on its individual circumstances. The policy offence; however, in the absence of an admission by the person, it indicates that, on most occasions, it may be in the greater public would be unlikely to result in a conviction without other supporting interest to overlook minor drug charges as this may have the evidence. It is in this context that circumstantial evidence, such as effect of removing fear of prosecution and encouraging people the possession of a needle and syringe, would be significant. present to call an ambulance without delay.50 It is clear that any person who feels that he or she is likely to These two policies are a welcome measure on the part of Victoria attract police attention soon after injecting (for instance, if the Police. Nevertheless, because of their role as enforcers of the law, person injects in a public place, such as a lane or public toilet police are constrained from going further to fully address the rather than at home) is likely to attempt to dispose of any concerns outlined above. circumstantial evidence as soon as possible, and have very little The Committee considers that those concerns can only be fully incentive to hold on to the needle and syringe until they can be addressed if section 75 of the Drugs Poisons and Controlled disposed of properly. Substances Act 1981 is repealed. Equally, any person who has taken heroin, or any other illegal Section 75 makes it an offence to use a drug of dependence. drug, will be reluctant to attract attention to himself or herself by Repeal of section 75 would not ‘decriminalise’ drugs of seeking assistance in the event of an overdose or other medical dependence because it would still be an offence to possess a problem unless it is absolutely necessary to do so. drug, even if the drug was possessed for the purpose of personal Victoria Police has acknowledged these concerns and has use. Repealing section 75 would mean that once a person has adopted policies to address them. administered the drug (whether by injection, inhalation, ingestion, Needles and syringes or so on), he or she is no longer committing an offence and will The policy adopted by Victoria Police regarding the Needle and not be deterred from safely disposing of equipment such as Syringe Program notes that the purposes of the program include syringes, or from seeking help if he or she encounters medical reducing the spread of blood-borne viruses in the community, and difficulties. providing a safe means to dispose of needles and syringes. The The repeal of section 75 would bring Victoria into line with other policy indicates that people should not be searched simply jurisdictions (both in Australia51 and overseas52) in which because they are entering or leaving a needle and syringe outlet. possession for personal use is an offence, but use itself is not. It goes on to indicate that it is not an offence to possess a needle How often is section 75 used? or syringe, and that members may only seize such equipment Section 75 offences (use) are relied on much less frequently than when it forms part of an offence.49 section 73 (possession) but are still significant. The relevant figures are set out in the table below.

Table 7.3: Consumption offences: offenders processed by Victoria Police (principal drug offence)

Use (s. 75) Possession (s.73) Total consumption offences 1996 - 97 2,791 (29%) 6,687 (71%) 9,478 (100%) 1997 - 98 3,151 (30%) 7,205 (70%) 10,356 (100%) 1998 - 99 3,604 (30%) 8,300 (70%) 11,904 (100%)

Source: Victoria Police LEAP database.

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As indicated earlier, the repeal of section 75 would not result in the 7.5.2 Cannabis law reform ‘decriminalisation’ of drugs. Any harm minimisation initiative that Use and possession seeks to pragmatically and realistically address the very difficult The available evidence indicates that cannabis is widely used in issues that drugs pose for our community is liable to be criticised Victoria. A survey in 1998 indicated that 35 per cent of Victorians for ‘sending out a message that drug use is OK’. The Committee had tried cannabis at some stage (as opposed to 28 per cent in considers that the question of messages to the community should 1995). This is very similar to the national rate in 1998 of 34 per be addressed through appropriate information and education cent.53 More detailed data on the use of cannabis are provided in programs, and that generalised concerns about messages should chapter 3. not prevent the adoption of measures that are likely to have significant public health benefits. Evaluations of the existing harm This use occurs despite the fact that, aside from very limited minimisation initiatives adopted in Victoria such as the needle and exceptions, the use, possession, cultivation and sale of cannabis syringe program, the Victoria Police policy on overdoses and the is prohibited in Victoria. The relevant maximum penalties are set various drug diversion programs, have been very positive. out below. The Committee believes that repeal of section 75 would have benefits for both users and the community without providing incentives for drug use.

Table 7.4: Canabis offences and maximum penalties

Offence Maximum penalty

Use of cannabis $500 fine

Possession of cannabis

• Small amount (no more than 50 gm) and not related $500 fine • to trafficking

• More than small amount, but the court is not satisfied that $3,000 fine and/or 1 year imprisonment • the possession related to trafficking

• If the court is not satisfied that the amount was not $40,000 fine and/or 5 years imprisonment • possessed for a purpose relating to trafficking

Trafficking in cannabis $100,000 fine and/or 15 years imprisonment

Trafficking to a child $240,000 fine and/or 20 years imprisonment

Trafficking in a commercial quantity (100 plants or 25 $250,000 and 25 years imprisonment kilograms)

Cultivation of cannabis

• Not related to trafficking $2,000 fine and/or 1 year imprisonment

• Related to trafficking $100,000 fine and/or 15 years imprisonment

• Related to trafficking in a commercial quantity $250,000 fine and 25 years imprisonment

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In 1996, PDAC recommended that the use and possession of a In considering the PDAC recommendation anew, the Government small quantity of cannabis no longer be an offence. The would also need to consider the effect of the international drug recommendation was based on PDAC’s observation that treaties to which Australia is a party. Those treaties do not directly cannabis use is widespread in our community and that strategies bind the Victorian Government nor the Victorian Parliament. to reduce use and misuse are most likely to be effective if the use Nevertheless, the Commonwealth Government is obliged to of cannabis is no longer a criminal offence but is regulated in ensure that Australia’s domestic laws are consistent with those other ways. treaties. If a Victorian law is inconsistent with a treaty obligation, Although this recommendation was not adopted, Victoria Police the Commonwealth Parliament may pass legislation to override 54 did initiate the Cannabis Cautioning Program, which is aimed a the Victorian law. diverting cannabis users from the criminal justice system. Since The Committee notes that there are diverging legal opinions as to the program was adopted throughout Victoria in 1998, the precise scope of Australia’s obligations under the relevant approximately 2,000 cannabis cautioning notices have been international treaties, and that it is beyond the ambit of this report issued each year. to examine the legal arguments in detail. The Committee considers The Committee welcomes the adoption of diversionary initiatives that care would need to be taken to ensure that any relaxation of such as the Cannabis Cautioning Program. Nevertheless, it must prohibition of use and possession of cannabis was not be remembered that the use and possession of cannabis remains incompatible with Australia’s obligations under international law. an offence in Victoria. The Cannabis Cautioning Program does not Medical use of cannabis apply to people who have previously been found guilty of a drug The Committee is aware of the renewed interest worldwide in the offence, or who have already received more than one caution possible therapeutic role of cannabinoids. The limited scientific notice. Despite the program, a significant number of such people evidence that is available indicates there are a number of areas continue to be arrested, charged and sentenced in relation to their where there may be some basis to the anecdotal claims for personal consumption of cannabis. therapeutic benefit. These include: The use of cannabis can carry substantial personal and public • weight loss and other symptoms associated with HIV/AIDS; health risks, as does the use of other drugs such as tobacco and • neurological disorders including multiple sclerosis; alcohol. As discussed elsewhere in this report, it is essential that • nausea and vomiting associated with chemotherapy; the public is properly informed of those risks, and that people who • glaucoma; and become dependent on cannabis are appropriately treated. • chronic pain. It is the Committee’s view that there has been no evidence since The cannabis plant and its derivatives are now approved for the PDAC report in 1996 that would lead it to do otherwise than medical use in treating conditions in several States in the US. concur with PDAC’s recommendation on decriminalisation. There is also interest in clinical trials and use by prescription in a PDAC’s careful consideration of all the legal issues relating to the number of countries. A House of Lords Select Committee inquired use of cannabis remain, in the Committee’s opinion, valid. into the matter in 1998 and concluded: Nonetheless, the Committee echoes the community’s concern at There is not enough rigorous scientific evidence to prove the possible link between cannabis use and psychiatric illness, conclusively that cannabis itself has, or indeed has not, and believes preventative strategies aimed at dealing with medical value of any kind. Nevertheless we have received cannabis use should be implemented as a matter of urgency. enough anecdotal evidence ... to convince us that cannabis Once the recommended preventive strategies have been almost certainly does have genuine medical applications, implemented, the Government should revisit the PDAC especially in treating the painful muscular spasms and other recommendation and consider changing the legal status of symptoms of MS and in the control of other forms of pain.55 cannabis in relation to possession and use of small quantities of The Select Committee recommended that UK doctors be allowed cannabis products. to prescribe cannabis for medical use.56 Clinical trials are now As stated in chapter 1, domestic cultivation of a small number of under way. plants should, at that time, be permitted in order to take the trade In the long term, overseas clinical trials will provide evidence as to out of criminal hands and reduce the market for cultivation of the application of cannabis products for medical purposes. The more potent forms of marijuana by those engaged in trafficking. Committee does not believe that the scientific evidence available This should be accompanied by explicit penalties for use of at this time is such that it can make a recommendation regarding cannabis in public places, and by people driving, or operating any change in the law relating to the use of cannabis for equipment in the workplace. therapeutic purposes, but it is of the view that the current trials should be closely monitored.

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In these circumstances, it is important that the community and, in Endnotes particular, Victoria Police, are aware of the current interest in

cannabis’ apparent therapeutic benefits, and that they use their 1 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug Report discretion regarding prosecution in cases where an individual is 1998-99, Commonwealth of Australia: Canberra, table 3.2, p. 40 and p. 41. using cannabis for purposes related to a serious or terminal health 2 Department of Justice Submission to the Drug Policy Expert Committee, condition. The Committee believes the Department of Human August 2000. Services should monitor the international research, and provide 3 Office of the Correctional Services Commissioner. (2000) Statistical Profile: The Victorian Prison System 1995-96 to 1998-99, OCSC: Melbourne, table advice to Victoria Police in any areas of uncertainty. 1, p. 8. 7.5.3 Alcoholics and Drug-dependent Persons 4 Department of Justice Submission to the Drug Policy Expert Committee, Act 1968 August 2000. 5 Ibid. In considering laws relevant to drug policy, the Committee briefly 6 Ibid. draws the Government’s attention to the Alcoholics and Drug- 7 Victoria Police. (2000) Policy Guidelines for the Establishment and dependent Persons Act 1968. This Act, which came into operation Maintenance of Local Safety Committees Under Local Priority Policing, p. 1. in 1976, deals principally with the provision of treatment services, 8 Ibid, p. 3. providing some level of regulation and registration of service 9 Australasian Centre for Policing Research. (2000) “The role of police in providers, and with voluntary and involuntary attendance at reducing harmful illicit drug use practices”, a discussion paper for the Drug assessment and treatment centres. Policy Subcommittee of the Conferences of Commissioners of Police of Australasia and the South West Pacific Region, October 2000 Parliamentary debate on the most recent changes to the (unpublished), p. 2. legislation in 1994 acknowledged difficulties in its interpretation 10 National Institute on Drug Abuse. (1999) Principles of Drug Addiction and operation, and flagged the need for an extensive review.57 In Treatment: A Research Based Guide, National Institutes of Health Publication No 99-4180, NIH: Bethesda, p. 9. (Online: key respects, the Act reflects an attitude to drug treatment at odds http://athealth.com/practitioner/ceduc/PODAT.html Accessed: 01/11/2000.) with accepted contemporary responses. It is now effectively 11 Fitzgerald, J.L., Broad, S., and Dare, A. (1999) Regulating the Street Heroin superseded, and very limited use is made of its provisions. Market in Fitzroy/Collingwood, The University of Melbourne: Parkville, p. 81. Therefore, the Committee recommends that the Act now be 12 Maher, L., and Dixon, D. (1999) “Policing and Public Health: Law Enforcement and Harm Minimisation in a Street-level Drug Market”, British reviewed, with a view to consideration as to whether it should Journal of Criminology, Vol. 39, No. 4, Autumn, pp. 488-512 at pp. 497 and remain on the statute books. 500. 13 Ibid, p. 505. 7.6 Conclusion 14 Fitzgerald, J.L., Broad S., and Dare, A. (1999) Regulating the Street Heroin The various sections of the law enforcement and criminal justice Market in Fitzroy/Collingwood, The University of Melbourne: Parkville, p. 81. system are strongly interlinked, so that changes in policing, for 15 Weatherburn, D., and Lind, B. (1995) Drug Law Enforcement Policy and Its Impact on the Heroin Market, NSW Bureau of Crime Statistics and example, can have profound effects on both the courts and the Research: Sydney. correctional system. The Committee has noted the impacts on the 16 Ibid, pp. 35-37. law enforcement and criminal justice system as a result of the 17 Keelty, M. (1999) “Operation Linnet and its Implications for Law increase in drug-related crime in recent years, as well as the many Enforcement”, paper delivered at the Australasian Drug Strategy initiatives launched in the different sectors of the system to Conference, Adelaide, April 1999. respond. Although the Committee applauds these attempts to 18 Weatherburn, D., and Lind, B. (1997) “The Impact of Law Enforcement Activity on a Heroin Market”, Addiction, Vol. 92, No.5, pp. 557-569. meet the challenges arising from the drug problem, it believes that 19 Australasian Centre for Policing Research. (2000) “The role of police in current as well as future initiatives must be clearly framed in a reducing harmful illicit drug use practices”, a discussion paper for the Drug harm minimisation context, and that any change must be carefully Policy Subcommittee of the Conferences of Commissioners of Police of informed by consideration of its impacts on the law enforcement Australasia and the South West Pacific Region, October 2000 (unpublished), p. 2. and criminal justice system as a whole. 20 Weatherburn, D., Lind, B., and Forsythe, L. (1999). Drug Law Enforcement: Its Effect on Treatment Experience and Injection Practices, NSW Bureau of Crime Statistics and Research: Sydney, p. vi. 21 Weatherburn, D. (2000) “Performance Indicators for Drug Law Enforcement”, Crime and Justice Bulletin, NSW Bureau of Crime Statistics and Research: Sydney, No 48, February. 22 Fowler, G., Allsop, S., Melville, D., and Wilkinson, C. (1999) Drug Harm Minimisation Education for Police in Australia, National Drug Strategy Monograph Series No. 41, Commonwealth of Australia: Canberra, pp. 55-56. 23 Discussed in Australasian Centre for Policing Research. (2000) “The role of police in reducing harmful illicit drug use practices”, a discussion paper for the Drug Policy Subcommittee of the Conferences of Commissioners of Police of Australasia and the South West Pacific Region, October 2000 (unpublished), p. 6.

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24 Australian Bureau of Criminal Intelligence. (2000) Australian Illicit Drug 47 Maher, L., and Dixon, D. (1999) “Law Enforcement and Harm Minimisation Report 1998-99, Commonwealth of Australia: Canberra, table 3.2, p. 40 and in a Street-level Drug Market”, British Journal of Criminology, Vol. 39 No. 4 p. 41; Australian Bureau of Criminal Intelligence. (1999) Australian Illicit Drug Autumn, pp. 488-512. Report 1997-98, Commonwealth of Australia: Canberra, table 3.2, p. 39. 48 Weatherburn, D., and Lind, B. (1995) Drug Law Enforcement Policy and its Victoria’s heroin arrests increased in the period 1997-1998 to 1998-99 by Impact on the Heroin Market, NSW Bureau of Crime Statistics and 47%, as against a national increase of 38%. Research: Sydney. 25 These figures are based on the Magistrates’ Court Statistics for 1998-99. 49 Chief Commissioner’s Instruction 4/99. Department of Justice. (2000) Statistics of the Magistrates’ Court of Victoria 50 Chief Commissioner’s Instructions 3/98 and 5/99. 1998/99, Department of Justice: Melbourne. 51 Queensland. 26 Department of Justice Submission to the Drug Policy Expert Committee, August 2000. 52 These include Italy, The Netherlands and Spain. 27 The number of applications refused does not include instances in which 53 Victorian Department of Human Services. (in press) “1998 National Drug further applications were subsequently approved. Household Survey: Victoria Results”, DHS: Melbourne, table 30, p. 34. 28 Turning Point Alcohol and Drug Centre.(1999) Court Referral and Evaluation 54 In doing so, the Commonwealth Parliament could rely upon the external for Drug Intervention and Treatment (CREDIT), Turning Point Alcohol and affairs power contained in section 51(xxiv) of the Commonwealth Drug Centre: Fitzroy, p. ii. Constitution. 29 The maximum sentence of imprisonment that can be imposed by the 55 House of Lords Select Committee on Science and Technology. (1998) Ninth Magistrates’ Court for any drug offence is three years. The County Court Report: Cannabis, HL Paper 151, The Stationary Office: London, paras. 8.1- and the Supreme Court have the power to impose much longer sentences 8.2. of imprisonment (up to 25 years for trafficking in a commercial quantity of a 56 Ibid, para. 8.6. drug). 57 Parliament of Victoria. (1994) Hansard, Legislative Assembly, Second 30 Sentencing Act 1991, section 5(4). Reading Speech, 22 March 1994, p. 376 (Mr Gude); 28 April 1994, p. 1282 31 Department of Human Services. (2000) Community Correctional Services (Mr Leighton). Review Issues Paper, September 2000, State of Victoria: Melbourne, p. 14. 32 National Institute on Drug Abuse. (1999) Principles of Drug Addiction Treatment: A Research Based Guide, National Institutes of Health Publication No 99-4180, NIH: Bethesda, p. 9 (Online: http://athealth.com/practitioner/ceduc/PODAT6.html Accessed: 01/11/2000), 33 Premier’s Drug Advisory Council. (1996) Drugs and our Community, Victorian Government: Melbourne, section 3.6.5. 34 Ibid, section 3.6.5 35 Victorian Department of Human Services. (1999) Evaluation of COATS: the Community Offenders Advice and Treatment Service, State of Victoria: Melbourne, p. 7. 36 Victorian Department of Human Services. (2000) Community Correctional Services Review: Issues Paper, 8 September 2000, State of Victoria: Melbourne, p. 11. 37 Turning Point Alcohol and Drug Centre. (1999) Court Referral and Evaluation for Drug Intervention and Treatment (CREDIT), Turning Point Alcohol and Drug Centre: Fitzroy. 38 Victorian Department of Human Services. (1999) Evaluation of COATS: The Community Offenders Advice and Treatment Service, State of Victoria: Melbourne, p. 51. 39 Victorian Department of Human Services. (2000) Community Correctional Services Review Issues Paper, September 2000, State of Victoria: Melbourne, p. 11. 40 See CORE - the Public Correctional Enterprise. (1998) Operating Procedures Manual Operating Procedure No. 5.1: Offender Management (issued 1 May 1998). 41 Sanerive (Supreme Court of Victoria, unreported, 23 June 1995) per Ormiston J. 42 Department of Justice Submission to the Drug Policy Expert Committee, August 2000. 43 Office of the Correctional Services Commissioner. (2000) “Corrections Drug Strategy 2201-2003: Summary of Initiatives” (unpublished, provided to the Drug Policy Expert Committee). 44 Victorian Department of Human Services. (1996) 1996 Victorian Needle and Syringe Program and Pharmacy Sale of Needles and Syringes, DHS: Melbourne, pp. 35-37. 45 Fitzgerald, J.L., and Hope, A.F. (1999) The Social and Economic Impact of Injecting Drug Use, City of Melbourne: Melbourne, pp. 41-42. 46 Fitzgerald, J.L., and O’Brien, M.L. (1999) Health and Support Service Requirements of the Injecting Drug Using Population, City of Melbourne: Melbourne, p. 29.

