Understanding the impact of stigma
While Alcohol and Other Drug (AOD) use occurs across all sections of our society (e.g. people with the highest socioeconomic status are more likely to consume alcohol at risky levels than those with the lowest socioeconomic status), people who are socially disengaged, economically vulnerable and otherwise marginalised are more likely to develop AOD dependence.
Social attitudes that consider Alcohol and Other Drug (AOD) dependence as a moral failure or a threat to public safety have a powerful influence on the stigmatisation of people who are AOD dependent (and their families). This stigma further entrenches disadvantage, drives the shame experienced by those affected and fear of being publicly identified. Stigma plays a key role in making it harder for people to seek help, including accessing the necessary health and community services.
As most community members are not directly affected by Alcohol and Other Drug (AOD) dependence, media coverage and political rhetoric play a key role in shaping their attitudes towards those affected. The use of stigmatising headlines, inflammatory political rhetoric and fear-based social marketing campaigns and are politically popular, but do untold damage to some of our most vulnerable community members.
Even for those who have made changes to their AOD use, the impact of stigma can be long lasting. It can be a significant barrier to securing employment and making new social connections, and can pose a major challenge to the success of people’s recovery.
Myths about drug use
Everyone who uses drugs is dependent (addicted): Globally, only 10% of people who use alcohol and other drugs (AOD) become dependent. The great majority are able to maintain occasional or recreational levels of use.
You can become dependent after using just once: Alcohol and Other Drug (AOD) dependence occurs over time, as a person’s tolerance to a drug builds and their body adapts to the ongoing presence of a particular drug. A person does not become ‘addicted’ after using a drug once; however over time they may become dependent.
Drug use is always a sign of a deeper problem: For most people, the use of Alcohol and Other Drugs (AODs) is social or recreational. Some people do ‘self-medicate’ with AODs as a coping strategy for managing the impact of previous (or ongoing) trauma, social isolation or mental health symptoms, but this is a minority of people who use drugs. While self-medication carries many risks, it is important to recognise that for many people, it is a strategy they have learnt in order to manage and assert a degree of control over a range of impacts that their mental health has on their health and wellbeing.
Harm reduction condones drug use: Harm reduction acknowledges that there will always be some people who use drugs, and that most people who use drugs do so occasionally and for a short period in their lives. Most people who use alcohol and other drugs are in the 20s with the next most in their 30s, and after that there is a big drop off in the number of people using alcohol and other drugs. The aim is to set up an environment that keeps those few people who use illicit drugs or over use alcohol and pharmaceuticals safe in the period of their life they choose to use these drugs.
Models of alcohol and other drug use and dependence
There are various models for understanding dependence/addiction. There are many schools of thought about how it develops (and how it should be treated). The Disease model dominates US drug policy and treatment system – addiction is considered as a ‘brain disease’ that needs to be managed like other ongoing chronic medical conditions (like diabetes or bipolar disorder); treatments might include 12-step programs or medications. But this is not the only model. Other models include:
The Social Learning Model – Within this model dependence is considered a ‘learned behaviour’ that is considered to be normal and occurs on a continuum. People can become dependent on Substances, Objects, Activities or People (SOAP), things that provide us with pleasure. The degree of dependence is determined by the amount of distress that is experienced when a person is unable to engage in the SOAP. Addiction occurs when a person feels a compulsion to engage in the behaviour (or feeling out of control) and can only be addressed when the individual perceives that the costs of the behaviour outweigh the benefits. Treatments involve behavioural strategies such as replacing the dependence with new and more adaptive coping strategies and behaviours.
The Socio-Cultural Model – This model contends that societal factors impact people’s alcohol and other drug (AOD) use. In particular, this model makes links between inequality and drug use. That is, people who belong to groups who are marginalised are more likely to experience dependence. Further, by stigmatising people who use drugs, the socio-cultural model proposes the AOD problems experienced by these marginalised individuals is exacerbated. It highlights the need for social change to address alcohol and other drug issues
The Public Health Model – This model is at the heart of Australian drug policy and recognises that alcohol and other drug-related harms occur through an interaction between AODs (e.g., purity, accessibility and route of administration), the person (e.g., their mental state) and the environment (e.g., drinking at home versus drinking at a nightclub). The Public Health Model underpins harm reduction, which is defined as any effort to prevent people from experiencing harms from AODs without necessarily requiring a reduction in drug consumption.
In reality alcohol and other drug-related problems are multifaceted and any one individual may develop problems from one or a number of influences. Their drug use may be maintained by different influences than those that started the drug use in the first place.
AOD use in Australia: current and emerging issues
All drugs – legal, pharmaceutical and illicit – come with a range of benefits and harms. Managing trends is about balancing the harms with the benefits.
Alcohol remains (by far) the drug responsible for most harm within our communities, but fewer people (particularly young people) are drinking at harmful levels. Within a broad pattern of an overall decline in alcohol consumption, significant alcohol-related harm is experienced by people in the following groups:
- Young people drinking at high levels (occasionally referred to as ‘super binge drinkers’);
- Middle-aged people drinking to cope with work or family-related stress; and
- Older people experiencing the cumulative health impacts of long-term alcohol consumption.
Recent state and territory government measures to reduce alcohol-related violence in public spaces (e.g. lockouts and reduced trading hours) have generated fierce public debate, but have been shown to be effective in achieving their stated aims.
Alcohol plays a clear role in contributing to family violence, but is yet to be addressed effectively.
Many people try illicit drugs, but few people have problems with them. (including pharmaceutical drugs for non-medical purposes) in their lifetime. But only 12% use regularly and only 10% of people who use illicit drugs become dependent.
