4. Harm Reduction Model of Controlled Drug Availability

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Beyond Prohibition

Report of the Redfern Legal Centre Drug Law Reform Project

September 1996

4. Harm Reduction Model of Controlled Drug Availability (Second Edition)

This paper is in two Parts. Part A sets out Principles which should apply to the social and legal management of currently illicit drugs. Part B provides some examples of how these Principles might be applied for particular drugs. Individuals and organisations are invited to endorse the Principles of Controlled Availability contained in this proposal. (An earlier version of this paper was published in May 1995.)

PART A: PRINCIPLES

Preamble

Prohibition causes enormous social damage including:

Vastly increased drug-related property crime by drug users to pay prices inflated by the black market

Law enforcement costs to apprehend drug users and sellers, and those who commit drug-related crime, and increased costs and delays in the court system to process these cases

Corruption flourishing at all levels and in many forms: profits are so great that few police or other officials are able to resist the enormous sums offered as bribes

Violent crime developing from supplier competition

Thousands of Australians jailed for drug related crimes, leading to increased costs for corrective services and the need for more jails

Prohibition contributes to the spread of HIV and other blood-borne diseases such as Hepatitis B and C in the following ways:

Needle sharing among injectors of some currently illicit drugs can spread these infections: many drug users begin to inject to receive the greatest effect from the smallest quantity of the expensive drug

Some users of illicit drugs are forced into high-risk forms of sex to pay for drug use

Needle and syringe supply programs are difficult to establish and operate under regular threat of closure, despite significantly reducing the spread of HIV and other blood-borne diseases

Unsafe disposal of used needles and syringes increases because drug injectors believe that police will use these articles as the basis for prosecution

Drug injectors sent to prison continue to use drugs but have virtually no means to protect themselves from infection

Laws prohibiting certain drugs have driven users of currently illicit drugs from their social support networks, making it hard to reach them with education messages about protecting themselves and others from infection

Marginalisation of drug users (encouraged by prohibition) has led most Australians to care little what happens to drug users

Prohibition causes damage to the health of drug users (and consequently increases health costs to society) by:

Users paying black market prices for drugs, leading to increasing malnutrition and other health deficits related to poverty

Adulterants and inconsistent drug type or dose (caused by unregulated manufacturing due to prohibition) causing health damage, overdose and death among users of currently illicit drugs

Marginalisation of drug users leads to lower self esteem and decreases motivation for self-care

Goals of Rational Drug Policy

Drug policy should:

Have realistic goals

Take account of the different patterns and types of harms caused by specific drugs

Be shown to be effective or be changed

Separate arguments about the consequences of drug use from arguments about morals

Be developed in the light of the costs of control as well as the benefits

Ensure that the harms caused by the control regimes themselves do not outweigh the harms prevented by them

Recognise the existence of multiple goals, but ensure that contradictory goals are minimised

We believe that this proposal achieves each of these policy objectives.

The specific goals of this proposal are to simultaneously reduce the size and profits of the illicit drug market by the greatest amount; and provide the greatest level of harm reduction for users of currently illicit drugs; and minimise the number of users of these drugs who experience problems related to their drug use

Defining Harm Reduction

We use the term "harm reduction" to mean:

A policy or programme directed towards reducing the adverse health, social and economic consequences of drug use to the community and to the individual user, even though the user may continue to use psychoactive drugs at this time.

Harm reduction policies and programmes must be part of a public health approach to managing drug use. Protecting the health of the community must include protecting the health of drug users.

Principles of Controlled Availability

Applying these policy goals under the above definition of harm reduction, we propose that a system of controlled availability of currently illicit drugs be introduced.

Such a system should have the following principles as its key elements:

1. The use and possession of currently illicit drugs should be made legal, in an environment of controlled availability.

2. The regulated manufacture, supply and sale of selected drugs should be allowed.

3. The drugs selected for controlled availability should include cannabis, heroin, amphetamine, ecstasy and anabolic steroids.

4. The drugs selected for should be made available either:

a) Over the counter from licensed premises in specified (generally low) dosages of known purity, clearly labelled with ingredients shown; or

b) By prescription.