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Mobilising communities and supporting the drug strategy

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8.1 Introduction Second, some elements of the current strategy are reaching the limits of their effectiveness. There is always room for further The Victorian community has made its concern about drugs expansion in treatment and law enforcement efforts. However, it is abundantly clear to the Committee. Communities are demanding clear that demand reduction requires more attention, and that skill action and, more importantly, are willing to get involved in levels across the social infrastructure need to be increased developing solutions. In recent years, governments have committed alongside those in the specialist drug workforce. New approaches additional resources and have sought to establish partnerships with are required if these problems are to be properly addressed. communities. As outlined in chapter 2, funds already committed will Without these, further investments in existing approaches will not nearly double government spending on drugs in Victoria between have the desired effects. 1998-99 and 2002-03. There is also the uncounted government investment in other services where drugs have an impact. In Capacity building has several distinct but linked elements. The addition, local governments and communities are making an Committee has chosen to focus on two major elements: increasing investment in responding to drug problems. • community mobilisation. The Committee’s Stage One report highlighted the importance of community mobilisation as part This chapter deals with the critical issue of how the Government of a response to drug use. That report noted, and subsequent and the community can get maximum value for this investment. consultations have confirmed, the desire of many individuals Funding increases are always welcome, and can have large and organisations to contribute to tackling the drug problem. It impacts. However, there are also ways of using current funding is also clear that government services alone will not deal with more effectively. We need to build the capacity of communities, the problem. The drug problem is everybody’s responsibility, and the many elements of the Government’s drug effort, to tackle and it will not be solved unless all parties are involved in drug problems effectively. developing solutions. Communities have a strong interest in, and a major responsibility • operational infrastructure. The community’s response to the for, tackling drug problems. The Committee’s consultations drug problem can be characterised as a complex range of around Victoria have shown most communities are services, dealing with changing circumstance, working in an acknowledging the impact that drugs have. The drug issues that area where much remains to be learned. The capacity of all communities identify as priorities range from concern about street elements of government to deal with drug issues needs to be heroin markets in parts of Melbourne, to problems with underage strengthened. To effectively support these services, attention drinking and cannabis use in regional Victoria. The variety of these needs to be paid to: impacts means solutions need to have a strong local component. - workforce development; The Government’s role must include supporting communities to - monitoring and evaluation; identify and deal with the specific problems they face. - research; Concern about drugs and the desire to put as much money as - ongoing policy development; and possible into directly addressing problems create a danger that - program coordination. drug services will grow without adequate planning and support. This chapter provides an overview of the issues that require Effective service delivery requires trained personnel, and activities attention if the service and program initiatives already announced need to be based on evidence and be subject to rigorous and those resulting from the Government’s response to this report evaluation. These things need to be seen as investments in an are to achieve their maximum effect. effective response to drug problems, not as costs that draw money away from direct service delivery. 8.2 Mobilising and Building the capacity of the system is necessary for two reasons. strengthening communities First, there are limited government and community resources to The Committee’s Stage One report placed communities at the deal with the complexity of the drug problem. The system must be centre of Victoria’s response to drug issues. The importance and as effective as possible in directing resources to areas where potential benefits of engaging communities, and the enthusiasm there is evidence that they will have the maximum impact. Put of many community members, have been strongly reinforced simply, some programs work better than others. Many programs during the consultations that have been held to inform the and services that have been tried have failed, although some of Committee’s preparation of this report. Engaging local these continue to be funded. Governments need to be prepared communities more fully in responding to drug issues will allow to face evidence that established programs are not working, and them to address their local drug problems, and can also build insist on changes or redirection of resources to areas where they stronger communities that are equipped to go on and tackle other can do more good. There should be space for ‘trying things’, issues of concern. and new ideas require time to develop and prove themselves. However, this is an argument for a measured approach to The key matters that the Committee wishes to draw attention to in evaluation, not for excusing these programs from being this report are outlined below. evaluated at all.

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8.2.1 Clarifying what community strengthening 8.2.2 Clarifying what governments can do means It is critical that the current interest in community does not In recent years, there has been an increasing worldwide interest in become an excuse for shifting responsibility for social problems the characteristics of strong, vibrant communities. This has grown such as drugs onto communities. These problems often impact from a recognition that neither governments nor markets can most severely on those communities least able to deal with them. create many of the things people really want from their lives. There The recent review of community care observed that many are clear signs that many people derive benefits from social vulnerable communities have lost not only physical assets, but cohesion and tolerance, and from opportunities to share also their ‘know how’, and will require development before they economic and social relationships in a relatively equal fashion.1 At are able to address their problems.5 Handing responsibility to its most general, community strengthening is about promoting communities without support will set them up to fail, and may cohesion, acceptance and engagement, and about providing actually weaken the community’s self-image and ability to tackle access to health, employment, social, sporting and cultural future problems. services and opportunities. Rapid social and economic changes In its recent attempts to combat social exclusion, the UK have diminished some communities’ access to these services Government has done much work on empowering communities. and opportunities, increased the marginalisation of some This focus on community is driven, in part, by the observation that individuals and social groups, and raised uncertainties regarding an enormous amount of money has been spent by various our commitment to fairness and equity. programs on poor neighbourhoods since at least the late 1960s, These problems are often described in terms of the concept of but many of the most deprived neighbourhoods today were also social capital. Social capital has been defined as the ‘features of that way in Victorian times. It is not clear that a series of high- social organization, such as networks, norms and trust, that profile, well-resourced government programs has had any greater facilitate coordination and cooperation for mutual benefit’.2 It is the effect than simply handing the money to residents of these areas.6 willingness to do something for others on the basis that someone These problems appear to be too complex, interlinked and will do the same for you one day. Such a system can only work in entrenched for action based around individual programs to have a a situation where people believe most other people, at least within lasting effect. a particular community, are trustworthy. In diagnosing the causes of this failure, the UK Government’s There is evidence that social capital is a precondition for Social Exclusion Unit has focused on the: addressing many of the complex problems that communities face. • failure to link solutions to complex and connected problems In a pioneering study, Robert Putnam observed the establishment such as unemployment, crime and poor quality housing; of regional governments across Italy from 1970. This initiative • series of overlapping and temporary initiatives that have failed involved placing almost identical institutions in widely different to stay in place long enough to realise results; and contexts, and created an opportunity to observe the factors that • failure to utilise and increase the potential of the communities make local government successful.3 The study found that the and individuals affected to develop solutions.7 most powerful predictor of the success of these regional Government interventions in communities do not necessarily governments was the level of civic engagement in the strengthen them. Particular attention needs to be paid to working communities they served (voter turnout, newspaper readership, out what governments can do to empower communities. It is membership of choral societies and football clubs). These sorts of probable that this will involve new initiatives that focus on research findings have led to interest in measuring social capital, community leadership and capacity and, importantly, reform of and in attempts to develop strategies to build social capital in what is currently done to make it more sustaining and reinforcing communities where it is lacking. for communities. Many government provided or funded programs The relationship between community action on drug issues and could develop a greater community strengthening capacity social capital is complex. Communities with high levels of social without diminishing their core role. The workforces employed capital are well placed to prevent drug problems. Chapter 5 has through these programs can, in many cases, be provided with made it clear that connection to a community is a key protective skills and opportunities to assist communities to develop local factor against developing drug problems, as well as a range of solutions to their problems. Building stronger communities needs other problems. At the same time, action to address problems to be seen as a legitimate outcome for government programs, that are seen by local people as priorities is a key strategy to and to rank in importance with the more specific goals of each develop social capital. Successfully tackling a problem that has individual program. been causing concern in the community creates an ongoing Governments need to tread a line between trying to do everything 4 ability to identify and address existing and new problems. In for communities, and simply leaving them alone to deal with the many communities, drugs will be one of the major issues to be issues that confront them. Governments provide or fund services tackled. In others, action may begin with other issues and move that communities need. They can also provide community on to drugs. However, even in these cases, any strengthening of initiatives with much needed funds and information about what the community is likely to have an impact on the drug problem has and has not worked in other communities. Governments have even before formal drug strategies are developed. a vital role in creating the environment where communities can develop informed and effective solutions to their own problems.

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8.2.3 Focusing on drugs 8.2.4 Creating an informed community debate Drugs are only one issue around which community strengthening Growing concern about drugs in Victoria has led to more can take place. However, drugs are particularly important because discussion of drug issues and encouraging progress in seeking of the level of concern and anxiety they cause, their capacity to solutions to drug problems. There is an increased recognition that contribute to the marginalisation and exclusion of some drugs are everybody’s problem, and most individuals and community members, and because of the range of community communities are keen to be involved in developing solutions. The services that need to be involved in responding to drug issues. In general impression gained from the Committee’s community consulting with communities across Victoria, the Committee has consultations is that people are eager to be involved in action to seen many examples where communities have identified drugs as address drug problems, and are hungry for accurate information a priority issue, often in local health or community safety plans. about drug issues and the pros and cons of different solutions Since action to strengthen communities is most meaningful when that will provide them with a basis for action. it addresses the community’s key priorities, action concerning The public debate on drug issues needs to be a two-way street. It drugs presents an opportunity for many communities to develop is not enough for the Government to ask communities for their and test new ways of working together. views. Accurate information needs to be provided to communities The Committee has seen many valuable examples of direct to maximise the effectiveness of the solutions they develop. community action related to drugs that are important in their own 8.2.5 Sharing and celebrating success right, but have also had significant impacts on the communities One of the potential pitfalls of local, community-based action is the that developed them. Government funds have supported much of risk that each community will be forced to start from scratch, even the good work at the local level, and this work ranges from videos when they are dealing with very similar problems. There is a clear for local schools to information strategies for parents and traders. need for a network that links Victorian communities to information Agencies such as Turning Point Alcohol and Drug Centre and and personal contacts from communities across the world. several local councils have developed guidelines and protocols for engaging communities in drug-specific planning and initiatives, A clearing house is one model for linking communities to the and these should be disseminated and further developed as part information they need to develop drug and other community of the overall community strengthening strategy. strengthening strategies. Such a body would assemble information and lists of key contacts in the areas of community While an important part of community strengthening is that development, prevention and health promotion. Groups such as communities select their own priority areas for action, maximum the Victorian Local Governance Association already play a impact on drugs and other problems can be achieved by focusing valuable role in linking local councils together, and may be well on the groups or sectors most closely involved with these placed to become involved in such an initiative. problems. A prominent example of such a focus would be to work with communities that are involved with vulnerable young people The Committee also believes the value placed on community such as those in the child protection system, or with refugees and development would be increased if good performance in this area their children. was formally recognised. This could take the form of awards for community action, or newsletters and other means of Chapters 2 and 6 of this report highlighted the importance of disseminating and celebrating successful efforts. The focus of reintegrating former drug users into the community, and of these initiatives would not necessarily be on drugs. However, as employment in helping people make the necessary lifestyle discussed above, it is likely that many communities would place changes. While responsibility for expanding the labour market and drug issues high on their lists of priorities for action. Furthermore, creating jobs lies with industry and governments, communities progress toward addressing the drug problem will be made can play a role in this through local schemes, apprenticeships, through all these community strengthening activities, and not just traineeships and mentoring by employers. This is a community those directed specifically at drugs. strengthening priority that will require resourcing at the local level and through broader business partnerships. 8.3 Independent advice to Individual actions across a range of areas can have significant impacts. However, it is important that individual strategies are government and the community linked to generic structures (such as local drug, community safety It is important that the Government’s policy on drugs is informed by or public health plans) and result in stronger communities as well independent, authoritative advice. There is also a need for a strong as achieving their specific goals. and informed voice in the community debate on drug issues. For this reason, the Committee recommends that an independent body with close links to the Government be established to contribute to the development and implementation of drug policy in Victoria. It is proposed that this body would provide a comprehensive focus on drug policy and strategy involving law enforcement, education, health, housing, welfare and business sectors. Attention would have to be paid to making links with organisations involved in related issues such as homelessness, suicide prevention, mental health and youth services.

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This independent body would: While the Committee has emphasised the importance of its • assist the Government to develop drug-related policy and independence and expertise, the new body must also have close programs by providing strategic advice and technical and effective working relationships with the Government and the assistance; relevant departments if it is to be influential and effective. The • facilitate and lead informed community discussion on drug body’s role in relation to the Government should be that of an issues with a view to reducing misunderstanding and expert, ‘critical friend’ that can assist in implementing government increasing support for policies based on evidence about policy while also advising on the weaknesses of current programs and interventions that are known to work; arrangements and opportunities for reform. The body cannot • advocate for the importance of drug issues, and for groups achieve these goals unless it is well informed and involved in the affected by drugs whose voices are not currently represented process. Formal processes will be required to ensure working in the public debate; arrangements between the body and the Government and its • undertake independent analysis and commentary on drug data agencies are clear and effective. In particular, the body will require available from government, non-government and international guaranteed and early access to data collected by government sources; agencies to ensure its data analysis is accurate and timely. • commission research and evaluation on priority issues across It is not the Committee’s intention that this body undertakes drug policy and related topics, and ensure research results service delivery of any kind. This would confuse its role and lead were effectively disseminated; and to potential conflict of interest. However, the body will need to • support the development of shared drug strategies across the have substantial and detailed involvement with service providers social infrastructure. across the drug domain. This is critical because these agencies The Committee believes it is desirable that the new body be carry part of the responsibility for communicating with and recognised in statute to provide it with status and a greater degree engaging the community in tackling drug issues, and provide of certainty than is possible with a body established as a result of intelligence about the effectiveness of policy and drug strategy. administrative decisions. Legislation to establish an independent For some years, the Government has supported Turning Point board or authority, were it supported by the Parliament, would Alcohol and Drug Centre. Turning Point performs some of the signal to the community shared commitment to developing policy functions outlined above, and its future would have to be in this field, and could provide a formal mechanism for cooperation considered when establishing the new body. The Committee does across the political spectrum on drug issues. not advocate that Turning Point simply be recognised as the body Effective governance of this new body will require a wide range of because it is important that the proposed body is seen as a new expertise. The committee members charged with its management initiative that is deliberately established with a whole-of- should be appointed on the basis of their expertise rather than government, rather than sectoral, brief. Turning Point was being formal representatives of any organisation or sector. The established as a research and development organisation that effectiveness of the body will largely depend on the competence focuses predominantly on treatment service provision. It is of the management committee and its expertise across a range of important that these functions continue, but not as part of the sectors that have a stake in these issues. Key areas of expertise proposed body’s work. that should be reflected in the membership of the body are: The new body, whether established statutorily or administratively, • law enforcement; will need to be adequately resourced. While the funding sources • drug treatment; are an issue solely for the Government, the Committee suggests • education; that consideration be given to using funds acquired from the • local government; confiscated proceeds of drug crime. This would mean existing • health promotion; resources are not taken away from program delivery. • mental health; • housing; 8.4 Developing the infrastructure • criminology; The drug strategy supported by the Government is now • youth affairs; increasingly complex because of the diverse range of government • public administration; instrumentalities and programs involved, and because of its • drug users; and impact across the community rather than in highly defined sectors • research. or subpopulations. The Government has given high priority to reducing the impact of drugs and now has a substantial economic investment in its response. The investment’s overall effectiveness will be substantially diminished if it is not supported by an efficient operational and developmental infrastructure.

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The State Government’s investment in the drug service system A substantial investment was made in workforce development as has expanded rapidly in recent years, notably through the Turning part of the Turning the Tide strategy. Some $4 million has been the Tide initiatives and the recently announced Council of committed through this strategy to in-service training and pre- Australian Governments (COAG) National Drug Diversion service education activities. The focus was on skills development Program, which significantly expand the specialist drug treatment across a wide range of occupational categories including school system. The amount of government resources devoted to dealing principals, nurses, mental health staff, child protection workers with drug problems indirectly has also expanded, as people with and police. In-service training focused on equipping staff with the drug problems make up a growing percentage of the clients of skills required to more effectively assist people affected by drugs. other services. The impact of drugs on other government services Pre-service training reforms were intended to equip people with is discussed further in chapter 4. the requisite skills for work in a range of occupations including Too often, these initiatives have seen a rapid expansion in services specialist drug treatment. This training was designed to give a without adequate support to ensure these services are effective. wide range of workers the confidence and willingness to engage Turning the Tide had a significant research component, and many with drug issues, and knowledge of how and where to access of its elements were evaluated. Unfortunately, many of these further information and support. The skills in relation to drug and evaluations focused on process rather than on the impact of alcohol issues are also largely transferable across a number of these initiatives. Little was done in a recurrent or systematic way to fields. Turning the Tide represented an important start on develop a robust infrastructure to support the services delivered. increasing the skill levels of people across the social infrastructure The COAG initiative offers some training but, in the Committee’s in dealing with drug issues. Valuable curriculum and resource view, will not provide sufficient support for the expanded treatment materials have also been developed. However, this funding has system it envisages. now virtually all been committed, and it has become clear that this type of one-off initiative will not be adequate to develop the skills Governments experience understandable pressure to spend every base needed to support drug policy in Victoria. possible dollar on direct services to meet identified needs. These pressures can have perverse consequences, such as failing to Some ongoing initiatives are also in place. The Department of fund prevention programs rather than treatment, or to support Human Services manages a continuing training program that services to ensure their long-term effectiveness. They also create emphasises the role of general practitioners. Turning Point Alcohol a real risk that money will continue to be poured into programs and Drug Centre and the Youth Substance Abuse Service are that are not working, in the absence of an evaluation that can registered training organisations and they have established point out their deficiencies. Directing money to the support specialist alcohol and drug training services. However, resource infrastructure needs to be seen as an investment that will constraints have meant these initiatives have barely kept up with maximise, rather than reduce, the outcomes from government- the recent rate of expansion. New approaches will be needed to supported services. support the further expansion already announced and the reforms proposed in this report. The elements of the support infrastructure that require attention are discussed in the following section. The objectives outlined in The Committee proposes that the Government develop a chapter 2 provide a framework for developing actions in these key comprehensive training strategy. Specialist and generalist areas. workforces are the core of the community’s response to drug issues. In the end, this response can only be as good as the 8.4.1 Workforce development people delivering it. The task of developing the skills of this The direct drug workforce is large and growing, as is the range of workforce is too important to be left to ad hoc and one-off people now dealing with drug issues as part of their day-to-day initiatives. A skills development strategy is required for the work. The Committee believes many of the Government’s drug specialist drug workforce, and must be backed up by ongoing policy objectives will not be achieved without a substantial funding for training. Other areas that are feeling the impact of investment in workforce development. Unfortunately, funding for drugs must be supported and resourced so they can consider training is often the first casualty of budget pressures, and release and act on their own skill development needs. from duties for training is often eroded under pressure to devote The objectives outlined in chapter 2 provide a framework for time to direct service delivery. proposing necessary actions: • further develop an effective workforce in the health, welfare, education and law enforcement sectors; and • increase the capacity of the generalist health and welfare workforce to identify drug problems and related harm, and apply evidence-based interventions.

