THE INTERNATIONAL JOURNAL OF DRUG POLICY 1993 4 2

DEVELOPING AMPHETAMINE-RELATED STRATEGIES WITHIN A HARM-REDUCTION FRAMEWORK

Martin Turnbull looks at amphetamines and considers options for social policy describing the response to the problems posed in Australia and looks at the implications for HIV prevention.

This article is adapted from a presentation at The Third International Conference on the Reduction of Drug-related Harm held in Melbourne in March 1992.

INTRODUCTION

One of the most significant drug issues to arise in Australia over the last few years is that of amphetamine use. The rapidity with which this issue has emerged from obscurity to become regarded as a major social problem is matched only by the rise of the crack phenomenon in the USA. 1 would like here to explore the way amphetamine use has been defined in social policy terms, and how government bodies are now responding by developing strategies to deal with the issue within established policy frameworks explicitly based on harm-minimisation principles. In doing this, 1 want to suggest how specific characteristics of the amphetamine problem challenge society's dominant paradigms of illicit drug use and, hence, the way we conceive and implement a total harm-reduction drug strategy. Of particular importance in this is the link between drug policy and HIV prevention.

Before going any further, I need to clarify a couple of things. First, in talking about amphetamines we are clearly faced with a diversity of both substances and users. My main concern here will be with those stimulants known colloquially as 'speed' - consisting predominantly of either methamphetamine or dexamphetamine. These drugs are used illicitly in Australia by groups ranging from street kids to truck drivers to business executives, and are variously taken as tablets, snorted or injected. It is important to keep in mind, however, that these drugs are closely linked with a range of common stimulants such as ephedrine, on the one hand, and with designer drugs such as MDMA, on the other. The similarities and the popular confusion between these drugs and amphetamines is a significant factor to be considered in the framing of any strategy. In some cases it may actually be more effective to address amphetamines as part of a broader psychostimulants strategy.

The second point I need to make by way of introduction is that this is very much a national issueandone which has prompted close cooperation between the eight states and territories that make up Australia's federal system of government. At the same time, the extent and nature of the problem does vary considerably from state to state. So while 1 will be referring to the Australian experience broadly, my personal perspective is that of the State of Victoria - Australia's second most populous state - and not everything in this article will necessarily apply equally to the rest of the country.

THE PROBLEM

As recently as 1986, a Ministerial Review of Health Promotion in Victoria noted that amphetamine use is 'much less prevalent than formerly and does not appear to be a significant problem now'. Just three years later, police seizures of amphetamines in Victoria had almost tripled to outnumber heroin seizures, drug treatment workers were proclaiming amphetamines to be agreater danger than heroin, and amphetamine use was being hailed specifically as the way in which HIV would enter the broad community. This dramatic change partly reflected a real and rapid increase in the local availability of amphetamines and the prevalence of use; yet it wasalso a case of public recognition of what had been in many ways a hidden problem. As one Melbourne journalistwrote:'Speed, itseems, has always had something of an identity problem and has never feature3prominently in the public drug debate.'

As in the USA, amphetamines have been used in Australia for non-medica I purposes since the 19 50s. By the late 1960s use was common among groups such as bikies, truck drivers and students. They were also being used extensively by women for weight loss purposes. As a result of this use, strict regulations on the legal sale of these drugs were introduced in the early 1970s. In the 1980s, while we waited (largely in vain) for cocaine to hit Australia as it had hit America, amphetamines cheaper and locallyproduced -were left largely uncontrolled to become Australia's alternative stimulant of choice. The extent of amphetamine use by the end of the 1980s is not accurately known, yet some of the facts are startling.

The number of amphetamine -related deaths in Australia increased from 8 in 1987 to 45 in 1988 (the majority of these being overdoses by people aged 20-29), and amphetamine-related poisonings increased sharply as a percentage of totaldrug mentions from 1985 to 1989. The numbers of persons seeking treatment specifically for amphetamine problems in Victoria increased by over 30% between 1988 and 1989. A national survey in 1987 found that 1.6% of the, population reported having used amphetamine last year compared to 0.1% for heroin and 0.3% for cocaine, while among illicit drug users surveyed 2 1 % used amphetamines compared to 3% for heroin. We also know that amphetamine use is highest among 20-24 year olds, and it is the most commonly used illicit drug after marijuana.

AMPHETAMINE USE AS A SOCIAL ISSUE

What gives these facts wider significance, however, is the awareness of specific types of harm associated with amphetamine use. In particular, the risk of HIV infection looms large as an increasing number of amphetamine users are found to be injecting the drug. Estimates of this number vary, depending on location, socioeconomic status and otherfactors. One recentsurvey in Canberra - the nation's capital city - found that 58% of amphetamine users in a sample of young illicit drug users were injecting, whereas a Victorian study estimated that about 40% of users were injecting. This is of particular concern because the majority of amphetamine users are casual recreational users who m,iyonlyuseafewtimesa month and are not linked into harm-reduction services established for intravenous drug users.