Illicit drug use among young adults has been steadily decreasing over the past decade.
Methamphetamine use been decreasing over the past decade, but harms have increased as a result of the way it is used and the type of methamphetamine used. It is become stronger and cheaper. The proportion of people using methamphetamine is low at 2% of the adult population. This demonstrates why a focus on harms is more important than a focus on use.
As a result of harms increasing, there has been a huge increase in people presenting for treatment,ranging from 20-40% among some publicly funded treatment Alcohol and Other Drug (AOD) providers.
Following years of steady decline, heroin related harms are again on the rise in Australia. Increasing the risk of opioid overdose fatalities is the emergence of powerful synthetic opioids (such as fentanyl and carfentanil) that have been detected in Australia. The presence of these synthetic opioids in heroin being sold in the US and Canada has been directly linked to a significant increase in overdose deaths.
In February 2016, the Therapeutic Goods Administration removed some access barriers to the opioid overdose-reversal drug naloxone (also known as Narcan), making it available for ‘over the counter’ sales, but to date, distribution has been limited at a national level and is a significant barrier to wider uptake by people likely to encounter opioid overdoses.
Australia has one of the highest rates of Cannabis use in the world, despite it being an illegal drug. In aNational survey conducted in 2013 it was estimated that 35% of Australian’s over the age of had used it in their lifetime, with 1 in 10 reporting using it the past 12 months. A recent study at the Australian National University found that 43% of Australian’s supported it’s regulation for recreational use.
Over the past 25 years there has been a significant move internationally to allow people access to cannabis. There are two main policy focuses with cannabis: medicinal use and recreation use. The issues are very different with both
In many countries, including some jurisdictions in Australia, cannabis is still illegal but does not come with criminal penalties. This is known as decriminalisation. People who are caught with small amounts of cannabis may be diverted to treatment or given a caution, instead of receiving criminal charges.
Some countries are now also starting to allow legal access to cannabis for recreational use. This is known as legalisation. Eight US states have passed legislation to allow people access to cannabis for recreational use. We don’t know what the full consequences of this will be, as these changes are very recent, but early data shows that there hasn’t been a huge increase in use or harms.
In terms of medicinal cannabis, in the US alone 28 states have regulated access, while 8 states have passed legislation to allow people access to cannabis for recreational use. Australia has recently seen legislative changes that will allow people access to medicinal Cannabis, with each state proposing different models.
Given these shifts at an international and local level, does this mean that Cannabis is a safe drug? The answer is that no drug is safe, but the potential to experience harm from Cannabis is low compared to other drugs, including alcohol. 10% of people who use Cannabis will develop a dependence on it in their lifetime, which is lower than for alcohol, which is 14%. Perhaps the biggest concern regarding Cannabis is suggestions that that it might cause psychotic disorders like Schizophrenia. Despite decades of research the relationship between Cannabis and Schizophrenia is still not clear. A single gene has been found that is linked with people developing Schizophrenia. If a person with the gene smokes Cannabis before aged 18, but not if they smoke it after the age of 18 then they are highly likely to develop Schizophrenia. It is likely that Cannabis is a contributing factor to the development of Schizophrenia in people who are predisposed to the condition, though it is hard to say whether the disorder would not develop in the absence of Cannabis due to other stressful precipitating factors. Indeed, despite a significant increase worldwide in the consumption of Cannabis over that past 60 years, the rate of Schizophrenia has remained stable and there a no differences in rates between countries that have high rates of Cannabis use and those with low rates.
New or Novel Psychoactives
One of the unintended consequences of making certain drugs illegal has been the rapid emergence of a range of new psychoactive substances that are designed to mimic traditional drugs. Some of these drugs were originally developed in the course of academic research into brain function, and many of the newer drugs are rationally-designed variants or derivatives of these original research compounds. Some of these drugs are very potent and can be more toxic than the drugs that they are intended to mimic.
Because of the way drug laws are designed, illegal drugs need to be listed on a schedule that identifies their legal status. Any drugs that are not listed are in theory legal to use and sell. New psychoactive substances are being manufactured faster than we can identify them and add them to the schedule. One of the major problems with these drugs is that because they are so new, many people are trying them for the first time and do not have knowledge of the effects in order to reduce harms.
One policy response that would assist in reducing harm to people being exposed to these drugs would be the introduction of more rapid drug monitoring systems, where consumers and other stakeholders could submit drug samples for rapid chemical testing.
Workplace and roadside drug testing
Current policies (including workplace drug testing policies) contribute to demand for ‘synthetic cannabis’ products which are sold with quasi-legal status. Government policies in banning certain chemicals contained in synthetic cannabis have led to highly variable and uncertain makeup of ‘synthetic cannabis’ products that could contain a multitude of different chemicals and have been linked to significant harms for people using the products.
Australian and global drug policy
Broad global pattern of shift away from the ‘war on drugs’ model, towards greater focus on AOD use as a health issue and law reform (particularly for cannabis) to reduce AOD-related harm. Australia’s Harm Minimisation drug policy framework has been in place for over 30 years. It provides a structure for integrating a wide range of policy responses within the three pillars of:
- Supply reduction – controlling the supply of AODs through age restrictions, taxation, border control, and policing;
- Demand reduction – reducing demand for AODs within Australia through provision of treatment services, social marketing and education campaigns;
- Harm reduction – reducing harm amongst those currently using AODs through services such as Needle and Syringe Programs or Medically Supervised Injecting Centres, and peer education and support at music and cultural festivals.