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This report has emphasised the fact that drug misuse is putting Further rapid expansion of the specialist treatment system will pressure on all types of government and non-government create further problems in finding skilled people. At the same time, services. It has also highlighted the role these services have in this expansion provides opportunities to restructure the field in preventing and responding to drug problems. State Government ways that make it a more attractive career option. A swift and supported programs or service systems need assistance to extensive effort needs to be made to enhance the skills of this reassess their service designs and workforce requirements. It is workforce, and to provide career development opportunities to no longer possible or appropriate to use short-term funds to make working in the field on a longer term basis an attractive provide in-service training across many sectors. A strategy for option. building staff competence in dealing with drug issues must be Particular attention needs to be paid to: incorporated into the reassessment of existing programs, and • finalising training competencies, developing course resource must become the responsibility of these programs. The materials, and establishing prerequisite training for alcohol and Committee expects this work will be done as part of the program drug workers. In this, Victoria needs to collaborate with other reassessment described in chapters 2 and 4. Funding jurisdictions; arrangements need to support the development of an • developing career structures and other incentives that will appropriately skilled workforce. attract and retain senior people in the drug field. A number of Many recommendations in this report will need to be supported services have made significant efforts to develop and sustain with appropriate skill development strategies. For example, the senior staff and provide leadership in the field. However, a State Government should continue and expand the work being more coordinated effort will be required to see the system done with regard to general practitioner training to support their through a new period of expansion and greater engagement expanded role in treatment and the pharmacotherapy services with other services. program. A mixture of medical, nursing, social work, psychology and Government also needs to be vigorously involved in work with the youth work skills is required. Developing this leadership university and TAFE training sectors to ensure all relevant curricula capacity will require attention to recruitment, remuneration and deal appropriately with drug issues, and that the significance of professional development opportunities. While these senior these issues in professional practice is recognised. people must have a commitment to the field, we must also • Increase capacity to attract and retain a highly skilled specialist recognise that the drug field competes with many others for workforce in the health system the best people, and that the fields that reward excellence are most likely to retain their finest staff. Models for such The specialist drug treatment system remains a critical element of professional leadership exist in other fields, although they tend the community’s response to drug issues. Enhancing the capacity to be profession-specific rather than the integrated leadership and effectiveness of other parts of the social infrastructure will not required by the drug treatment field; diminish the importance of this sector. Instead, it is likely that • increasing the availability and prestige of postgraduate increasing demands, particularly for collaborative practice and qualifications related to drugs. Postgraduate qualifications not skilled consultation, will be made on staff working in the treatment only provide further skill development for people already in or system. Recent growth in demand and the expansion of the wishing to enter the drug workforce, but also give the field service system have, and will continue, to create stress in legitimacy and prestige. There is a particular issue here in recruiting and retaining staff with sufficient skills and knowledge. relation to medicine, where the lack of a recognised speciality One-quarter of drug and alcohol workers who responded to a means there is little incentive to specialise in treating addiction. recent survey indicated that they have no tertiary qualifications, Doctors who work in this field often pass up more lucrative and and 15 percent did not complete secondary school.8 At present, prestigious opportunities to do so. This story is repeated there is no formal qualification requirement for drug and alcohol across a number of disciplines, and shows how an increased workers. commitment to skill development can have a number of benefits for the drug field. As with all these workforce development initiatives, a greater emphasis on postgraduate study will require a financial investment. However, it must be seen as an investment in boosting the quality of the workforce as a whole, given the leadership that well-trained specialists can provide;

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• ensuring staff, including new staff recruited to operate the • continue to educate the health, education, law enforcement services provided through the recently announced policy workforce in principles that underpin strategies to reduce the initiatives (COAG and State Government), are given adequate harm caused by illicit drugs; induction training and continuing training. In many cases, it is Previously, the emphasis has been on technical or service- likely that these services will be recruiting staff with little or no oriented training or development. This training and experience in the drug treatment field and so they will lack key development must be provided in ways that reinforce the skills. Service agencies should invest in competency-based philosophical approach underpinning Victoria’s drug policy. training that is accredited or allows for articulation into • maintain a skilled and supported specialist drug law recognised course structures. Training should be designed to enforcement workforce; ensure an agency’s workforce has an adequate mix of skills It is critical to ensure those police involved in specialist drug and competence, and to provide career development law enforcement are skilled technically and in harm-reduction opportunities for staff. The funding provided to these agencies principles. These police do essential work in controlling supply, needs to recognise the requirements for skills development. and they can provide role models and training for the general Formal in-service training requirements should be included in police force whose training needs have already been funding and accountability arrangements, and systemic discussed. Given that most drug-related policing occurs at the support provided for these services, possibly through the local level, those police specifically trained in dealing with drug appointment of training coordinators. These coordinators, issues have a key role in educating other police. The gap working as a team but spending part of their time in particular between the goals of specialist drug police, and the pressures regions, could create linkages with the TAFE and university facing police dealing with local issues at the street level, was systems and provide basic training directly. It is important to identified in a 1996 evaluation as a major barrier to an ensure these coordinators work in partnership with each other, integrated approach to drug law enforcement and harm especially when negotiating with other sectors. minimisation.9 Specialist drug police taking a greater Agencies receiving funding under the COAG initiative will be leadership role may be one way to close this gap. required to undergo an accreditation process. At the moment, • develop a skilled and supported health-promotion workforce this requires nomination and government approval of a suitably familiar with evidence-based health promotion and the qualified clinical supervisor. This is a welcome step toward antecedents of drug use. quality assurance, and the Committee supports proposed Chapter 4 of this report outlined the role that staff in many places moves to develop a more comprehensive accreditation system can play in preventing drug misuse. This ranges from the role of for specialist drug treatment services in Victoria. The skill levels general practitioners in talking to patients about their substance and qualifications of the workforce should be considered as use, to the importance of schools in creating a feeling of one part of an accreditation standard. Accreditation is connectedness that is a protective factor against substance discussed further in chapter 6; misuse. All of the workforce development strategies outlined must • matching the focus on pre-service training and attracting include relevant prevention skills and knowledge components. quality new staff with efforts to improve the skill base in the Staff working with drug users on the street and in drug treatment existing workforce. This workforce has a range of skills and services have vital opportunities to prevent further harm to the experience that is not necessarily reflected in their formal individual and community. The State has a small but growing qualifications. Retaining these staff and broadening their skill group of health-promotion specialists. They can provide critical base must be a high priority. Any minimum qualification technical support in integrating drug-related health promotion if requirement that is introduced will need to be accompanied by they fully understand the needs of the drug field and the principle a strategy to bring workers already in the field up to the of harm minimisation. As with many other areas of public debate, minimum standard wherever possible; and there is a need to keep drugs on the health-promotion agenda. • paying specific attention to some other areas. One of these is 8.4.2 Monitoring and evaluation ensuring drug treatment services working with young users retain or enhance their technical skill base without reducing The complexity of the drug problem, and the community concern their youth work capabilities. Another is developing it generates, have led to a vast array of programs being arrangements to support services working with drug users in developed across a range of areas and funded from various an outreach capacity, such as needle and syringe or primary sources. New and better solutions to problems ranging from health care services. Many more such areas will, no doubt, be preventing the uptake of drug use to reforming the most hardened identified in creating a workforce development strategy. users are constantly proposed. At the same time, various claims Further discussion of strategies to increase skill levels in the are made about the severity of the problem, and whether it is specialist drug treatment workforce is provided in chapter 6. getting worse or better. In such a climate, accurate data and rigorous evaluation of the outcomes of programs are crucial.

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An evaluation culture is not easy to develop. The nature of • data are often inadequately interpreted. Getting maximum evaluation is that it sometimes throws up surprising results, and value from the available data is just as important as expanding popular programs that have an intuitive appeal may turn out to be the scope of the data collected; ineffective. Courage is required to both face and act on these • the intelligence that is collected is often not disseminated to findings. Similarly, having accurate data indicating the extent of a those agencies able to utilise it; and particular problem creates the opportunity and the obligation to • there are no guarantees of the accuracy of much of this data. correct assertions that seek to deny or exaggerate the problem. With limited information available, there is a tendency for The alternative is to continue to fund programs that are having people looking for information to seize on whatever is little or no effect, or that are actually counterproductive. This is not available. However, if this information is to become the basis only a waste of resources, but also denies funding to programs for policy making, more attention must be paid to ensuring the that could make a difference. Spending money on evaluation raw data and the analysis applied to them are accurate. needs to be seen as an investment in getting the most out of the Decision makers need to be able to call not only on the data, funds that are spent on service delivery. but also on an authoritative assessment of the usefulness of different pieces of information. The foundation of an overall evaluation of the effectiveness of the drug strategy is accurate data. An ability to monitor the current The Committee believes it is imperative that Victoria commit to situation is also crucial to developing future drug policy. The developing a highly organised surveillance monitoring system to Committee has invested considerable time and effort in gathering provide key data on the situation relating to drugs in Victoria. The and analysing the data contained in this and its earlier report. Committee considers the success of the HIV/AIDS/sexually These reports demonstrate there is a considerable amount of data transmitted disease surveillance system used for over a decade to related to drugs available. At the same time, many of these monitor infection could provide a model that could be adapted to 10 datasets are still being developed, and ongoing effort is required drug use in Victoria. The Committee believes there are important to enhance their reliability and validity. There are numerous parallels in the tasks of creating an HIV/AIDS/sexually transmitted problems that need to be resolved to establish a suitable and disease and a drug use surveillance system, not least of which is accessible monitoring system commensurate with the complexity obtaining accurate data from hidden and hard-to-reach and importance of the drug problem and the community’s populations. response to it. The current data collections that could form the basis of a Major issues include: surveillance system include: • data are gathered, nationally and at the State level, to meet the • the Victoria Police Law Enforcement Assistance Program needs of particular agencies or programs but do not link to (LEAP) database, for information on drug-related seizure and other data collections. Consequently, there are limitations on arrest rates; the data’s usefulness, particularly for overall drug policy and • the Illicit Drug Reporting System (IDRS), which currently strategy monitoring purposes. If aggregated, the data could collects data on price, purity and availability of illicit drugs; provide the basis for an invaluable system of monitoring • the Coroner’s Office data collection, for drug-related deaths; existing drug patterns and emerging trends; • ambulance data on the number of non-fatal overdoses • there is considerable duplication of effort and data collection attended; because projects are undertaken in an uncoordinated way and • the Alcohol and Drug Information System (ADIS) data collected often receive funding from numerous different sources. This through specialist drug treatment services; often results in a series of smaller studies that overlap or have • correctional services data, on those whose offence is linked to significant gaps. However, the quantum of funds used could drug use; be combined to provide fewer but more robustly designed • hospital data on emergency presentations and inpatient data; programs that come closer to answering the most urgent • Juvenile Justice and Child Protection data, which indicate the questions facing drug policy in the current climate; frequency of drug involvement in cases where State • there are considerable time delays involved in extracting key intervention is required, and the nature of the drug concerned; data from many databases. This makes timely operational • needle and syringe data; decision making in a changing environment difficult; • databases kept by Public Health in cases of approval to • the national household and student surveys, which are the prescribe methadone and, when they become available, other basic information source on usage and prevalence patterns, pharmacotherapies; and are flawed, particularly the data relating to illegal drugs. The • the Secondary School Students Survey and the Household available data can be used and assumed to provide valid Survey. information about trends but cannot be relied upon in absolute terms. Other data sources suffer from the same problems. This reinforces the need for multiple data sources to provide a range of perspectives on a particular issue;

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To obtain the maximum value from these databases for drug policy, Within this evaluation strategy, decisions need to be made on the it may be necessary to work with relevant agencies to ensure the distribution of evaluation effort. It is better to fund a smaller most meaningful data are collected without having significant number of rigorous outcome evaluations than to attempt to impacts on workload or the other objectives of the data collection. evaluate all programs and end up with a series of process As this may involve some adjustment to existing collection evaluations that look at program implementation rather than instruments, negotiation at senior levels is likely to be required. ultimate impacts. Evaluation effort should be directed toward Even if the data sets listed above are linked, there are still critical areas that: gaps in the information. The Committee believes these gaps can • take up a large number of resources. Clearly, there is a greater be filled through commissioning additional surveys. A number of need to know whether a program costing millions of dollars is methods can potentially provide more concrete data on numbers working than one costing a few thousand; of drug users. These include: • are ongoing or relevant to future programs. While much can be • telephone surveys; learnt by evaluating one-off efforts, the overall goal of • linkages with key individuals in organisations that provide evaluation should be to guide future efforts and resource health and other services to users, who will provide intelligence allocation; and at regular intervals as to numbers and trends; and • are open to change. The focus should be upon programs or • regular surveys with user populations who are reached via services that have sufficient maturity and track record to be the organisations such as needle and syringe programs, VIVAIDS subject of scrutiny, and where change can be managed (the Victorian Drug User Group) or drug treatment agencies. effectively and productively. The Committee acknowledges the valuable work undertaken by Setting evaluation priorities in this way is not intended to let other Turning Point and the National Drug and Alcohol Research Centre programs off the hook; rather, it is a case of matching the as part of the Illicit Drug Reporting System to provide core resources devoted to evaluation to its likely impact. An evaluation information about users and drug markets. The Committee culture will build some evaluation into each program on the believes this must be built on, and regular reports provided. successes and failures of implementation and the lessons for the future, even if it is only routine reflection by those involved and A comprehensive data collection system would be a key affected. component of an overall evaluation of the effectiveness of drug policy in Victoria, and provide a sound basis for planning future To assist system-wide policy development and implementation, actions. However, it would only be one element of the broader there is a strong argument for establishing a central data evaluation culture that is required if the Victorian community’s coordination function. This function would not take direct investment in its drug strategy is to have the desired results. There responsibility for all data collection and management, as these are are signs that an evaluation culture is developing in Victoria, essential functions of individual programs. However, the new notably in the evaluations of Turning the Tide and its component function would be responsible for advising government on ways to programs. This approach must be continued and enhanced in achieve consistency, relevance and accuracy in data gathered. It coming years. would also provide the capacity to undertake analysis of drug issues on a whole-of-government basis rather than through An overall monitoring and evaluation strategy is needed that is individual programs or departments. directly linked to the objectives proposed in chapter 2. Developing such a strategy will require reviewing existing data collections and 8.4.3 Research negotiating with other jurisdictions, including the Commonwealth, The framework for drug strategy outlined in this report represents to refine or revise existing national data collections. a substantial and innovative approach to reducing drug use and Key elements of the monitoring and evaluation strategy are: harm; however, much remains to be learned about how to achieve • reporting the results of the research strategy; these objectives. A research strategy is required. • gathering trend data about supply and usage patterns and trends internationally, nationally, statewide and locally with appropriate disaggregation of particular subpopulations; • collecting qualitative information on drug use patterns and emerging trends, especially among subpopulations of identified importance; • estimating the social, health and economic costs of drug use; • assessing service usage/intervention patterns across prevention, treatment and law enforcement domains in a consistent manner; and • independently evaluating services, programs and service systems with a view to understanding the dynamic of service systems.

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In recent years, a number of significant developments have The Committee proposes that a formal State drug research occurred in drug-related research in Victoria. Together, they have strategy be developed to achieve these objectives. Involvement of created a substantial body of knowledge in the field. Developing a the Victorian Public Health Research and Education Council, formal research strategy is the next step in broadening this effort which has convened a working group involving researchers and and linking it to the statewide drug strategy. Some key research senior public servants, would be valuable. The Committee would activities of the last few years are: strongly propose that a mechanism be developed to provide this • the New Pharmacotherapy project and the Drugs in a group with perspectives from the law enforcement, education and Multicultural Community Project. These projects have other service systems to ensure advice flowing to the Government produced significant bodies of work that will inform the about research priorities reflects the range of areas that now deal direction of drug strategy for some years to come. They were with drug issues. This could be achieved by broadening the supported through Turning the Tide; council’s membership, or by developing a separate but linked • the establishment of Turning Point Alcohol and Drug Centre as group to consider priorities for drug research. a key research agency funded by the State Government. It is a The Wills report into medical research recommended that funds vital element of the existing drug service infrastructure; and allocated to this purpose should increase by 15 per cent per year • three research centres focused on drug issues. These are for five years from an already substantial base. The report notes funded by the Commonwealth Government directly, and it also that this would still not lift Australia’s spending to the levels seen in allocates funds to the National Health and Medical Research many comparable countries. It further recommends that research Council for drug-related research. should receive 1 per cent of the Commonwealth Government’s Combined with research funded from other sources, and the body outlays on health.11 While this is an appropriate benchmark in the of work carried out interstate and overseas, there is a great deal of overall health context it would be insufficient in the much smaller potentially beneficial work being conducted. However, neither drugs sector. The Committee suggests that the Government set a Victoria nor any other jurisdiction has strong systems to target for research funding from all sources of 5 per cent of the disseminate research results or monitor work being done drug budget. elsewhere. The Committee hopes the recently established The strategy also needs to develop a capacity to disseminate National Drug Research Advisory Committee will deal with this information about the research findings, and to integrate these issue in some way. However, action will also be required at the into program design or practice. A specific element of the drug State level to ensure policy making and service delivery in Victoria research strategy needs to tackle this problem by establishing are informed by the best possible information. routine research monitoring mechanisms, and formal There is also considerable research being done across the social communication and planning systems. Research findings need to infrastructure about the impact of drugs on the relevant sector. In be conveyed to those involved in workforce development, policy the prevention area, Victoria is already supporting a range of formulation and program coordination. critical research projects that lead the nation. A strategy needs to 8.4.4 Program coordination be found to expand the horizons of researchers and those who A challenging reform and development agenda has been outlined fund research so drug issues are included more often. Equally, in this report, and the diversity and complexity of the task facing the results of research undertaken in these fields need to be the Victorian community and the Government in tackling the drug systematically disseminated to those dealing with drug issues. problem have been emphasised. Maximising the effectiveness of The objectives proposed clearly articulate the Committee’s the community’s investment in tackling drug problems requires aspirations in this area. They are to: that a strong leadership, coordination and policy development • increase evidence-based practice in health, education, welfare infrastructure be established. and law enforcement sectors; Drug policy is no longer a statement about government initiatives • increase instances of integrated and collaborative research or services relating to drugs. It requires attention to the and development between health, law enforcement and effectiveness of a broad range of services provided and funded education and welfare sectors; by government, and needs to engage and involve communities • better focus research priorities; with government. Explicitly drug-related services and programs • increase participation in international law enforcement and must become more effective and better linked with the other health research projects; and services with which they share common clients. Achieving real • maintain and enhance support for policies, programs and gains in addressing drug and other social problems needs to be interventions that use the best available research evidence. given priority over the interests of existing programs and bureaucracies.