5. The age limit for the regulated supply of currently illicit drugs should be the same as it is for alcohol.

6. Advertising and marketing should be the minimum necessary (eg, for brand identification) to ensure that non-users are not attracted into drug use by marketing.

7. Prices of regulated drugs should be set so that least harmful forms of the drug (usually lower dosages) are substantially less costly than more harmful forms of the drug.

8. Users must demonstrate adequate knowledge about the effects of the drug they intend to purchase, and about safe usage.

9. Profits earned from the commercial production or supply of drugs should be taxed. Revenues obtained from taxes and licence fees must be applied (in whole or in large part) to education, and to treatment for those drug users who want it.

10. Controlled availability should operate in a framework of:

a) education in which doctors and other health professionals, licensed drug sellers and drug users all participate in baseline and follow-up education based on valid research; and

b) widespread, easily accessible treatment for drug-related problems, with funding to be provided to a wide variety of non-coercive options for positive change.

11. The prescription system should have the following characteristics:

a) Appropriate criteria for a drug to be prescribed to an individual would be:

i. regular frequent use (usually daily);

ii. clear evidence of dependence;

iii. continued use having a severe effect on lifestyle;

iv. the harms associated with non-prescribed use being significantly greater than those associated with prescription.

b) A variety of forms for oral, smokable or injectable use be made available, in a range of doses up to a negotiated maximum dose. Users must also have access to appropriate drug using equipment.

C) Users of the prescription system be registered.

d) The prescription system would operate in a framework of:

i. Harm reduction and full consumer participation.

ii. Entry assessment to ensure that the individual wants to be maintained on the drug: this assessment must be carried out by a trained, qualified drugs worker and must include a full and frank discussion of the likely consequences of a range of options including maintenance, detoxification, selective detoxification, and controlled using.

iii. Options for dispensing which may include:

Pharmacy dispensing

Drug clinic dispensing

Home delivery or mobile van for long-term illness, palliative care or isolated individuals

Safe injecting spaces ("shooting rooms") in areas with a high concentration of drug injectors, especially those who are homeless.

iv. Reasonable cost to the consumer. Services to clients on low incomes would be delivered through the public health system.

PART B: CASE STUDIES

In this Part we propose some concrete examples of how these Principles might be applied for particular drugs.

We do not suggest that the proposals in this Part describe the only possible application of these principles.

Cannabis

We use the term "cannabis" to refer to the complete range of cannabis products including marijuana, hashish resin and oil, and other preparations, as well as industrial hemp.

It would be legal to grow up to 10 cannabis plants for personal use. It would be legal to consume cannabis products or to possess up to 50 grams (dry weight) of cannabis for personal use. It would be legal to supply in small quantities (up to 50 grams) to people aged 18 and over for no payment.

It would be legal to grow larger quantities of cannabis under licence to a State Government Office of Drug Revenue (ODR). Officially sanctioned cannabis growers would be allowed to sell their products to cannabis shops or Kafes, or to manufacturers of other cannabis products such as biscuits and cakes, rope, paper, textiles, etc. A regulation system would ensure that grades of cannabis (principally by THC content) are adhered to, providing quality assurance for end users. A differential tax could operate with different grades being subject to different tax.

A system of cannabis Kafes would be established for retail sales of cannabis, both for consumption on the premises and for take-away consumption to people aged 18 and over. A range of cannabis products from rolled cigarettes to biscuits might be available, together with smoking implements designed to reduce the level of harm associated with smoking cannabis products (eg bongs).

Other retailers (eg tobacconists) would be licensed to sell take away cannabis products. Cannabis seeds, and information about home cultivation, would also be available.

Commercial cannabis suppliers would be required to label their products with consumer information concerning weight, THC content, recommended dosage, and approved health warnings.

Profits earned from the commercial manufacture or supply of cannabis would be taxed.

Prices for cannabis products should be comparable with prices of alcoholic spirits. Prices should be set to encourage users to eat cannabis products rather than smoke.

Sales to people under 18 and unlicensed (ie untaxed) sales would be illegal.

Advertising and marketing of cannabis products would be restricted to the minimum necessary (eg for brand identification). It might include a statement outside and inside Kafes that "cannabis products are sold here", or perhaps a discrete symbol indicating availability of cannabis products.