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Drug policy is one the greatest challenges facing the Government • breadth of input. This includes the need to: given the consistent problems in making ‘cross-cutting’ programs - consider and act on policy from a whole-of-government or policies work. It has become a litmus test for a new approach perspective that overrides the interests of individual program to social policy implementation and public administration areas. Staff and working arrangements need to include arrangements. The Committee does not believe it has solutions to health, law enforcement and education perspectives; these complex problems, but it considers a number of actions will - have regular formal and informal contact with the range of contribute to a coherent policy implementation and review people involved in dealing with drug problems in the mechanism. community. The independent evaluation of the Turning the One key factor in effectively coordinating services is strong Tide strategy highlighted the problems that resulted from the leadership at the senior levels of the Government. There must be failure to meet this requirement; structures to coordinate the government response to drugs at the • structural tools. Governments rightly seek to hold accountable ministerial and senior public servant levels. those responsible for managing public funds and have well- developed mechanisms for doing so. While these The Government has already taken one of the key steps to arrangements are good at establishing and enforcing establishing policy leadership by establishing a Cabinet decision accountability for specific programs, there is a risk that no one making process that gives appropriate recognition to drug policy. will end up being accountable for cross-government strategies The Committee is aware that the Government has established a such as drug policy. It is not possible for an independent and high-level Inter Departmental Committee on Drugs as the key external committee to propose detailed alternative internal government advisory body. The Department of Human accountability mechanisms. However, two options the Services leads this group, reflecting the importance of dealing Committee believes should be considered are: with drug issues primarily as a health issue. - the Drug Cabinet Committee should undertake a systematic Bureaucratic leadership of drug policy is important and across-government assessment of budget and governments have tried differing organisational arrangements accountability requirements. It could then recommend from time to time. Popular choices are to locate drug policy with consistent and mutually reinforcing proposals for the health function or within the Premier’s department. This consideration within the normal budget process; and reflects the importance of drug issues and the cross-government - a single purchasing pool should be created to provide response required. The location of the lead responsibility can integrated responses to people who require multiple send powerful messages, but paying too much attention to this services across the service system. This would involve issue reinforces the focus on existing programs. It is more integrated assessment and then access to a range of important that there should be a strong leadership structure that services. More details of a possible trial of such an approach can coordinate a cross-government response, and that this are provided below. leadership has access to the right information and advice from If the elements of strong leadership outlined above can be put in inside the Government and from across the community. place, Victoria will have taken significant steps toward a Key prerequisites for effective policy leadership include: coordinated approach to tackling the drug problem in our • strength of leadership. Senior officials involved in policy community. The following section provides more detail on some leadership and program implementation roles need to be possible structures the Committee believes would assist the clearly committed to cross-government approaches. Senior Government to achieve these aims. officers who perform sectoral roles must step out of these in Structures to enhance coordination across government leading the implementation and review of drug policy and strategy; Developing a genuinely coordinated approach to tackling • knowledge. Leadership roles require a strong knowledge complex issues such as drugs is one of the most important and, base. This does not mean only people with extensive at the same time, intractable problems facing governments experience in drug service roles are appropriate. It does mean worldwide. The Committee does not hope to solve this problem a broad approach to social policy, and an awareness of the here. However, some possible ways forward in dealing with drug role, needs and pressures of a wide range of service systems issues in Victoria are the: (including drug specialist services) are required. The workforce • Cross-Sectoral Prevention Coordinating Committee proposed development strategy will need to include the development in chapter 5. It would be a multi-program or ‘horizontal’ group needs of the bureaucratic leaders, given the sectoral limits of designed to capture and act upon a common approach to most managers’ roles; prevention at all levels;

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• service reassessment and design process proposed for the Case management is currently expected to be provided to relevant elements of the social infrastructure outlined in chapter people who are clients of specialist drug treatment services 4. It should have a major focus on identifying opportunities for but, in practice, is often limited to navigating their passage cross-program cooperation. Once these opportunities have through the treatment system. A broader case management been identified, program managers need to be made approach has potential in assisting people with substance use accountable for implementing them. A similar process needs problems and deserves to be carefully tested. Considerable to be followed when programs are reviewed in future. Where effort will have to be put into trial design and staff training, relevant, these reviews need to take account of drug issues in given the diversity and complexity of the needs of the people their terms of reference and membership; and likely to access these services; and • trial of integrated or pooled funding proposed above. People • development of strong links between services at the local level. with multiple needs are faced with a bewildering array of Important work has been done in recent years to establish government services, each administered by a different agency, sound working relationships at these levels but much remains and with its own rules and regulations. At the same time, these to be done, particularly to create the collaborative services people are often the least able to navigate this maze, and they required by many drug users. The Primary Care Partnerships risk missing out on many of the services to which they are model being developed by the Department of Human Services entitled. The multiple needs of many people with substance and the Crime Prevention strategies of the Department of use problems have been emphasised throughout this report. Justice are worthy examples that need to be sustained and Drug treatment is only one step for many of these people, who linked together. Local drug planning round tables, such as then need to address housing, health and employment issues, those established as a result of the Committee’s first report, among others. During the Committee’s community provide a model, as do the Local Priority Policing Committees. consultations, the difficulty that even those working within the However, it is important that the control of these committees is system have in putting together a package of services for their effectively shared between all the relevant partners. clients was constantly emphasised. For those coming from outside, the challenge is almost impossible. 8.5 Conclusion One approach to these problems is to set up an area-based This chapter, and this report, have outlined a challenging reform pool of funding to meet these people’s requirements. Case agenda. This agenda not only addresses drug issues, but also managers would assist individuals to identify and access the argues for a new approach to the way governments and portfolio of services that met their needs, and would organise communities address complex social issues. This chapter has funding for them. Similar approaches have been proposed for outlined some of the elements that are often overlooked in trial in the recent review of Community Care in Victoria and in attempts to improve direct service delivery. It is only by involving the UK. The Community Care review proposes the communities and ensuring service delivery is adequately development of Community Care Networks to identify the suite supported that effective, lasting solutions to the complex of services needed in a particular area, and to establish problems posed by drugs can be developed. funding and accountability mechanisms for their delivery.12 In the UK, the Social Exclusion Unit has proposed a trial of a system where neighbourhood managers would be responsible for coordinating services, initially in the most disadvantaged neighbourhoods.13 These schemes have a common commitment to local coordination of a range of services. Currently, services often fail to link with each other and the needs of the communities they serve. Their success should be monitored, and specialist drug services must be ready to be involved in any such initiatives in Victoria.

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Endnotes

1 Woolcock, M. (2000) “The Place of Social Capital in Understanding Social and Economic Outcomes”, Paper prepared for an international symposium on The Contribution of Human and Social Capital to Sustained Economic Growth and Well-being, Organised by Human Resources Development Canada and the OECD Chateau Frontenac, Quebec City, March 19-21, p. 4. 2 Putnam, R. (1993) ‘The Prosperous Community: Social Capital and Public Life’, The American Prospect, 13, Spring 1993, (Online: http://www.prospect.org/archives/13/13putn.html. Accessed: 16/11/00.) 3 Ibid. 4 Hawe, P. (2000) ‘Capacity Building: For What?’, NSW Public Health Bulletin, 11 (3), March 2000, p. 23. 5 Carter, J. (2000) Report of the Community Care Review, Department of Human Services: Melbourne, pp. 82-83. 6 Social Exclusion Unit, (1998), Bringing Britain Together: A National Strategy for Neighbourhood Renewal, UK Cabinet Office, London Chapter 2, (Online: http://www.cabinet-office.gov.uk/seu/1998/bbt/nr2.htm. Accessed 11/8/00.) 7 Ibid. 8 Training Census conducted by the Drug Treatment Unit, Victorian Department of Human Services, 2000. 9 Sutton, A. and James, S. (1996) Evaluation of Australian Anti-Trafficking Law Enforcement, National Police Research Unit, pp. 118-119. 10 Crofts, N. (2000) personal communication. 11 Department of Health and Aged Care. (1999) The Virtuous Cycle - Working Together for Health and Medical Research, DHAC: Canberra. pp. 185-190. 12 Carter, J. (2000) Report of the Community Care Review, Department of Human Services: Melbourne, pp. 118-124. 13 UK Government National Strategy for Neighbourhood Renewal. (2000) Report of Policy Action Team 4: “Neighbourhood Management” , The Stationery Office: London.

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Recommendations

Drugs of all kinds have the capacity to cause harm to users, family and the community. Misuse of illegal drugs is now having an impact on the fabric of society. Government and the community must meet the challenge together. The Committee recommends:

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Recommendation 1 Recommendation 1.5 THAT THE VICTORIAN GOVERNMENT IMPLEMENT A That the Government, in consultation with the Koori community COMPREHENSIVE STRATEGY TO TACKLE THE IMPACT OF and relevant peak bodies, resource and support the DRUGS IN PARTNERSHIP WITH THE COMMUNITY. development of a Koori Drug Strategy as an integrated yet identifiable component of the overall drug strategy. [CHAPTER 2] [Chapter 2] Section 2.8 The Committee wishes to ensure drug policy continues to focus on the harm that results from drug use regardless of legal status. Recommendation 1.6 That the Government ensure that all elements of the drug Recommendation 1.1 strategy: That the Government affirm that the strategy will: • are responsive to the cultural and linguistic needs of the • maintain an integrated approach to legal and illegal drugs; community; • be based upon health-promotion and harm-minimisation • provide opportunities for communities to be engaged in principles; and drug issues in culturally appropriate ways; and • reflect the broad impact of drugs on the full range of the • are adequately resourced. government’s social policies and services. [Chapter 2] Section 2.8 [Chapter 2]

A central element of the Government’s drug policy focuses on The Committee believes the impact of drug misuse will only be saving the lives of drug users. This is a critical element of the drug reduced when the full range of services that assist people affected strategy given the current overdose rates, and one that, to date, by drugs are able to do this effectively while continuing to provide has been underdeveloped and fragmented. The Committee their core services. Changes in usage patterns and levels of use are believes much more should be done within the areas affected and placing increasing burdens on a wide range of services operated or across the State. Specific proposals are included here, but it supported by the State Government. Many government-funded should be noted that saving lives is a responsibility of all aspects programs have the capacity to contribute to the drug prevention of drug policy. strategy and to reintegration of drug users if program redesign is carefully crafted. The Committee believes a concerted effort is Recommendation 1.7 required to more effectively support these services. That the Government introduce a comprehensive ‘saving lives’ Recommendation 1.2 strategy designed to: • provide health, welfare and emergency service support to That the Government require that all relevant State-funded high-risk drug users and the communities in which they live; programs reassess program design, staffing and other • strengthen local partnerships with and between educational, arrangements to ensure they are able to meet the consequences police, health, treatment and needle and syringe programs; of increased drug use on their service user group. and [Chapters 2 and 4] • involve the relevant community in dealing with the issues that affect them. Recommendation 1.3 [Chapter 2] Section 2.5 That the Government ensure necessary drug information and expertise is available to support program reassessments. The long-term success of drug policy depends upon its ability to [Chapters 4 and 6] prevent use, care for users, and assist those who have become dependent and involved in the drug culture to be reintegrated into Recommendation 1.4 normal community life through access to education, employment, That the Government strengthen existing initiatives that create housing and social support. The State and Commonwealth linkages between programs and services in order to reduce the Governments have key roles to play here, as do the business barriers to meeting the needs of service users. community, local government and other community organisations. [Chapter 4 and 6]

The Committee believes the policy and strategy requirements of the diverse Victorian community have not been adequately met. More targeted and culturally relevant responses are needed.

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Recommendation 1.8 There is a need to develop a sustained communication strategy That the Government, in partnership with local government, on drugs that informs and educates all members of the business and community organisations, develop a strategy to community. The strategy should be developed over several years establish: and priority should be given to cannabis, given its status as the • education; most used illegal drug. Particular attention should also be paid to • employment access and support; and the needs of diverse language and cultural communities. The • related services strategy must have the capacity to deal with all drugs and their that reintegrate current and former dependent drug users into risks, and to build over time. the community. [Chapter 2] Section 2.6 Recommendation 2.2 That the Government participate in a comprehensive and Recommendation 1.9 multifaceted drug communication strategy designed to: That the Government strongly advocate changes to the income • provide information to the community about drugs; and security and employment policies of the Commonwealth • engage the community in tackling the issue. Government to ensure vulnerable young people and dependent The communication strategy should: drug users are effectively supported to access basic income, • involve targeted use of mass media, other media and direct housing and employment opportunities. community contact; [Chapter 2] Section 2.6 • involve the community and identified target groups in better understanding drug issues; • give early attention to explaining the risks of excessive and Prevention hazardous cannabis use to young people; and Discouraging people commencing use, reducing • support all other elements of the drug strategy in an experimentation and increasing the safety of those appropriate manner. who continue to use is critical. The implementation [Chapter 5] Section 5.8.5 of a comprehensive, integrated and sustained prevention strategy is one of the most essential Parents play a vital role in preventing drug problems and face requirements of a more effective drug strategy. great difficulties when they arise. Better equipping parents with the The Committee believes that 10 per cent of the skills and knowledge to deal with drug issues is important in its drug budget should be committed to prevention own right, and will contribute to a generally more competent next strategies. generation. Parents can be participants in, and providers of, information, education and skills development. Parents also need support if their family is directly affected. Recommendation 2 THAT THE VICTORIAN GOVERNMENT INTRODUCE A Recommendation 2.3 COMPREHENSIVE DRUG PREVENTION STRATEGY THAT That the Government support an extensive education, RECOGNISES THE CRITICAL ROLE COMMUNITY SERVICES information, support and skills development strategy for parents PERFORM, AND THE NEED FOR A RANGE OF DRUG- that includes a range of approaches designed to appeal to SPECIFIC INITIATIVES INVOLVING GOVERNMENT AND different groups, be relevant to children of different ages, and COMMUNITY ORGANISATIONS. which links to school and community-based strategies [CHAPTER 5] [Chapter 5] Section 5.8.3 The critical role of communities in tackling the drug problem directly and more generally in providing safe, secure and The education system is the social institution that, after families, supportive places for children and families has been emphasised has the greatest opportunity to affect children, adolescents and in the research and in consultations. young adults. Drug prevention programs are now seen as a core part of school life. This is a significant gain that needs to be Recommendation 2.1 sustained and linked to the overall prevention strategy. The Committee wants to make the education process educationally The Committee reaffirms the recommendation made in its and socially meaningful and supportive for all young people. Stage One report that the Government commit itself to a Recent reports to the Government provide the framework for community mobilisation strategy. systemic responses that the Committee would endorse. [Chapter 5] Section 5.8.1

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Recommendation 2.4 Recommendation 2.6 That the Government implement reforms to the education That the Government work with drug users to implement a system to strengthen the capacity of school and other strategy designed to reduce use and misuse and which: educational environments to provide supportive environments for • actively involves current users in reducing the harm they do all students and, in so doing: themselves and others; • strengthen the overall welfare framework; • links current drug users to health, welfare and treatment • provide systematic support through an enhanced youth services; and support service for schools that focuses upon improved • supports the saving lives strategy outlined in learning outcomes for all students; recommendation 1.7. • monitor the social climate of schools; and [Chapter 5] Section 5.8.6 • continue to provide systematic support for effective drug prevention programs through ongoing curriculum Prevention of drug use and misuse has been given lower priority development, staff training and whole-school planning. than other areas of the drug strategy. The reforms recommended in [Chapter 5] Section 5.8.4 this report will require particular support if they are to be effective.

Some young people will continue to be vulnerable, marginalised Recommendation 2.7 and, in some cases, come into contact with the child protection That the Government establish a highly skilled team to provide and legal systems. These young people can be made vulnerable technical and program support to major prevention initiatives. by early drug use, or drug use can commence as a response to Priority should be given to supporting the educational reforms, the circumstances in which the young person finds themself. A parent support initiatives and other initiatives at the local level. more systematic approach is required to working with these [Chapter 5] Section 5.8.7 young people. Recommendation 2.8 Recommendation 2.5 That the Government support the above initiatives through: That State and local governments implement an integrated • establishing a prevention planning committee that involves approach to supporting vulnerable young people. It should senior staff from all relevant government departments; focus on providing continuing support for children and • instituting regular processes to ensure the voice of youth is adolescents who have been affected either by parental or heard in drug policy and strategy implementation; and personal drug use, and proactively support them to: • establishing a clearing house to disseminate information • stay at or return to school; about effective drug prevention strategies in association with • move into higher education, TAFE, apprenticeships or work; the resource team proposed in recommendation 2.7. and [Chapter 5] Section 5.9 • engage in positive social and recreational activities not related to drug use [Chapter 5] Section 5.8.5

Prevention involves reducing the damage done by drug use, including that done to dependent users. An integrated strategy that works directly with these people is urgently needed in areas affected by heavy street usage and across the State.

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Treatment and support Recommendation 3.3 The health and social consequences of sustained That the Government undertake a systematic review of drug use are serious and long lasting. The State prescriber and dispenser arrangements with each General needs a range of services that are capable of Practice Division and local pharmacists to: providing proactive intervention and support at the • identify strategies that will increase prescribing and earliest opportunity, meeting the general health dispensing to enable continued methadone program needs of drug users, and providing specialist growth; and treatment for those with more serious problems. • prepare for the introduction of additional pharmacotherapies. The specialist services also have an obligation to [Chapter 6] Section 6.3.3 provide professional advice and technical support to other service providers. Recommendation 3.4 That the Government initiate discussions with the Commonwealth Government about long-term support for Recommendation 3 pharmacotherapy service. This should include funding support THAT THE VICTORIAN GOVERNMENT CONTINUE THE for methadone and new pharmacotherapies DEVELOPMENT OF TREATMENT SERVICES AND GIVE [Chapter 6] Section 6.3.3 PRIORITY TO THE FURTHER LINKAGE OF EARLY INTERVENTION, SPECIALIST TREATMENTS AND Recommendation 3.5 MAINSTREAM SERVICE PROVIDERS, THE DEVELOPMENT That the Government enhance training for pharmacotherapy OF PHARMACOTHERAPY SERVICES, AND THE providers to strengthen the current service and prepare for the REHABILITATION AND REINTEGRATION OF DRUG USERS. introduction of new pharmacotherapies. [CHAPTER 6] [Chapter 6] Section 6.3.3

Increased recognition needs to be given to the importance of Recommendation 3.6 early intervention in people’s drug using and the role general That the Government commission the preparation of a revised practitioners can play in this area. and updated heroin trial design, and give consideration to taking a leadership role in establishing a trial as soon as circumstances Recommendation 3.1 make this possible. That the Victorian Government work with the Commonwealth [Chapter 6] Section 6.3.3 Government and Divisions of General Practice to enhance the effectiveness of general practitioners in interventions in drug- Safe dispensing of methadone requires very regular attendance at related issues, and their willingness to participate in the community pharmacies. Other pharmacotherapies will also require pharmacotherapy service. routine attendance. The cost burden for this currently falls on the [Chapter 6] Section 6.3.1 former drug user. This can be a disincentive, particularly for those at the beginning of the program, or whose age limits their capacity Opiate dependence causes widespread concern to the to earn an income. community. Provision of methadone is a core of the treatment plan for many of these people. Growth in the system in recent years has Recommendation 3.7 placed substantial strain on providers and dispensers and so, for That the Government introduce a program to reduce the cost to some people, the service is less than optimal. Important research drug users of receiving methadone. The subsidy should meet done in this State on alternative pharmacotherapies means there is the full cost for all those aged under 18 years, all who are now the potential to establish an integrated pharmacotherapy subject to juvenile justice orders, and the first eight weeks for service over the next few years. This integrated service will have to adults on the program. be able to sustain continued growth in the order of 15 per cent [Chapter 6] Section 6.3.3 over each of the next three to five years. Further research is also required in this area and should include preparation for a future In recent years, there has been substantial growth and improved formal prescribed heroin trial. capacity in specialist treatment services. The key priorities for the future should be providing the existing service system with the Recommendation 3.2 capacity to more effectively deal with the complex needs of That the Government introduce departmental and service service users, integrating the pharmacotherapy services, and delivery arrangements that seek to ensure every drug user, for supporting non-specialist services in their dealings with people whom it is appropriate, has access to methadone or other affected by drug use. pharmacotherapies and is supported by the specialist treatment system. [Chapter 6] Section 6.3.3

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Recommendation 3.8 Recommendation 3.14 That the Government refocus the specialist drug treatment That the Government establish a working group to build on the program structure to provide for: Youth Substance Abuse Service and to consider additional • simple, short-term and one-off treatment episodes; models for providing drug treatment specifically to young people. • flexible pathways through all stages of treatment, and [Chapter 6] Section 6.4.1 rehabilitation and reintegration for drug clients with complex and social deficits and needs; and Recommendation 3.15 • formalised links between pharmacotherapies and all drug That the Government set aside a proportion of new public and treatment services. community housing acquisitions for young people and adults [Chapter 6] Section 6.3.3 seeking to re-integrate into the community whilst dealing with the consequences of drug dependency, including people Recommendation 3.9 recently released from prisons or youth training centres, and That the Government undertake regional planning reviews to: who are otherwise unable to secure stable affordable • introduce regional assessment and referral arrangements accommodation. that facilitate the provision of integrated client services; and [Chapter 6] Section 6.4.5 • ensure pharmacotherapy provision is directly linked with other treatment services. Recommendation 3.16 [Chapter 6] Section 6.3.3 That the Government ensure community agencies directly involved in working with vulnerable young people and young Recommendation 3.10 offenders are supported to provide counselling and assistance That the Government ensure funding (unit costs) and directly rather than brokered through separate organisations accountability (service agreements) arrangements be amended [Chapter 6] Section 6.4.5 to accommodate the revised service framework proposed and the different cost structures for providers that will result from It is important that the Government moves to correct the mismatch creating improved career structures. between community expectations about drug treatment, and the [Chapter 6] Section 6.3.3 research outcomes that indicate drug dependence is a chronic relapsing condition most likely to require multiple treatment Recommendation 3.11 episodes. The drug treatment system is now a complex and That the Government support accreditation of funded alcohol diverse service that requires considerable support. and drug treatment services, against standards developed for the purpose, by a registered accreditation body as part of a Recommendation 3.17 quality assurance strategy. That the Government develops strategies aimed at increasing [Chapter 6] Section 6.3.3 the level of understanding of drug users, their families/significant others and the general community about drug dependence, Recommendation 3.12 drug treatment services and the drug treatment process. That the Government ensure that the broader health and welfare [Chapter 6] Section 6.2.2 service system have the support of the specialist drug treatment services through specialist consultancy, technical advice and support services. [Chapter 6] Section 6.3.3

Recommendation 3.13 That the Government ensure the specific needs of women are considered in treatment service planning by: • making available gender-specific treatment options; and • facilitating access to child care as required. [Chapter 6] Section 6.4.3

Young people experiencing difficulties as a result of substance misuse are a key priority. Improved services have been developed in recent years. Attention to the needs of young people leaving the juvenile justice system is required and to those who are homeless.

Recommendations 182

Criminal justice and law Recommendation 4.4 That Victoria Police continues to invest in harm-minimisation enforcement training, and monitors and appraises members’ performance The role of law enforcement in dealing with drug following training. The investment should continue to include issues has traditionally received particular members at all levels of the force. emphasis, both in policy and resource terms. [Chapter 7] Section 7.2 While a stronger focus on prevention, treatment and capacity building is now appropriate, the law The importance of community involvement in drug-related issues enforcement system remains central to an effective and crime prevention has been emphasised in this report, as it drug strategy. was in the Committee’s Stage One report. So too has the role of local government in facilitating local planning. Police involvement in these community-based initiatives is vital. Recommendation 4 Recommendation 4.5 THAT THE VICTORIAN GOVERNMENT CONTINUE TO ACKNOWLEDGE THE IMPORTANT ROLE THAT ALL That local government establish a community-based forum COMPONENTS OF THE CRIMINAL JUSTICE SYSTEM PLAY focused upon drugs, community safety and crime prevention in IN AN OVERALL HARM-MINIMISATION STRATEGY. which police and other stakeholders participate where such a [CHAPTER 7] forum does not currently exist [Chapter 7] Section 7.2

Victoria Police has demonstrated a strong commitment to harm minimisation, local and State partnerships and continued vigilance Victoria has provided leadership in the development of diversion in tackling commercial and serious trafficking while actively programs and the courts have an important role in these diverting drug users from the system. The development of the programs. The level of drug-related crime means the courts will drug diversion initiative is a major achievement that will be critical continue to have to deal with a large number of complex cases in assisting drug users and reducing the load on courts and that cannot be diverted. It is important that the courts are well corrections systems in the future. supported to meet their justice responsibilities through sound legislation and effective technical and other support services. Recommendation 4.1 That a Victoria Police reference group be established involving Recommendation 4.6 senior police, health and other representatives to: That the Government continues to develop the range and • provide advice about the implications of new directions and number of programs that link drug-dependent defendants with strategy; appropriate support services including drug-specific, general • review the overall drug strategy of Victoria Police; and health, accommodation and employment services. • provide advice on indicators to be used by police to monitor [Chapter 7] Section 7.3.4 and inform police drug efforts. [Chapter 7] Section 7.2 Recommendation 4.7 That the Government support the phased establishment of an Recommendation 4.2 integrated court drug program in the Magistrates’ Court. The That Victoria Police ensure local drug law enforcement program should: operational policies and strategies are discussed on a regular • enhance magistrates’ specialist knowledge of drug issues basis with relevant agencies. This will ensure operational relevant to their responsibilities; decision making is well informed and, where appropriate, that • improve targeting of assessment and court support services; backup support is provided by these agencies. • enhance linkage to relevant community support services; [Chapter 7] Section 7.2 and • increase supervision by the court of the offenders’ Recommendation 4.3 compliance with the program commensurate with the level of risk of each offender. That regional commanders within Victoria Police ensure: [Chapter 7] Section7.3.4 • drug law enforcement strategies are monitored to ensure that negative impacts do not occur in other areas; and • strategies that reduce the harm from drugs are implemented Recommendation 4.8 across districts That the Government commission an independent review of its [Chapter 7] Section 7.2 diversion programs including COATS and CREDIT in 2002. [Chapter 7] Section7.3.4]

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 183

The courts are dealing with a growing number of drug-related Recommendation 4.13 cases and many involve increasingly complex challenges. The That in the context of the current review of the Sentencing Act courts depend on the social infrastructure in many ways and their 1991, the Government consider the potential role of deferred dependence needs to be recognised. and suspended sentences for those who have committed drug- related offences, conditional upon them attending drug Recommendation 4.9 treatment and relevant supporting programs. [Chapter 7] Section 7.3.3 That the Government ensure appropriate accommodation and support facilities are available to people with drug problems who would otherwise be refused bail, and that special provision is Recommendation 4.14 made for young people. That the Government repeal section 75 of the Drugs Poisons and [Chapter 7] Section 7.3.2 Controlled Substances Act 1981. [Chapter 7] Section 7.5.1]

Increased misuse of drugs, high numbers of arrests compared with other States and revised sentencing laws mean the Recommendation 4.15 corrections system is facing increasing demand. Current service That the Government undertake a review of the Alcoholics and provision arrangements are clearly inadequate. Drug-dependent Persons Act 1968. [Chapter 7] Section 7.5.3 Recommendation 4.10 That the Government ensure the Community Corrections Service There is increasing evidence that cannabis has a therapeutic has the resources and the breadth and depth of skills required benefit for people suffering from a small number of conditions to meet the needs of drug-using offenders. such as advanced cases of cancer and AIDS. There is renewed [Chapter 7] Section 7.4.3 interest worldwide and rigorous scientific trials are being conducted in the United Kingdom and elsewhere. While awaiting Recommendation 4.11 the outcome of the trials, some discretion should be used by Victoria Police and the courts. That Victoria Police, the Office of the Correctional Services Commissioner and the Department of Human Services establish a system that will enable the health records of defendants and Recommendation 4.16 offenders to travel with them during their time in the custody of That Victoria Police and the courts use their discretion when police and the adult corrections and juvenile justice services. dealing with people using cannabis to manage the symptoms of [Chapter 7] Section 7.4.4 serious, debilitating and often terminal conditions for which there are indications of therapeutic effect. Recommendation 4.12 [Chapter 7] Section 7.5.2 That the Government support the proposed major initiatives of the Office of the Correctional Services Commissioner in relation to a prison drug strategy, and the development of new initiatives in its drug strategy in the juvenile justice system. In particular, those which: • make available appropriate and consistent drug treatment programs including methadone and other pharmacotherapies; • render unnecessary multiple assessments; • incorporate active and appropriate harm-reduction strategies such as needle and syringe services; and • seek to reduce drug use of prisoners. [Chapter 7] Section 7.4.4

The effectiveness of the response to drugs is, in part, affected by the legal arrangements established by the Government. The legal regime affects prevention, treatment and law enforcement systems and needs regular review.

Recommendations 184

Supporting and developing the Recommendation 5.3 That the Government support the establishment of an drug strategy independent statutory body to assist in the implementation of Government initiatives and leadership are the drug strategy by: essential to the development of a drug strategy • advising the Government on ongoing options for drug that has the capacity to respond to the extent and policy reform; complexity of the problem. However, government • supporting the engagement of the community in informed initiatives alone will be insufficient. Local discussion regarding drug matters; and government, business, community organisations • advising on the monitoring, research and evaluation and individuals all have critically important roles to strategies required. play. One of the State Government’s most [Chapter 8] Section 8.3 important roles is to encourage, support and resource the effective engagement of the Skilled and flexible workforces will be required in many health, community in drug issues. welfare, education, court and justice services if the challenge of dealing with drugs more effectively is to be met. This includes those involved in prevention as well as the various intervention Recommendation 5 services. Senior managers and operating staff need to be assisted to more effectively deal with drug issues as part of their Recommendation 5.1 routine work. That the Government continue to support the community’s and local government’s roles in drug strategy. Recommendation 5.4 [Chapter 8] Section 8.2 That the Government require the preparation and implementation of consistent workforce development strategies that seek to ensure: The range of services and agencies involved in drug issues is • there is a highly skilled and competent specialist service necessarily large and diverse. It is important to recognise that the workforce supporting those most affected by substance infrastructure supporting drug strategy has been outgrown by misuse; and recent changes and a more comprehensive underpinning is • relevant staff in all social infrastructure programs are required. Complex challenges are still to be met. Particular equipped with the necessary range and levels of challenges will have to be addressed if the new services competencies to deal with drug issues. proposed and the revised arrangements outlined in this report are [Chapter 8.3.1] to be established and work effectively.

Recommendation 5. 2 Recommendation 5.5 That priority be given to: That the Victorian Government ensure the drug strategy is • expanding and better resourcing postgraduate training supported by an adequate investment in workforce opportunities in addiction-related studies for relevant development, research, monitoring, evaluation and ongoing disciplines including medicine; policy development. • ensuring salary and other incentives are provided to attract [Chapter 8] Section 8.3 skilled staff into roles involving work with people affected by substance use; Ensuring that the drug strategy is effective requires policy • introducing basic training requirements for staff in drug and monitoring and review. External input to policy making and alcohol services; implementation is required. This process can also provide critical • providing induction training for new staff within the treatment information to the community and key stakeholders about system given the service expansion; emerging issues, and help in maintaining an informed community • providing special training for operational police, particularly debate on drug issues. The partnership between the Government those likely to directly interface with drug use and dealing; and the community that has been advocated throughout this and report should include a close working relationship between the • supporting ongoing and integrated in-service training and Government and an independent body that collaborates in development across generalist and specialist providers at supporting implementation of the drug strategy. the regional level. [Chapter 8] Section 8.3.1

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 185

Developing and maintaining effective service systems and Conclusion recognising the impacts of, and gaps in, service systems requires This report, and the recommendations outlined above, provide a regular and rigorous data gathering, monitoring and evaluation. framework for drug strategy development for the next five or more Strategies for these functions need to balance the routine years. Much of what is recommended can be implemented requirements of managers and the need for a wholistic system- quickly but will take time to have a positive impact on the wide picture. These needs are statewide, regional and local. problem. Other recommendations will require careful planning and can only be implemented in the medium term. Whatever the Recommendation 5.6 timeframe, the strategy will require many partners and sustained That an assessment is made of the data required to monitor and effort if the Victorian community is to ‘Meet the Challenge’. manage the drug strategy. Key areas for inclusion in an enhanced and integrated monitoring strategy are: • data required to monitor Victorian and local drug trends and dynamics; • data required to monitor drug trends nationally and internationally; • strategies for gathering and assessing information about best practice models; and • assessment of the effectiveness of the service responses. [Chapter 8] Section 8.3.2

Recommendation 5.7 That the Government support the preparation of a drug policy evaluation strategy, in conjunction with the body recommended in 5.3, that: • focuses on critical areas of policy and strategy; • emphasises the need for outcome evaluation; and • recognises the cross-policy imperatives of the drug strategy. [Chapter 8] Section 8.3.2

Recommendation 5.8 That the Government support and encourage the development of national monitoring and evaluation strategies that provide a comparative basis for assessing drug effort and effectiveness. [Chapter 8] Section 8.3.2

In a policy area as diverse, complex and rapidly changing as drugs, research is a key priority. Research is needed to inform practice and the development of services within the current policy framework, and to provide material that can also be used to inform new policy.

Recommendation 5.9 That the Government support, in conjunction with the body recommended in 5.3, a research strategy in consultation with relevant stakeholders that: • establishes State priorities; • focuses on applied research; • attracts funding for State priorities from a range of research funding and community bodies; and • ensures effective dissemination of the research results. [Chapter 8] Section 8.3.3

Recommendations 186

Appendices

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 10 187

Appendix 1: Drug Policy Expert Committee Stage 2 Terms of Reference

In the context of the Government’s licit and illicit drug policy, the In providing advice on these matters, the Committee should: Drug Policy Expert Committee will, following consultation with local • consult with social policy, drug and legal experts and local councils, community, business and other stakeholders, provide government; reports on: • take account of Commonwealth government policies and A. Options for strengthening legal and illegal drug prevention, planned outlays within Victoria as they may impact upon treatment and control strategies in ways that would be government policy; consistent with the policy, and which address shortcomings of • use available evaluations and data, review the effectiveness of existing drug strategies as identified by independent evaluators existing services and arrangements; and key stakeholders. • assess the civil, criminal and inter-governmental issues relating to proposals which may require legislative change; and B. The implications of changing patterns of demand and supply • take account of the need to ensure services are appropriately and recent developments in the prevention, treatment and linked to, and integrated with, primary health, community control of all non-prescribed drugs nationally and welfare and mental health services. internationally. C. Arrangements that would assist community, local government and expert stakeholders to support and be involved in the drug policy initiatives. D. Leadership, accountability and coordination arrangements across government required to maximise the effectiveness of the policy. E. The most appropriate range and mix of interventions required to implement the Government’s policy and achieve its policy goals.

Appendices 188

Appendix 2: DRUG POLICY EXPERT COMMITTEE

Dr David Penington, AC (Chair) Cr Dick Gross David Penington holds degrees in medicine from the University of Dick Gross was the Mayor of the City of Port Phillip. In that Oxford and an honorary Doctorate of Law from the University of capacity he has conducted an award winning campaign on the Melbourne. He has held the positions of Dean of the Faculty of regulation of foreshore development as well as taking an interest Medicine, University of Melbourne (1978-83) and Vice Chancellor in drug law reform. He is a lawyer and was the coordinator of the of the University of Melbourne (1988-95). His extensive career has Consumer Credit Legal Service. He conducts his own small spanned positions on a number of high level university and business. governmental boards and committees, including membership of Mr Robert Richter QC the National Health and Medical Research Council (NH&MRC) Robert Richter is a barrister with a long standing interest in social (1982-87) and Chair of the Australian Red Cross Blood policy matters. He was a member of the Committee of the Transfusion Committee (1976-83), the AIDS Task Force (1984-87) Criminal Bar Association of Victoria and of the Victorian Bar and the Victorian Premier’s Drug Advisory Council (1995-96). Dr Council from 1997 to 1999. He was President of the Victorian Penington has since chaired an advisory committee for the Council for Civil Liberties from 1994 to 1996, and a Part-time Australian Capital City Lord Mayors (1996-99), recommending Commissioner of the Law Reform Commission of Victoria from strategies to handle the problems associated with illicit drugs. In 1989 to 1992. November 1999 the Victorian Government appointed Dr Penington to chair the Drug Policy Expert Committee. The Mr Bernie Geary Committee was established to provide advice on the Bernie Geary is the Director of Programs at Jesuit Social Services. implementation of a range of drug policy initiatives. He is a member of the Victorian Youth Parole Board, Chair of the In addition to the above, Dr Penington is President of the Banyule Community Legal Service and is on the Boards of Museums Board of Victoria, and is chair of Cochlear Ltd, the Management of the Banyule Community Health Centre, and the company that produces and markets worldwide the bionic ear. Youth Substance Abuse Service. He has had significant He is a Director of Pacific Dunlop Ltd and a Principal of Foursight community experience including 25 years as a youth worker. He Associates Pty Ltd. is also a member of Archibishop Pell’s Drug Advisory Council and a member of the Victorian Police Ethics and Standard’s Advisory Professor Margaret Hamilton Committee. Margaret Hamilton is the Director of the Turning Point Alcohol and Dr Rob Moodie Drug Centre. Her experience in the drug and alcohol area spans 25 years and includes clinical practice, education and research at Rob Moodie is CEO of VicHealth, Editor of the Australian Health the University of Melbourne in both social work and public health. Promotion Journal, and has professional appointments in public She has had extensive involvement in senior policy and advisory health at Melbourne and Monash Universities. He was previously bodies at the state and national levels. She was a member of the a Director in the joint UN programme on AIDS (UNAIDS) based in Victorian Premier’s Drug Advisory Council in 1995-96 and is a Geneva, and is currently a Board member of Medicins Sans member of the advisory committee to the Capital City Lord Frontiers (MSF) Australia. Mayors. She has published widely on drug related matters. Professor Pat O’Malley Pat O’Malley is Professor of Law and Legal Studies at La Trobe University and was a member of the Victorian Premier’s Drug Advisory Council in 1995-96. He has researched and published extensively on the governance of illicit drugs and on risk in relation to crime and crime prevention.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 189