Cannabis smoking would be banned in places where tobacco smoking is banned.

A realistic education campaign about the hazards of using cannabis, concentrating on safe cannabis use, "dope-driving", the effects of both shortterm and chronic use, and the use of cannabis and alcohol together, would be carried out at regular intervals. The cost of this campaign and ongoing campaigns directed at school students, homeless and working youth and visitors to the State would be paid for by tax revenues from cannabis sales.

Revenues from taxes and licence fees would be used to administer the regulatory system and to provide education and treatment services through services funded by the Health Department.

It would remain an offence to drive while under the influence of cannabis, unless further research proves that cannabis does not impair driving ability. Research should be conducted to determine what (if any) level of cannabis intoxication would not adversely affects drivers' ability.

It would remain illegal to import or export cannabis.

Heroin & other opioids

In this section, we refer to heroin and other currently illicit opioids such as opium, as well as currently restricted drugs such as methadone.

It would be legal to use heroin and all currently illicit opioid products, and to possess small quantities (2 grams) for personal use.

It would remain illegal to supply, manufacture or traffic in currently illicit opioid drugs except as follows:

Opiated teas, tinctures, tonics and other products, clearly showing the percentage of opioid per volume would be manufactured under licence to a State Government Office of Drug Revenue (ODR) and sold through pharmacies to people over the age of 18. All ingredients of these products would be listed on their packaging. Taxes raise from the sale of these products would be used to fund treatment and education programs.

Smokable opium and heroin would be manufactured under licence to the ODR and sold in pharmacies to people over the age of 18, together with smoking implements designed to reduce the level of harm associated with opium and heroin smoking (ie. smoke cooling equipment such as hookahs and long pipes). Prices of these products would be set so that they would:

(a) encourage opium use over heroin use, but which

(b) encourage opioid smoking over opioid injecting.

Sales of these products would be in small quantities only (enough for 3-4 episodes of intoxication). Taxes raised from sales would be used to fund treatment and education programs, and to subsidise the prescription system.

By prescription (see below).

The pharmacy sales of opiated products, opium and heroin would be regulated by officers of the ODR, not by the police.

The retail system would be accompanied by an education, information and referral system. A general education campaign would be carried out to provide the rationale for this system and to explain its workings.

Commercial suppliers would be required to label their products with consumer information concerning weight, recommended dosage, and approved health warnings.

Profits earned from the commercial manufacture or supply of heroin and other opioids would be taxed.

There would be no advertising or marketing of opioid products except for the minimum necessary for brand identification. Realistic education materials would be available in a range of formats to opioid product buyers.

Training would also be provided to pharmacists in early identification of opiate-related problems, assessment of these problems, and referral for assistance via prescribed opioids, drug treatment or other help as negotiated with the consumer. Part of this training would be in obtaining information from new buyers about their level of knowledge of opioid use, and ensuring that new buyers especially have access to appropriate education materials.

It would remain an offence to drive while under the influence of heroin or other opioids.

Prescription

The prescribing system should be established for registered "dependents" (people who are or believe that they are dependent on a drug). Such a prescription system would have the following as its essential elements:

The system should have as its core values harm reduction and full consumer participation. The system should have an entry assessment to ensure that the individual wants to be maintained on an opioid drug. Assessment must be carried out by a trained, qualified drugs worker. A full and frank assessment of the likely consequences of a range of options including maintenance, detoxification, selective detoxification, controlled using, etc should be negotiated with the individual.

The prescription system should make available a choice of the five most popular opioid drugs in a variety of forms for oral or injectable use, in a range of doses up to a negotiated maximum dose when they so desire.

To avoid "double" prescribing, a computerised register would be kept of the dependent person's name, address, preferred drug(s) and maximum dose(s).

Options for dispensing should also be negotiated. They may include: Pharmacy dispensing Drug clinic dispensing Home delivery for long-term illness or palliative care. Safe injecting spaces ("shooting rooms") in areas with a high concentration of drug injectors, especially those who are homeless.

The system should be costed at a reasonable fee to the consumer. Services to clients on low incomes should be delivered through the public health system. Operating costs will be supplemented by some of the revenues from the ODR.