Appendix 3: Glossary

PLEASE NOTE, THIS GLOSSARY OF TERMS REFERS ONLY Dependent use TO HOW THE FOLLOWING TERMS ARE USED IN THIS Using drugs in a regular pattern because of the loss of voluntary REPORT. DIFFERENT DEFINITIONS MAY EXIST IN OTHER control over drug taking to the point where a drug or drugs must CONTEXTS. be present to facilitate daily activities and avoid the onset of Abstinence withdrawal. To not use a drug, or a type of drugs, with the aim of remaining Detoxification free of the influence of that drug or drugs. The process of remaining abstinent from a drug or drugs upon Abuse which one is dependent to experience withdrawal symptoms, and The different meanings that have become attached to this term, remain abstinent from that drug or drugs so withdrawal symptoms and the possible negative implications associated with it, mean it subside, meaning the drug is no longer required for normal has not been used in this report. functioning. Addiction Drug To become dependent on a substance or substances to the point A chemical substance that, once ingested, exerts a where an individual cannot operate normally without that substance pharmacological effect. or substances being present in the body at particular levels. Experimentation/experimental use Binge The non-habitual use of a drug or drugs with the aim of Heavy drug use over a period of time set aside specifically for the experiencing the effects of that drug. purpose of using drugs that may be either legal or illegal. For Harm minimisation legal drugs, a binge would involve use at levels in excess of the The limiting of the harm caused to individuals and the community National Health and Medical Research Council guidelines; illegal by the use of harm-reduction, demand-reduction, and supply- drugs have no such limits determined. reduction measures. Community strengthening Harm reduction Increasing the ability of a community to deal with the problems Strategies aimed at minimising the harm associated with drug facing it and support its members. use. These often involve providing information (and, in some Decriminalisation instances, equipment) to enable the use of particular drugs to be “Decriminalisation” as used in this report means changing from a done more safely. system of total prohibition to partial prohibition. Under a system of Demand reduction total prohibition, the use, possession, production and distribution Strategies aimed at reducing the demand for drugs, including of a specified drug is a criminal offence. Under a system of partial prevention strategies prohibition, the production and distribution of the drug is a Supply reduction criminal offence, but the use of the drug is not a criminal offence and the production and possession of a small quantity of the drug Strategies aimed at reducing and/or better regulating the drug is not an offence if it is for the purpose of personal use. supply in a community. Demand reduction Harm reduction see: Harm minimisation. see: Harm minimisation. Dependence Illegal drug The loss of voluntary control over drug taking to the point where a Refers to drugs or a class of drugs that, under the law, are drug or drugs must be present to facilitate daily activities and prohibited from being supplied, possessed, used and trafficked. avoid the onset of withdrawal. All of these are prosecutable offences. Psychological dependence Legal Usually develops over time where drug use becomes far more In this report, this term refers to drugs that are suppliable under important than other things in an individual’s life. It includes current laws; however, the use of drugs in certain contexts may be feelings of craving for the drug and an inability to cope without it. illegal, such as underage drinking or the supply of prescription drugs without an appropriate prescription. Physiological dependence Legalisation Usually develops as a result of adapting to consistent levels of a drug or drugs in the body. It results in tolerance of a drug or The process of changing the status of a drug from illegal to legal. drugs, meaning that higher levels of the drug are needed to Maintenance therapy produce effect. Sudden cessation of drug use will most often Treating drug dependence by medically prescribing a substitute result in onset of withdrawal symptoms. that has similar properties but is legally produced and the contents of which are pharmacologically known.

Appendices 190

Misuse Recreational use The use of drugs in such a way as to cause harmful The occasional use of legal or illegal substances in the context of consequences to one’s legal, personal or health status. attempting to enhance the enjoyment of activities such as social Opiates interaction or leisure. A range of drugs that are derived from the opium poppy and are Rehabilitation strong central nervous system depressants and pain killers. Drugs The process of recovery from an acute episode of drug treatment. include opium, heroin, morphine and codeine. Reintegration Pharmacotherapy The process of assisting those recovering from drug treatment The provision of prescribed drugs to people dependent on more back into the community with the aim of living independently. hazardous substances. Resilience Prevention Personal resources an individual calls upon to deal with problems Primary prevention that may arise from entering different social settings and The employment of strategies aimed at avoiding the uptake of encountering life events. drug use among non-users. Risk factor Secondary prevention Elements of community, school, family and individual/peer The employment of strategies aimed at preventing problematic relations that appear to contribute to the increased likelihood of substance use and the progression of use to the point of the development of later problems. dependence. Social marketing Tertiary prevention The use of mass media and more targeted communication The employment of strategies aimed at reducing harm among strategies with the aim of providing information and creating a those with problematic substance use and to assist those with this climate of behavioural change. level of use to reduce or discontinue use. Substance use Polydrug use The ingestion of substances, legal or illegal, on a regular basis. The regular use of one or more drugs that may be either legal or Substance use problem illegal. see: Problematic substance use. Problematic substance use Supply reduction The regular use of a substance, legal or illegal, to the point where see: Harm minimisation. the consequences of that drug use impact negatively on a user’s Therapeutic community life. Residential-based, group treatment programs that aim to provide Protective factor rehabilitation from drug dependence, usually in an isolated and/or Elements of community, school, family and individual/peer highly structured environment with strict rules applying to the relations that appear to provide an armour against the behaviour of group members. development of later problems. Tolerance Psychoactive The adaptation response resulting from repeated exposure to The cognitive and behavioural effects resulting from the use of a either a particular drug or drugs, with the effect that increased substance. amounts of that drug or drugs are needed to obtain effect. Physiological dependence Withdrawal see: Dependence. The process experienced by a drug-dependent person when the Psychological dependence effects of a drug wear off. Withdrawal is characterised by physical see: Dependence. and psychological symptoms that can last for several days, weeks, or months depending on the drug and other factors.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 191

Appendix 4 : Drug Policy Expert Committee comment on the report of the Victorian Coroner

State Coroner’s report recommendations DPEC comment

Recommendation 1 The Committee endorses much of the analysis that underpins the recommendation to establish an independent centre with responsibility for The Victorian Government consider the establishment of a research, evaluation and policy development. However, the Committee doubts government-funded independent centre or institute that some of the other functions can effectively be undertaken in the way established by statute for the management of drug proposed. addiction and dependency with a primary responsibility to develop drug strategy, conduct and/or coordinate One of the themes of the report is that drug policy and strategy is necessarily research, assist in coordinating drug addiction services, the responsibility of many bodies, organisations and arms of government. A evaluate and audit the operation and effectiveness of single, independent agency may be able to take direct responsibility for some strategies and services. parts of the specialist service system, but cannot take responsibility for the many other agencies and services now dealing with drug issues as part of Ideally, in the long term, with the potential for involvement their ordinary business. Statewide coordination is important and improvements of the Federal and other State and Territory Governments, need to be made. More importantly, the collaborative arrangements between any such institution could also be decentralised service providers at the local and regional level must be improved, and this throughout Australia. needs to built up through quality practice rather than through a central body. Separating the funding and accountability of drug-related policing from other aspects of the work of Victoria Police would be counterproductive, particularly given the development of local priority policing. The need for external input to policy making, research and evaluation is critical, and the Committee’s reports make proposals on these matters that achieve the goals underpinning the Coroner’s recommendation. They seek to establish partnerships in which government leadership and resources are central and support local agencies and communities to tackle the drug issue.

Recommendation 2 The Committee recognises the importance of developing consistent approaches to case management, but has not had the opportunity to fully That the respective Victorian Departments of Human assess the benefits of an integrated system. The Committee recognises there Services and Justice consider introducing a statewide, would be considerable difficulty in achieving this goal given the diverse range of integrated case management system for all drug addicted needs and issues other than drugs being addressed by each service system. persons to assist in managing all relevant health, justice (including the prison system) employment and housing The Committee does recommend: needs of the individual client (it may also be necessary to That Victoria Police, the Office of the Correctional Services Commissioner and consult with a wide range of government departments and the Department of Human Services establish a system that will enable the agencies as a precursor to the introduction of a case health records of defendants and offenders to travel with them during their management system). time in the custody of police and the adult and juvenile justice corrections Standards should also be developed for the delivery of a services. statewide management system. This would ensure clients The Committee strongly supports to proposal that families are involved in all receive the best possible management assistance, which aspects of drugs including treatment. also could be audited against the standard. The case management system should also have, as one of its aims, the involvement (where appropriate) of the client’s family and other support networks. It is essential that the case management system should continue to apply (where practical) whether or not the client is in treatment.

Recommendation 3 Chapter 6 of this report deals, in detail, with the issue of demand for treatment services. The Committee recognises the new services will be established as a The Drug Policy Expert Committee with the Departments of result of the State Government’s drug policy and the Commonwealth/State Human Services and Justice should consider forming a Drug Diversion program. The Committee makes numerous recommendations subcommittee of appropriate agencies and experts to about reform and enhancement of the treatment system. examine whether there is a statewide problem with availability of treatment services, their nature (or direction), whether the programs are regularly evaluated and knowledge of relevant client groups of the service. In the event that problems are identified, then countermeasures may need to be developed and resourced.

Appendices 192

State Coroner’s report recommendations DPEC comment

Recommendation 4 The Committee encourages all schools to be involved in drug education and in working with the whole school community to prevent use and misuse of drugs. It is of serious concern that all independent schools are Chapter 5 of this report highlights the role that schools play in prevention, and not involved in Turning the Tide initiative. The Drug Policy the benefits that drug education can provide if done in this broad context. Expert Committee with the Department of Education, Human Services and Justice (with representatives from independent and Catholic schools) consider developing ways of encouraging all independent schools to be involved in the programs as the drug (and deaths from drugs) issue cuts across, and will continue to cut across, all sectors of our society.

Recommendation 5 The Committee endorses the need for a broadly based drug information strategy that would include the activities proposed. This is discussed in It appears that some individuals in the community, relevant chapter 5. professionals and agencies working in the drugs area (ambulance service, general practitioners, nursing profession, psychologists, psychiatrists, courts, etc.) may not fully understand the extent and breadth of the work being undertaken by our educational system. This is an issue that may need addressing. Accordingly, the Department’s of Education, Human Services and Justice should urgently consider developing appropriate mechanisms to regularly disseminate information on educational directions in the area of drugs (and receive feedback) from a wide range of professional agencies working on the issue of drugs. The general community may also need to be made aware of the thrust (and long-term structural nature) of the current education programs.

Recommendation 6 This recommendation is supported and should be considered in the development of the overall prevention strategy discussed in chapter 5. The Department of Human Services and the Education Department consider working with universities on the issue of drug awareness and education to university students (especially to those who have moved from country areas to the city).

Recommendation 7 The Committee endorses this recommendation and, in chapter 5, makes recommendations on actions that should be taken to better equip the One of the key educational strategies, to be fully education system to support at-risk young people. supported at every level of the system, should be that of early identification of an intervention with potentially ‘at risk’ children or young persons, followed up by programs designed to avoid the cycle leading to drug taking. Training should be considered for teachers to improve their capacity and skill in the identification of at risk students.

Recommendation 8 The Government has announced its commitment to a range of parent information, education and support strategies including the development of a The Department of Human Services consider establishing new parent telephone support service. The Committee recommends the a well-resourced, specialist unit in Melbourne (with development of a broad range of family support initiatives as part of its representatives in country regions) aimed at providing prevention strategy. This issue is discussed in chapter 5. advice, assistance and practical support to families of drug-addicted persons. Ideally, the service would provide ongoing direct assistance and advice. It would also provide links for families to other support services throughout the community.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 193

State Coroner’s report recommendations DPEC comment

Recommendation 9 The Committee proposes that the Government adopt a broadly based prevention strategy including a drug information and education component The Drug Policy Expert Committee with the Department of that would deal with the issues raised in this recommendation. The issues Human Services should urgently consider forming a outlined in the Coroner’s recommendation are dealt with in chapter 5. subcommittee of appropriate agencies and experts (with advice from users/families) to determine (by way of example): * a simplified and uniform list of common risk factors and appropriate health (or other) messages directed toward harm minimisation (to be used statewide by all agencies); * the best mechanisms whereby the information contained in the list can be disseminated to the appropriate groups and individuals; * examine the benefits of using treating medical practitioners and dispensing pharmacists to disseminate the uniform messages to drug-addicted patients; * examine the benefits of utilising peer groups to disseminate the information; and * examine the feasibility and potential effectiveness of a major television/radio press campaign delivering the risk/health management messages.

Recommendation 10 The Drug Policy Expert Committee believes these recommendations should be included in the Heroin Overdose Prevention strategies announced by the The Drug Policy Expert Committee with the Department of Government and integrated into local drug strategies being developed at the Human Services should urgently consider forming a municipal level. The Committee recommends that the Government establish a subcommittee of appropriate agencies and experts to strategy that involves drug users in preventing further harm, and this would review the level of information available for families (and deal with the specific matters raised in the Coroner’s recommendation. others) on how to recognise (that is, unrousable or loud snoring) and manage a potential emergency with the person who may be at risk. The findings (and recommendations) of Coroner Lambden in Vanderburgt (and the 1996 methadone-related findings) should also be considered in the context of this subcommittee. Adequate resources will need to be made available to disseminate the information and provide appropriate advice support mechanisms. The message about the very limited role of the police when an ambulance is called should be regularly disseminated. As indicated Victoria Police are concerned about saving lives - so the message should be to call an ambulance.

Recommendation 11 See 10 above. Once the uniform risk messages have been developed, the media (print, television and radio) should consider regularly highlighting the risks and the dangers associated with taking heroin combined with other drugs such as benzodiazepines and/or alcohol. The media should consider delivering its messages in accordance with the recognised and uniform risk messages. (Note: The use of the term ‘heroin’ alone without a full explanation of the risk factors of using in combination with other drugs and/or alcohol use may be fraught with danger for the community of users as it does not assist in educating the community as to the true picture and extent of the problem and its risks.)

Appendices 194

State Coroner’s report recommendations DPEC comment

Recommendation 12 See 10 above. Once the uniform messages on warning signs are developed, the media (print, television and radio) should consider regularly highlighting the warning signs associated with potential drug overdose and encourage intervention by calling the ambulance.

Recommendation 13 The Drug Policy Expert Committee supports this recommendation. The Federal Health Department (with State and Territory Health Departments and representatives of the medical and pharmacy professions) develop, and implement as a matter of urgency, a computer aided system to begin to manage the problem of ‘doctor’ and ‘pharmacy shopping’. The system would need to be readily available to all prescribing medical practitioners and/or dispensing pharmacies. It would also need to operate in real time.

Recommendation 14 The Drug Policy Expert Committee supports this recommendation. The Federal Health Department (with State and Territory Health Departments and representatives of the medical and pharmacy professions) develop appropriate health management programs (and education packages for the medical/pharmacy professions) to deal with problems occurring as a result of reduction of the amount of therapeutic drugs available on prescription to individual drug addicted patients.

Recommendation 15 The Drug Policy Expert Committee supports this recommendation. In the interim (before the introduction of a universal real time system to manage the issue of ‘doctor’ and ‘pharmacy shopping’) the Australian Council for Safety and Quality in Health Care with the Australian Medical Association and the Doctors Reform Society should consider reinforcing the need for all medical practitioners to be aware of all the risks associated with prescription of benzodiazepines to patients who may be heroin users.

Recommendation 16 The Drug Policy Expert Committee endorses this recommendation and believes it should be given priority by Divisions of General Practice. 1. The Australian Council for Safety and Quality in Health Care, the Australian Medical Association, the Doctors Reform Society and the Peek Pharmacy Associations (with any other relevant experts) should consider the development of training packages for the medical/pharmacy professions to reinforce the issues and risks associated with treating patients who may be drug addicted. 2. As part of the development of training packages, medical treatment protocols for patients seeking therapeutic drugs of potential addiction or dependence should also be developed. Such protocols should also require regular follow up of the patient by the prescribing medical practitioner. 3. Training packages/protocols could also be distributed to the medical/pharmacy professions via the Internet. 4. The medical/pharmacy professions should also consider distributing the uniform information on risk and managing and emergency to its patients/customers (also see Recommendation 9).

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 195

State Coroner’s report recommendations DPEC comment

Recommendation 17 The Drug Policy Expert Committee supports this recommendation. Also in the interim (before the introduction of a universal real time system to manage the issue of ‘doctor’ and ‘pharmacy shopping’) the College of General Practitioners with assistance from the AMA and the Victorian Department of Human Services consider a review of the 1993 publication for general practitioners by the Victorian Medical Postgraduate Foundation dealing with ‘Drug Seeking for Benzodiazepines’ to bring the information up to date. As part of the process of review of the 1993 guide it may be necessary to access similar publications in Australia or overseas. Any document developed by this process could be useful to the agencies developing training packages (see Recommendations 16 (1) and (2) above). The development of a new publication could assist in further drawing the attention of the medical profession to the extent of the problem with all areas of ‘doctor’ and ‘pharmacy’ shopping (not just related to illicit drugs).

Recommendation 18 The Drug Policy Expert Committee does not believe the recommendation in this form can be justified. The volume of drug prescriptions that would be The Victorian Health Department consider urgently included would impose burdens on prescribers and pharmacists without a rescheduling all Benzodiazapines to come under the sufficient community benefit to justify the cost. operation of Schedule 8 of the Drugs, Poisons and Controlled Substances Act 1981 (as amended) and Drugs, Poisons and Controlled Substances Regulations 1995.

Recommendation 19 The Committee supports the need for a Narcan trial, in the first instance, which focuses on staff working directly with users in areas of high street usage. This The Drug Policy Expert Committee with the Department of trial is included in the priority research agenda proposed by the Committee. Human Services consider forming a subcommittee of appropriate experts to consider the desirability of undertaking a limited trial releasing Narcan to a number of addicted persons with the aim of reducing the risks. The precise format of the trial would need to be decided by the subcommittee. It is essential that adequate educational material (and/or training, if practicable) be delivered to addicted persons, their families and supporters at the time of delivery of Narcan.

Recommendation 20 The Drug Policy Expert Committee supports this recommendation. The State Coroner’s Office with the Victoria Police Drug Squad, the Coroner’s Assistants Office and the Victorian Institute of Forensic Medicine establish a Committee to develop minimum investigatory standards in drug-related deaths. Also it is essential that drug-related deaths be investigated by qualified and trained police investigators.

Appendices 196

Appendix 5: Additional Services Accessed by Clients

of Drug Treatment Services - A Sample Other Services Other

Acute Health Acute

Services Correctional

Justice Juvenile

Services

Support

Homeless

Services Mental Health Mental

Child Protection Child

Practitioner General

Methadone Community Based Order (CBO) Bail/Charged CBO Bail/Charged Order (ICO) Psychiatric Other Medical Psychiatric Other Medical Chronic pain Psychiatric Other Medical Other Medical Bail/Charged Amphetamines Benzodiazepines Cannabis Opiates Ecstasy Tobacco Cannabis Opiates Tobacco Alcohol Amphetamines Cannabis Opiates Tobacco Tobacco Tranquilizers Opiates Female 22Female Opiates Other Male 20 Cannabis Opiates Alcohol 34Female Barbituates Benzodiazepines Psychiatric CBO Sex / Age Primary Drugs Other Drugs Comorbidity Legal Male 42 Alcohol 20Female AlcoholMale 29 Opiates Benzodiazepines Cannabis Psychiatric 20Female Alcohol Other Medical 36Female CBO AlcoholMale 45 CannabisMale 37 Alcohol Tobacco Alcohol PsychiatricMale 27 Psychiatric CBO 37Female Benzodiazepines Cannabis Opiates Psychiatric Alcohol CBO Court Order 22Female Alcohol Cannabis Bail/Charged Male 28 Alcohol Psychiatric Tobacco Alcohol Opiates Cannabis Parole PsychiatricMale 24 ICO Alcohol Intensive Corrections Tobacco CBO

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge

197 Other Services Other

Acute Health Acute

Services Correctional

Justice Juvenile

Services

Support

Homeless

Services Mental Health Mental

Child Protection Child

Practitioner General

Methadone and Treatment Order and Treatment (CCTO) CBO Bail/Charged Bail/Charged Psychiatric Bail/Charged ICO Psychiatric Other Medical Other Medical Parole Tobacco Other Tobacco Tranquilizers AlcoholTobacco CBO Parole Cannabis Cannabis Opiates Sex / Age Primary Drugs Other Drugs Comorbidity Legal Male 28 30Female Alcohol CannabisMale 33 46Female Opiates Alcohol 37Female Alcohol AlcoholMale 30 Tobacco Alcohol Opiates Cannabis Benzodiazepines PsychiatricMale 21 Other Medical ICO Combined Custody Benzodiazepines Other MedicalMale 38 Bond Opiates 20Female Cannabis OpiatesMale 25 Cannabis OpiatesMale 21 OpiatesMale 68 Psychiatric Cannabis Alcohol CBO ICO Other Medical CCTO Psychiatric CBO Psychiatric Male 23 Opiates Benzodiazepines 18Female Alcohol Cannabis CBO

NB. Services accessed over a 12 month period. Source: Alcohol and Drug Information System, Drug Treatment Services, Victorian Department of Human Services Appendices 198

Appendix 6: Example prevention programs

The following table demonstrates a range of opportunities, in a coordinated prevention framework, for programs that may be included at various life stages. Many of these programs already exist. Programs at various time points need to complement and reinforce each other. Programs included in this table are designed to provide examples only and should not be seen as a complete or definitive list. This list is not prioritised.

When Involving Example program

Ante Natal Parents • Clear information about impacts of parental smoking, drinking and other Hospital substance use on the newborn and child. Maternal and Child Health Services • Preparation for parenting. • Structured additional support for those mothers with particular needs (for example substance use problems or mental health).

Post Natal Parents • Access to advice on parenting. Maternal and Child Health Services • Family strengthening programs.

0 - 5 Parents • Programs aimed at improved learning and emotional development in those Child care particularly at risk. Preschools • Information for parents about modelling moderate substance use (for example, alcohol). • Programs to integrate isolated mothers into parent networks.

5 - 11 Teachers • Early years of schooling: transition program to support emotional growth and Student welfare officers social skills development. Parents • Mechanisms for teachers to access advice and mobilise additional support for children displaying aggression and poor socialisation skills (including bullying programs). • Programs to prepare children for the transition from primary to secondary school. • Programs to link with community groups, sport and activities. • Mechanisms to support parents.

11 - 18 Secondary schools • Programs to support children in the transition from primary to secondary school. Other pathways to employment • A focus on emotional and personal development. Media • Development of mechanisms to involve and support parents. School nurses • Clear information about drug use in our community. School-focused youth services • Development of a capacity to monitor truancy and school leaving. • Programs for reintegration into a learning environment for those who have ‘dropped out’.

14 - 21 Workplaces • Development of targeted information about substance use for those entering the Universities, TAFE institutions workforce or undertaking further study. • A program of support to assist young people in the transition from school to work, particularly for those who leave school early. • Recreation and public space projects. • Early detection of psychosis and mental illness.

21 + Professionals such as GPs • Clear information about safe levels of drug use. Peers • Support for GPs to provide advice about safe consumption levels of, for example, Workplaces alcohol. • Information about drugs at work, including appropriate alcohol consumption at social functions, for employers and workplaces. • Strategies to combat abuse of prescription medicines (including for older people).

A number of the programs set out above are universally focused. More highly targeted programs are also required. Other additional projects could include strategies to reduce inhalant use, programs for current injecting drug users, and strategies for homeless people and for current drug users who also have a mental illness. Specific strategies could include programs that focus on influencing the drug-using peer group and providing highly targeted information.

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 199

Appendix 7: Summary of studies of treatment outcomes across modalities

There have been a number of large and important treatment outcome studies reported for drug and alcohol. While not randomised controlled trials, the size of these studies warrants detailed consideration of their findings.

Study Description Treatment modalities Outcomes

Californian Drug & Large-scale • Residential programs* Treatment was found to be cost-effective. Providing treatment Alcohol Treatment before/after study • Social model recovery houses to the 150,000 participants cost $209 million while the Assessment of effectiveness, • Outpatient non-methadone* benefits to the taxpayer were in the order of $1.5 billion. (CALDATA) costs and overall • Methadone maintenance Crime decreased by two-thirds, and the greater the time in (3,055 individuals economic value to • Methadone treatment treatment, the greater the decrease. selected from society • Detoxification (both residential Substance use declined by two-fifths for all drugs across the 150,000 for follow-up) and outpatient) sample. (*Residential and outpatient non- Hospitalisation was reduced by two-thirds and there were methadone programs treated the corresponding increases in health. whole range of addictions. For each modality, there were slight or no differences in The social model was restricted to effectiveness by gender, age or cultural group. alcohol and/or stimulant dependency Overall, the economic situation for clients was not improved and methadone treatments to opioid dependency.) over the study period; however, clients retained in treatment for over one month did begin to show improvements.

National Treatment • Inpatient units stays of up to 3 Reductions in substance use (that is, the percentage of clients Outcome Research months; using drugs as well as quantity and frequency, was reduced). Study (NTORS) UK • Residential rehabilitation Needle sharing and criminal activity were found to be reduced, (1995-2001) (1,000 (including 12 step programs as well as improvements in physical and mental health. clients) and therapeutic (The authors caution against comparing modalities as there were communities); significant differences in clients attracted to each of the modalities.) • Outpatient methadone maintenance; and • Outpatient methadone reduction

Drug Abuse Follow-up at 3, 6 Outpatient methadone; Substantial and significant reductions in illegal drug use for Treatment Outcome and 12 month Long-term residential; clients in all modalities. Study (DATOS)* (US) intervals for those Short-term residential; and Reductions were greatest for long term residential treatment Three research clients still in Outpatient drug free. and out patient drug free clients treated for over three months centres involved treatment; 12 and for outpatient methadone clients still in treatment at the month follow up for time of follow-up. those who The relationship between treatment duration and completed effectiveness was evident. treatment - 3,000 clients in total were followed up at 12- months.

* DATOS was the third and most comprehensive in a series of national community-based treatment outcome studies sponsored by the National Institute on Drug Abuse (NIDA) in the USA. The first study in this series was the Drug Abuse Reporting Program (DARP). It collected data on 44,000 clients entering treatment between 1969 and 1973. The second study was the Treatment Outcome Prospective Study (TOPS). This was an expansion of DARP to obtain more patient and program information for the cohort of clients entering treatment between 1979 and 1981 (n=11,000). Both of these studies demonstrated reduced usage following treatment, and that length of stay in a program positively influences outcome. A minimum of three months was necessary to produce positive changes. Beyond those first three months, outcomes improved with time spent in treatment.

Appendices 200

Appendix 8: Impact on services of substance use problems within the client group - enhancing the capacity to respond to complex clients* One department reported 7% of clients have alcohol and/or other drugs as the primary reason for presentation to A&E. A further 7% to 10% of clients were estimated to have alcohol and/or other drugs as a secondary issue. Accident and emergency departments Some hospital A&E departments employ an A&D nurse and/or have links to local specialist drug treatment services for referrals. Continued use of A & E departments as crisis treatment centre. Increased drug treatment service accessibility to manage clients who may need/want drug treatment but do not want to be treated as hospital inpatients. Acquired brain injury Estimated that between 30% and 60% of clients in this area have a substance use problem. Alcohol is involved in more than 50% of head injuries. Cross-sectoral training and introduction of assessment process. Increasing numbers of clients with ABI that may be acquired through the use of narcotics and alcohol. Increased skill base among drug and alcohol workers in the sector so appropriate care is provided. Education and training options concerning ABI for those involved in their treatment planning. Adult corrections 63% of male and 84% of female first time prisoners have a drug use problem prior to imprisonment, rising to 84% of males and 92% of females on second or subsequent sentence. Treatment service Treatment providers are currently located within prisons. Larger proportion of client group will have substance use problems and may require more extensive primary health care. Improved treatment within prisons. Improved capacity (numbers and skills) of community corrections officers. Ambulance Ambulances often called to overdoses resulting from heroin and/or other drug use. Drug and alcohol as primary problem in 6% of all cases. Of that 6% it is estimated that alcohol is a primary issue in 20%, illegal drugs in 38% and other drugs in 42% of clients. Assessment, information and referral centre to drug overdose survivors. Increasing use of resources attending overdoses; poorer health status of clients leads to increased risk of secondary infection; vasculitis, pneumonia etc. Primary health care services for drug users outside the service system. Immediate counselling response for overdose survivors. Homelessness Large proportion of current client group are young people with substance use problems. Increasingly chaotic lifestyle is not necessarily suited to traditional housing options. Development of joint housing/drug treatment initiative/s. Larger proportion of client group will have substance use problems and could be difficult to place in housing Primary health care services for drug users in service system. Estimates of clients with mental health and drug use problems ranged from 10% to 40% of client group. Frequent presentations of clients with drug- induced psychosis. Mental Health Cross-sectoral training, collaboration and worker placement. Continuing frequent presentations of complex clients with multiple needs including possible increase in number of clients with dual diagnosis. Provision by Drug Services Treatment of education and training to staff in Mental Health sector. Development of protocols regarding responsibility for the client between services. Education and training for JJ workers in drug and alcohol issues; increased cross sectoral collaboration for shared clients through strategies such as Working Together. Clients presenting with drug and/or alcohol problem as primary problem ranged from 40% to 85%. Juvenile Justice Continuing increase in complexity of client group and drug and alcohol problems. Use of joint assessments. Cross-sectoral education and training. Family-focused drug treatment. Development of protocols between services; assertive outreach services for JJ clients. estimates of substance use problems (as a primary problem) among clients reported were 30% for adolescents and 50% for adults. Information sharing and training protocols Increased demand as a result of greater use and earlier induction Child Protection Use of joint assessments. Cross-sectoral education and training. Enhanced collaboration and information sharing. Service reforms to improve capacity of service system Current impact The highest linkage with Key specialist treatment system Likely future impact

* All data shown in this table were provided by the above service sectors/areas. It is acknowledged that some services do not collect data Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge on the alcohol and drug use of their client group. Therefore, figures forwarded to the Committee were often based on estimates. 201

Appendix 9: Cross-sectoral initiatives

The Department of Human Services has acknowledged the need The Working Together Strategy (WTS) to improve current access to services for those members of our The Drugs and Health Protection Services Branch, Juvenile community who require (often concurrently) assistance from more Justice, Protection and Care and Mental Health program areas, than one service sector. To this end, it has established initiatives and more recently the DisAbility and Housing areas of the DHS, such as the Working Together Strategy, the Primary Care are working collaboratively to: Partnerships and the Multi Service Clients Project. The DHS drug • identify best practice for clients requiring access to two or treatment services area is a partner in each of these major more services; initiatives and has instigated several other cross-sectoral projects • determine effective service relationships; that aim to improve service access and outcomes for their client • ensure understanding of existing programs and program group. These cross-sectoral initiatives are briefly described below. innovation; Primary Care Partnerships • establish ongoing intersectoral discussion, program innovation Primary Care Partnerships (PCPs) are voluntary alliances of and processes for continuous service improvements. primary health care providers, usually covering two or three local The first phase of the strategy, which is currently under way, government areas. PCPs aim to improve the health and wellbeing focuses on service improvements for high-need adolescent clients of their catchment’s population by better coordinating planning (aged 12-18 years). The first year of the WTS will be formally and service delivery in response to identified needs. Core evaluated. agencies in an alliance will typically include the following services: Dual Diagnosis Pilot Service • primary care services funded and delivered by local A Substance Abuse and Mental Illness Treatment Team (SUMITT) government; pilot was established in 1998-99 in the Western Metropolitan and • Home and Community Care (HACC); including district nursing; Grampians Regions. It aimed to improve service delivery to • general practice; people with dual diagnosis by developing and encouraging • psychiatric disability support; linkages between drug treatment and mental health services. • Psychogeriatric Assessment and Treatment Teams; Following a positive evaluation of the pilot, the program is to be • aged care assessment; extended with some metropolitan and rural agencies funded. It • women’s health; will connect specialist dual diagnosis positions in rural centres to • Aboriginal community controlled health services; the metropolitan teams. • sexual assault; Acquired Brain Injury • dental health; • community drug treatment services; and The Drugs and Health Protection Services Branch and Disability • local ethno-specific health services. Services collaborated in 1998-99 to fund research that aimed to determine the ways in which drug treatment services could better Multi-Service Clients Project cater for those people with acquired brain injury (ABI). Training has The Multi Service Clients Project (MSCP) aims to ‘address the now been provided to workers in acquired brain injury and drug difficulties and restraints created when the provision of services treatment service agencies to assist in the development of expertise requires interaction and collaboration across a number of in managing people with ABI and alcohol and drug use problems. program boundaries’. Drug treatment services/Juvenile Justice initiatives The target group for the project is young people and their families. To increase the availability of drug treatment services for young Sectors participating in this project include drug treatment, mental people, the Community Offenders Advice and Treatment Service health, juvenile justice, child protection, housing, and disability (COATS) has been extended to young parolees within the juvenile services. The project is investigating ways to enable service justice system. The Intensive Post-Prison Release Service sectors to respond in a more integrated way to clients who are (Stepout) has also been extended to young people leaving accessing services from two or more of these sectors. juvenile justice centres. Both initiatives were implemented as pilots and are currently being evaluated. High-Risk Adolescent Quality Improvement Initiative (HRAQII) This initiative was developed in 1997 to provide highly targeted, intensive case management and support services for high-risk young people. It was implemented as a pilot program in 1998, and provides access to services such as intensive case management, one-to-one home-based placements, and flexible brokerage funds for additional specialist services. The evaluation of this initiative is due for completion in 2001.

Appendices 202

Appendix 10: Pharmacotherapy treatments for heroin dependence

Heroin dependence Maintenance treatment Heroin dependence is a condition in which someone has limited The most effective form of treatment for heroin dependence is ability to control their use of heroin, and where drug use and maintenance treatment. Maintenance treatment is concerned with related behaviours take increasing importance in the person’s life providing a legal and safe form of medication to an individual, and at the expense of other activities. Heroin dependence is generally allowing time for the significant changes to be made in their a chronic relapsing condition. It often commences in the late physical, psychological and social circumstances so they no teens to early twenties and continues for many years. With longer require ongoing maintenance treatment. Maintenance ongoing and heavy use, individuals develop tolerance to the treatment works by providing a drug that prevents heroin effects of heroin, need to use more to get the same effect, and withdrawal symptoms, reduces cravings for heroin use, and experience a withdrawal syndrome upon ceasing or reducing reduces the euphoric effects of any additional heroin use. One of heroin use. Dependent heroin users may develop a range of the reasons that maintenance treatment works is that clients, on medical, psychological or social problems associated with their average, stay in treatment longer than for other treatments. use of heroin. It is usually to seek relief from these problems that The six treatment gaols for maintenance treatment are to: prompts someone to seek treatment. • reduce heroin and other drug use; Different types of treatment • reduce the transmission of blood-borne viruses, including HIV, No one treatment type will suit all individuals. Indeed, the greater Hepatitis C (HCV) and Hepatitis B (HBV); the range of treatment types, the more likely it is that someone will • reduce the risk of death; successfully access and complete treatment. Treatment for a • reduce drug-related crime; heroin problem involves many domains: the physical, the • enhance social functioning of clients; and psychological and the social. Treatment can take place in a variety • improve general health and wellbeing. of settings, such as community health centres, specialist residential Research has shown that maintenance treatment is highly drug treatment services, or through a general medical practice. effective in achieving these goals. It reduces heroin use, reduces There are three main forms of treatment: withdrawal, maintenance the risks of blood-borne virus transmission, is associated with less and psycho-social rehabilitation. Drug withdrawal, sometimes mortality, reduces crime, and improves clients’ social and called detoxification, is concerned with reversing the physical psychological functioning. These benefits apply to the individual dependence upon heroin. In general, drug withdrawal takes and the community at large. between five and seven days, and various drugs are used to Methadone maintenance and some of the problems manage the symptoms of withdrawal. Heroin withdrawal can be Methadone is currently the only pharmacotherapy available in very uncomfortable and unpleasant for the person, but is rarely life Australia for maintenance treatment. Perhaps surprisingly in light threatening. Of course, getting through a five-day detoxification of the research evidence demonstrating that maintenance does not necessarily assist with the sorts of long-term changes treatment works, it has been strongly criticised. The main criticism that a person has to make to their lifestyle to stay drug-free. Long- of maintenance treatment is that the person is still taking a drug, term changes in behaviour usually require long-term treatments. (even though it is a legally prescribed drug). The rationale for We know that people who complete withdrawal but then do not go maintenance treatment is that the provision of a legal, stable on to further treatment have no better long-term outcomes than source of opiate, in conjunction with appropriate counselling and drug users who did not complete withdrawal in the first place. A support services, enables the individual to cease heroin use and useful medical analogy is the admission to hospital of a patient the associated behaviours, such as drug-seeking. During the with an episode of severe asthma: access to acute medical period of maintenance, other lifestyle changes can be achieved services can be life saving in its own right, but long-term such as re-establishing relationships, gaining employment, and stabilisation and control of the patient’s asthma relies on long-term making meaningful contributions to the community. These interventions addressing lifestyle and compliance with medication. significant changes take considerable time, and the longer Psycho-social rehabilitation, provided by therapeutic communities, methadone programs have greater success. counselling services and self-help programs assist the heroin user There are other criticisms of methadone. Methadone, like most to develop skills and psychological resilience so they can maintain drugs, has side-effects (for example, nausea, sedation, a drug-free lifestyle. Usually, psycho-social treatment occurs after drowsiness, itchiness). Most are short-lived and usually subside the person has detoxified from heroin. Unfortunately, many heroin within days or weeks of commencing treatment. Methadone is an users do not complete withdrawal, and hence the actual numbers opiate and there is a significant withdrawal syndrome when it is who reach the psycho-social treatment stage is relatively small. stopped. This means clients need to go through a withdrawal program when they are ready to come off methadone. Methadone is a potent psycho-active medication that can be abused if diverted. For this reason, the Victorian system requires supervised daily dosing at an authorised pharmacy or dispensary, with limited