It would remain illegal to import or export heroin and opioids.

Amphetamine

It would be legal to consume amphetamine and to possess small quantities (2 grams) for personal use.

It would remain illegal to manufacture, supply or traffic in currently amphetamine except as follows:

Amphetamine would be manufactured under licence to a State Government Office of Drug Revenue (ODR) and sold in pharmacies to people over the age of 18. Prices of these products would be set so that they are much higher than cannabis products. Sales of amphetamine would be in small quantities only (enough for 3-4 episodes of intoxication). Taxes on sales would be used to fund treatment and education programs and to subsidise that prescription program.

By prescription.

The pharmacy sales of amphetamine would be regulated by officers of the ODR, not by the police.

Profits earned from the commercial manufacture or supply of amphetamine would be taxed.

Realistic education materials would be available in a range of formats to amphetamine buyers.

There would be no advertising or marketing of amphetamine except for strictly limited brand identification.

Commercial suppliers would be required to label their products with consumer information concerning weight, recommended dosage, and approved health warnings.

It would remain illegal to import or export amphetamine.

It would remain an offence to drive while under the influence of amphetamine.

Training would also be provided to pharmacists in early identification of amphetamine-related problems, assessment of these problems, and referral for assistance via prescribed amphetamine, drug treatment or other help as negotiated with the consumer. Part of this training would be in obtaining information from new buyers about their level of knowledge of stimulant use, and ensuring that new buyers especially have access to appropriate education materials.

The prescription system should be established for registered "dependents" (people who are or who believe they are dependent on a drug). Such a system should have the same essential elements as the opioid prescribing system described above.

Ecstasy

It would be legal to consume ecstasy and to possess up to 2 grams or 10 tablets.

Ecstasy may be manufactured and sold under licence in pharmacies to people over the age of 18. Licences to manufacturers, distributors and pharmacists would be issued by a State Government Office of Drug Revenue (ODR).

Pharmacists licensed to sell ecstasy would be required to complete suitable training in the pharmacological effects of MDMA. Part of this training would in obtaining information from new buyers about their level of knowledge of ecstasy use, and ensuring that new buyers especially have access to appropriate education materials.

Commercial suppliers would be required to label their products with consumer information concerning ingredients, recommended dosage, and approved health warnings. Ecstasy should be manufactured for sale in standardised doses.

Profits earned from the commercial manufacture or supply of ecstasy would be taxed.

Rave parties would be allowed subject to promoters obtaining a licence. To qualify for a licence, promoters must demonstrate that arrangements have been made to provide adequate supplies of free water, chill out rooms, and other appropriate health measures. [If a significant black market persists, it may be necessary to have a pharmacologist on-site to analyse tablets and powders on the request of patrons.]

Health information should be made available in appropriate formats at places where ecstasy use is predictable (eg raves). This information would include advice to drink adequate water and to rest and cool down regularly.

It would remain an offence to drive while under the influence of ecstasy.

It would remain illegal to import or export ecstasy.

Anabolic Steroids

Steroids represent a separate and different phenomenon of drug use to traditional psychoactive drugs. The relationship between effect desired and effect obtained is specific, and has less to do with the social and environmental context of drug use. A harm reduction approach to steroid use would include medical supervision of training and diet, as well as psychological and physical monitoring (such as testing for liver and kidney function).

It would be legal to use or possess small quantities of anabolic steroids, provided the user holds a current prescription from a medical practitioner authorising their use.

Prescriptions may be issued for a maximum single period of one month. Prescriptions could be renewed only after consultation with the prescriber.

Training in the physical and psychological effects of steroid use would be provided to those medical practitioners who wish to be steroid prescribers.

Commercial suppliers would be required to label their products with consumer information concerning ingredients, recommended dosage, and approved health warnings.

Education campaigns should be undertaken aimed at encouraging steroid users to moderate the quantities and dosages used, and to use steroids only under medical supervision.

Research should continue into the physical and psychological effects of use of anabolic steroids, especially long term use. The results of this research should be promoted widely among steroid users.

Sporting organisations would be able to continue to ban steroid users from competition, and to test competitors for steroid use.

It would remain illegal to import or export anabolic steroids.

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