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 203

take-home doses available for some clients. Diversion of While the majority of international research has focused on methadone to individuals not in methadone treatment is buprenorphine as a maintenance treatment, there is increasing potentially dangerous (as it can result in overdose). Supervised attention being paid to its use for managing heroin withdrawal. dispensing is required to minimise this risk. Unfortunately, Increasing the options methadone clients and their service providers may experience One of the problems for heroin users seeking treatment in considerable stigma from heroin users, clients in other treatment Australia is their limited choice. It is important to provide more modalities (for example, self-help programs), other drug treatment options for drug users. Having two other drugs available, LAAM providers, health professionals, and often the broader community. and buprenorphine, will provide doctors with greater ability to This stigma puts clients off entering methadone treatment or match the client to their preferred treatment. causes them to leave the program prematurely. It can result in methadone clients being excluded from other forms of treatment Where does naltrexone fit in? (for example, counselling, self-help groups), or being discriminated Naltrexone blocks the actions of other opiates but does not against in accessing general health and welfare programs. produce any sedation or euphoria. A patient taking naltrexone In spite of these problems, the evidence of the effectiveness of does not experience any effects from heroin, and most describe methadone maintenance in reducing heroin use and improving a reduction in cravings for heroin use. Its blockade effects wear clients’ health and social functioning is significant. In addition, off within two to three days of ceasing treatment. Unfortunately, there are community benefits from maintenance treatment: most clients don’t stay in naltrexone treatment. Separate to the reduction in blood-borne virus prevalence, reduction in crime, and issue of poor treatment compliance and relapse, there are a less reliance on social services. number of potential problems with naltrexone treatment. Individuals who stop taking it are at high risk of overdose should There are two newer maintenance treatment options that have the they return to heroin use, due to an increased sensitivity to potential to overcome some of the downsides of methadone: opiates upon ceasing naltrexone. LAAM and buprenorphine. Patients considering the use of naltrexone should have completed LAAM and buprenorphine withdrawal from heroin prior to commencing treatment. This LAAM (levomethadyl acetate) is a drug very similar to methadone means at least seven days without heroin use, or at least 10 days in its properties and its clinical application. It has been without the ingestion of methadone. For many heroin users, such investigated as a maintenance treatment for heroin dependence a period of abstinence is very difficult. This obstacle has led since the early 1970s, and has been registered for this purpose in some clinicians to consider naltrexone-assisted withdrawal, the USA since 1993. Research has shown that the safety and whereby the person is administered naltrexone to speed up the effectiveness of LAAM is the same as for methadone maintenance onset and shorten the duration of withdrawal. This usually requires treatment. The principles of LAAM maintenance treatment are the considerable sedation and close monitoring of the patient for one same as those for methadone. The key distinguishing feature of to three days, as withdrawal symptoms are more severe than with LAAM is its long duration of action: therapeutic effects last 48 to traditional withdrawal methods. The use of naltrexone in 72 hours. This allows the majority of individuals to be maintained withdrawal is now offered by a number of clinics around Australia. on three doses of LAAM per week, as opposed to daily dosing Current research is yet to demonstrate the safety or efficacy of with methadone. The potential advantages of LAAM are therefore, such procedures, given that naltrexone has been associated with less inconvenience (and possibly lower costs) for clients and a number of deaths and is expensive. Naltrexone is not registered pharmacists, decreased need for takeaway doses (and therefore for the purpose of opiate withdrawal in Australia. fewer risks associated with diversion of takeaways). Its long- acting nature means, for some clients, that it produces less sedation than methadone treatment. Research in the use of buprenorphine for managing heroin dependence commenced in the 1980s and has shown that it has positive treatment outcomes. Buprenorphine has many similar properties to methadone. It produces opiate-like effects that reduce cravings, it prevents withdrawal over extended periods of time, and it blocks the effects of additional heroin use. Buprenorphine also differs from methadone in certain respects: • it generally has milder opiate-like effects than high-dose methadone - this results in less sedation and less risk of overdose than methadone; • withdrawal is considerably milder than methadone withdrawal; • commencement of treatment is easier and faster than methadone; and • it has a very long duration of action when used at high doses, thereby allowing alternate day dosing and even three-day dosing for some individuals.

Appendices 204

Appendix 11: New pharmacotherapies project validated clinical guidelines for maintenance treatment with buprenorphine (being adopted nationally through NEACID); and training package developed and evaluated. approximately 70% of current methadone clients were either very or extremely interested in methadone withdrawal; the average methadone dose was 57mg; the average length of time in current methadone treatment was 34 months; between 18% and 30% of clients are likely to be suitable for withdrawal, based on criteria such as ongoing heroin use, social functioning; although a large number of clients want to withdraw from methadone, only smaller percentage may in fact be suitable according to clinical criteria. easily accomplished in clinic and general practice settings; no or mild and transient withdrawal experienced; dysphoria in 1/7 subjects; and nil heroin use in 6/7 subjects. validated clinical guidelines for maintenance treatment with LAAM - being adopted nationally through NEACID; and training package developed and evaluated. The SROM trial has recently commenced recruitment. No preliminary findings to date. Progress & early conclusions due for follow-ups completed. Trial Client recruitment completed and majority of six-month completion June 2001. Current products: • • and treatment outcomes not available until June 2001. Cost-effectiveness Trials completed. Reports available for the inpatient and outpatient dosing guidelines. Trials Randomised trial: preliminary findings indicate the vast superiority of buprenorphine over clonidine in withdrawal from heroin, as measured by retention treatment, heroin use and psycho-social outcomes. Clinical guidelines for buprenorphine in heroin withdrawal draft from, being adopted nationally (NEACID). Results of survey: • • • • • findings: Dosing guidelines available. Low dose methadone transfer to buprenorphine. Key • • • • Recruitment to the study is ceasing end September (n=100). follow-up data are collected. Data will not be analysed until after the six-month due for follow-ups completed. Trial Client recruitment completed and majority of six-month completion June 2001. Current products: • • and treatment outcomes not available until June 2001. Cost-effectiveness Research questions 1. Maintenance trial - Buprenorphine Implementation trial: Examined community-based buprenorphine maintenance treatment, the development of training programs, clinical guidelines for buprenorphine and analysis. cost-effectiveness 3. Methadone withdrawal using buprenorphine A survey was conducted of methadone clients to assess the numbers of methadone maintenance clients interested in, and assessed as, suitable for methadone withdrawal. Pilot dosing study of methadone withdrawal using buprenorphine completed. The naltrexone treatment outcome study is examining the role of psycho-social support in enhancing outcomes for naltrexone maintenance. The LAAM implementation trial is examining the use of as a maintenance treatment in community settings, the development of training programs, clinical guidelines for LAAM analysis. and cost-effectiveness Pilot study examining the required daily maintenance doses for SROM, and methods for monitoring treatment compliance illicit heroin use. 2. Heroin withdrawal using buprenorphine Three separate studies examining dosing regimes in inpatient and outpatient settings, a randomised trial comparing buprenorphine with clonidine. Drug Buprenorphine There were three main trials of buprenorphine: a maintenance trial, a heroin withdrawal trial, and a methadone withdrawal trial. Naltrexone LAAM Slow-release oral morphine

The Committee is grateful to Dr Alison Ritter, Head of Research. Turning Point Alcohol and Drug Centre for compiling this table Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge based on work done by Turning Point Alcohol and Drug Centre. 205

Appendix 12: Diversion and Sentencing Options for Drug and Drug-related Offences

Police • to allow for circumstances in which it is inappropriate to impose Young Offenders Diversion. Young offenders up to 17 years can any punishment other than a nominal punishment; be diverted from prosecution for any offence, including drug • to allow for the existence of other extenuating or exceptional offences. The senior station member can talk with offender and circumstances that justify the court showing mercy to an offender. guardian and provide advice and information. Adjourned undertaking on condition of drug education with or Cannabis Cautioning Program. Commenced in September without conviction. On finding an offender guilty of certain drug 1998. Applies to all adult offenders detected in possession of, or possession or use offences, the court may adjourn the matter for using, dried cannabis leaf, stem or seeds, weighing not more the up to twelve months on various conditions. If the offence involves 50 grams, for personal use. The offender must have no criminal a small quantity of a drug other than cannabis, the conditions must history of drug offences, must admit the offence and consent to include a condition that the offender complete an approved drug being cautioned. Other offences committed at the time which can education and information program (known as the First Offender be dealt with by means other than prosecution will not necessarily Court Intervention Service or FOCiS). preclude a person from being cautioned. The Caution Notice Fines, forfeiture and confiscation. Drug offenders are subject to given to the offender contains information about the health and maximum fines under the Drugs, Poisons and Controlled legal ramifications of cannabis use and the telephone number of a Substances Act 1981 ranging from $500 for use of cannabis to confidential drug information help line. education program. An $250,000 for trafficking in a commercial quantity of any drug. In offender can be cautioned no more than twice. addition to fines, offences such as trafficking or cultivating a drug Drug Diversion Program. Pilot commenced in September 1998. of dependence are also subject to a range of forfeiture and It is similar in operation to the Cannabis Cautioning Program but confiscation provisions contained in the Confiscation Act 1997. for other illegal drugs. An offender is referred on apprehension for Community based order (CBO). Community based orders assessment and appropriate treatment. It has now been involve the offender being released into the community under strict developed into the State-wide Illicit Drug Diversion Program, conditions on his or her behaviour and lifestyle while still enabling announced in August 2000. the offender to maintain family, social and employment links with the community. Conditions can include unpaid community work Magistrates Court and the undertaking of drug treatment. BAIL Intensive correction order (ICO). An intensive correction order is similar to a community based order, but involves a greater degree CREDIT. (Court Referral, Evaluation Drug Intervention & of supervision of the offender by community corrections officers. Treatment) Allows early intervention by Court. Referral to treatment is a condition of bail. Non-violent offenders only; can Suspended sentence. A court may impose a sentence of include traffic/cultivate offences. imprisonment and then order that all or part of the sentence be suspended for up to three years, in the case of the Supreme or SENTENCING OPTIONS County Court, or up to two years in the case of the Magistrates’ Deferred sentencing. The Magistrates’ Court has the power, Court. The offender is not required to serve the sentence in when sentencing an offender who is aged between 17 and 25, to custody unless the offender breaches the conditions of the order defer sentencing for up to six months to enable the offender to during the period of suspension. undergo drug treatment. Successful drug treatment can then be Combined custody and treatment order (CCTO). When a court taken into account when he or she comes back before the court is considering imposing a sentence of imprisonment of up to for sentencing. twelve months and is satisfied that the offender’s drunkenness or Dismissal with or without conviction. On finding an offender drug addiction contributed to the commission of the offence, the guilty a court may dismiss the offender without any other sanction. court may make a combined custody and treatment order. Under This can be done: such an order, at least six months of the sentence must be served • to provide for the rehabilitation of the offender by allowing the in prison, with the balance to be served in the community on sentence to be served in the community without supervision; certain conditions, including that the offender undergo drug • to take account of the trivial, technical or minor nature of an treatment. offence; Imprisonment. Other than use of cannabis, which does not carry • to allow for circumstances where it is not appropriate to record a a sentence of imprisonment, offences involving drugs of conviction (for example, because of the consequences of a dependence are subject to maximum sentences of imprisonment conviction for the future employment of the offender, and the ranging from one year (for use of a drug other than cannabis) to detrimental effect that this could have on the offender’s 25 years for trafficking in a commercial quantity. The maximum rehabilitation); penalty for trafficking in less than a commercial quantity is 15 years imprisonment.

Appendices 206

Appendix 13: Written submissions received in relation to both Stage One & Stage Two terms of reference Submissions from individuals Submissions from organisations Mr B Anderson ACCESS Drug & Alcohol Services Department of Psychology - University Mr P Anderson Addiction Research Institute of Melbourne Mr R Bawden Adolescent Forensic Health Service Division of Health Sciences - Curtin University Mr J Beckwith ANEX, Assoc. of Needle & Syringe Programs Drug-Arm Victoria Inc Ms S Ben-Simon Association of the Relatives and Friends of Dual Diagnosis Resource Centre Dr R Brough the Emotionally& Mentally ilI EastEnders Inc Ms C Brown Australian Buddhist Hermitage Eastern Drug & Alcohol Service Ms Z Cawthorne Australian Drug Foundation East Region Police & Community Alliance Mr C Corbett Australian Multicultural Foundation Submission Mr B Cossar Australian Parents for Drug Free Youth Endeavour Forum Inc Mr S Doherty Australian Retailers Association Victoria Faculty of Education - Language and Aviation Safety Advisory Services Ms A Duff Community Services Barwon South Western Region Dr B Eggins Family and Community Support - DHS Box Hill Hospital - Central East Health Mr J Evans Federation of Community Legal Centres Alliance Ms C Giulieri (Vic) Inc Brighton Grammar Mr J Hammond Fitzroy Legal Service Inc Brimbank City Council Mr & Ms A & G Holmes Fitzroy Street Traders Association Brotherhood of Saint Laurence Dr L Jackson Frankston Community Health Centre Buoyancy Foundation of Victoria Mr A T Kenos Genesis Medical Centre Catholic Education Office Ms J Kerslake Glen Eira City Council Central Bayside Community Health Service Ms A Kiewiet Hanover Welfare Services Centre for Adolescent Health Mr E Lang Homeless Person’s Programme Centre for Community Child Health - Royal Mr B Lumsden Humanist Society Of Victoria Childrens Hospital Mr V Mahon Hume Safe City Task Force Central Highlands Regional Youth Dr K McDonald Committee Bridge Programme Alcohol & Drug Services Mr B Michos Chemical Dependency Unit, Royal Womens Community Health Program Ms S Nichol Hospital Criminal Law Section Mr E Placer Children’s Court Victoria Hume City Council Professor D Ranson City of Monash Inner South Community Health Service Mr A Richards City of Port Phillip Institute of Family Studies Ms D Rodgers City of Whitehorse ISIS Primary Care Inc Dr N Ryan Convenience Advertising (Aust) Pty Ltd Jesuit Social Services Mr J Sapranidis Crime Prevention - Department of Justice Juvenile Justice - DHS Ms L Smith Crossroads Lodge Law Institute of Victoria, Criminal Law Section Ms L Spurr Department Of Community Medicine Macfarlane Burnet Centre for Medical Dr C Walsh & General Practice Research Ms J Wells Department of Employment, Education Magistrates’ Court of Victoria and Training Mr R Wells Maharishi Health Education Centres of Department of Human Services Australia Mr R Whiter Department of Justice Maharishi Vedec College Melbourne Division of General Practice Inc

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 207

Appendix 14: Written submissions received in relation to the Drug Policy Expert Committee’s Prevention Monash University Southern Health Care Network Pathology Issues Paper Moreland City Council Services Moreland Hall Southern Metropolitan Addiction Organisations Consultancy Clinic Municipal Association of Victoria Anti-Cancer Council of Victoria Springvale Secondary College Narconon Drug Rehabilitation and Attorney General’s Department St Vincent’s Hospital Melbourne Education Services Australian Drug Foundation Student Welfare and Drug Education, DEET National Council of Women of Victoria Inc. Australian Vietnamese Womens Welfare National Drug And Alcohol Research Centre Substance Use & Mental Illness Treatment Assoc. Team - North Western Health National Drug Research Institute Catholic Education Commission of Victoria The Bridge Health Group Newton Wayman Research Centre for Adolescent Health The Salvation Army North Western Health City of Casey The Salvation Army - Bridge Program North Yarra Community Health City of Whittlesea The Victorian Offender Support Agency Odyssey House Victoria Clockwork Young People’s Health Service Trinity Youth Services Inc Office for Youth - DEET Convenience Advertising Turning Point Alcohol & Drug Centre Open Family Australia Department of Education, Employment University of Queensland - School of Oxford Houses of Australia and Training (Eastern Metropolitan Region) Psychology Parents for Drugs Information and Support Eastenders Inc VACCHO Peninsula Health Care Network Endeavour Forum Inc Victorian Aboriginal Health Service Co- Focus on the Family Australia Pilot Project for Parent Education operative Ltd Glen Eira City Council Post Compulsory Education Review Victorian Aboriginal Legal Service Maharishi Health Education Centres of Property Council of Australia Victorian Council of Social Services Australia Queensland Alcohol and Drug Research Victorian Institute of Forensic Medicine Education Ctr - Department of Social & Melbourne’s Life Force Victorian Parenting Centre Preventative Medicine Moreland Drug and Alcohol Working Party VIVAIDS Redfern Legal Centre National Council of Women of Victoria Inc Wesley Central Mission Rehabilitation & Family Therapy Inc Pharmaceutical Society of Australia Western Health Drug & Alcohol Service Relatives Against The Intake of Narcotics Pharmacy Guild of Australia (Victorian Western Region Alcohol & Drug Centre Inc Residents 3000 Branch) Western Regional Health Centre RMIT Royal District Nursing Service - Homeless Westgate PCCC Drug Task Force Persons Program Royal Australian College of General Practitioners Westide Community Care The Royal Australian College of General Practitioners - Victoria Royal District Nursing Service Whittlesea Council TRANX Royal Women’s Hospital Winja Ulupna Victorian AIDS Council - Gay Mens Health Rumbalara Football and Netball Club Women’s & Children’s Health Care Network Centre Rural Workforce Agency, Victoria Ltd Women’s Christian Temperance Union of Victoria Victorian Parenting Centre Salt Shakers Inc Wyndham City Council SANE Australia Individuals Yarra City Council School of Psychology - Curtin University of Ms J Rossiter Yarra Drug & Health Forum Technology G Georgeievski School of Psychology - Deakin University Youth MHSKY SICMAA Inc. Youth Substance Abuse Service Southern Health Care Network - Community Health Program Appendices 208

Appendix 15: List of meetings and consultations under the Stage Two terms of reference

Culturally and Linguistically Diverse Communities Youth forums 25 July Consultation convened by the Australian 24 August Round table, 589 Collins Street Multicultural Foundation on behalf of DPEC 8 September Ballarat 7 September Treatment consultation 13 September Melton 12 September Prevention consultation Treatment consultations Prevention Service provider forum Prevention workshop 12 July 25 and 26 July Melbourne Consultation for current and previous users of drugs Schools and Education Sector Workshop 11 September 17 August Melbourne Strategic planning forum 1 September Regional consultations Cross-sectoral forum 9 August Ballarat 19 July 10 August Horsham 14 August Frankston Law enforcement 15 August Geelong Criminal justice forums 16 August Warrnambool 23 August Legal issues forum 4 September Mildura 30 August Community/service providers forum 18 August Melton Police consultations 21 August Bairnsdale 6 September Police Centre 22 August Leongatha Juvenile justice centre and prison visits 23 August Shepparton 6 June Malmsbury Juvenile Justice Centre 24 August Bendigo 28 July Port Phillip Prison 25 August Ringwood

Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 209

Appendix 16: Special Advisors to the Drug Policy Expert Committee

Mr Hass Dellal Executive Director Australian Multicultural Foundation

Mr Phong Nguyen Director Springvale Indo Chinese Mutual Assistance Association

Dr Nick Crofts Director The Centre for Harm Reduction Macfarlane Burnet Centre for Medical Research

Professor George Patton Director Centre for Adolescent Health

Professor Pat McGorry Director Mental Health Services for Kids and Youth (MHSKY)

Professor Roger Wales Dean Faculty of Humanities and Social Science La Trobe University

Dr Anne Sanson Principal Research Fellow Institute of Family Studies

Appendices 210

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Drug Policy Expert Committee Stage 2 Report Drugs: Meeting the Challenge 11 211

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