A second and perhaps more immediately concerning fact was a series of horrific road accidents in which stimulants were implicated. One particularly tragic bus crash in which 26 people died was found to have been caused by a truck driver who had hallucinated after injecting amphetamine. Amphetamine use for occupational reasons may he an easy progression from use of ephedrine -sometimes known as'shakers'.

A third factor, of major concern to a society increasingly troubled by recent episodes of community violence, is the link - a double link in fact - between amphetamines and violent crime. Amphetamine production and distribution in Australia is closely connected with bikie gangs and is surrounded by a paramilitary subculture which all too often explodes into violence. This violence is compounded by the irrational and psychotic behaviour that can be engendered by use of the drugs themselves - a fact evidenced by recent increases in the numbers of people presenting to psychiatric services with aniphetamine-induced problems. The amphetamine issue differs from other illicit drug issues in that violence and crime are linked to the drug itself as well as to the fact of its prohibition.

The diversity of these harms and the direct and indirect threats they pose to the whole community were key factors in the legitimisation of amphetamine abuse as a social issue. This legitimisation was problematic, however, due to the equivocal status of both amphetamines themselves and their users. The fact that these drugs are used not just by the so-called stereotypical 'junkie' or 'addict'but by ordinary hardworking people of middle Australia - truck drivers, businessmen, disco crowds has been both a spur and a barrier to action. Whi Ist this great diversity of users eventually created a greater sensitivity to the real dangers of the drug, it also meant that the issue lacked the simple focus and sense of moral imperative of more traditional illicit drug issues. Sitting uneasily at the boundary between normal and deviant behaviour, amphetamine use was a marginal behaviour which was not seen as immediately threatening to the social order.

Although amphetamine users defied neat stereotypes, the drugs themselves defied the neat categorisation of 'hard' versus 'soft' drugs; perceived by many as similar to legally available stimulants such as phedrine, amphetamine use is also variously linked to use of heroin (as a common element of polydrug use), marijuana (as an alternative cheap way of'getting stoned') and heavy drinking (amphetamines giving a greater tolerance to alcohol). Evidenc.e from surveys suggests that young people, in particuthr, tend not to regard amphetamines as dangerous and even many who inject themselves with the drug do not identify as intravenous drug users and are actually very critical of heroin users. The first challenge for a harm-reduction stratgy was clearly to get the users themselves to recognise that they are at risk and to break down speed's image as a 'clean'drug.

THE RESPONSE

Policy makers faced a number of barriers in their recognition of the amphetamine problem. This was partly due, 1 think, to the need for the relevant authorities to work through the sorts of ambiguities 1 have outlined in order to construct the problem as a public policy issue appropriately dealt with within established paradigms for illicit drug problems. Yet even as this occurred, those in the drugs field found themselves unprepared in several key respects. An almost complete lack of research on the illicit use of amphetamines in Australia left policy makers without a clear picture of the extent and sociocultural context of use. At the same time, law enforcement agencies were ill-prepared to control a drug locally manufactured and distributed through a highly organised network which had, as the police admitted, revolutionised overnight the illicit drug industry in Australia. Meanwhile, treatment agencies were still largely inexperienced in dealing with psychostimulant use, experiencing it chiefly as a complicating factor in their polydrug-using clients.

As the emerging issue was recognised there was a strong concern by government not to over-react and run the risk of exacerbating the problem by publicising a drug regarded by many as enjoyable and, by virtue of its use for legitimate medical purposes, safe. (This Was consistent with earlier planning of cocaine strategies in which high-profile, sensationalised campaigns were rejected as likely to be counterproductive.) From the beginning then, a balanced and holistic harm-reduction strategy rather than a heavy-handed war-againstthe-drug was seen to be the only viable approach.

As with most 'new'drug issues, the media played a key role in the broader public legitimisation of the amphetamine issue. In a manner slightly less sensational than most media reporting of illicit drug issues, a spate of newspaper articles appeared in late 1989 purporting to expose this'hidden epidemic'. The main issues promoted by the media were the way young people were supposedly being lured into swapping from marijuana use to amphetamine use, the community violence connected with amphetamines and, to a limited extent, the risk of HIV infection. For many others, however, it was the use by truck drivers and the resulting road trauma above all that made the problem an urgent social issue. In portraying the amphetamine problem as a reflection of social and work pressures, and the infiltration of greed and a violent subculture into middle Australia, the media ushered the issue into public debate not simply as another evil threat from without, but as a symptom of ordinary life in the 1980s.

This media interest culminated in a major television documentary screened in April last year. In a hardhitting expos6, this programme brought together the many diverse aspects of the amphetamine problem and the threats it posed to mainstream Australia. One of the most revealing aspects of the programme was the appearance of senior police officers publicly urging that health authorities urgently take a much higher profile in the issue. As with many drug problems, it is the lawenforcement bodies, seeing the immediate problems of crime and violence, who ring the early warning bells, while health issues only develop over time. What was  remarkable in this situation was the rapidity with which ~ the problem was recognised as having overtaken the boundsofa I aw-enforcement approach. Reflecting thi . s, the television programme ended with a clear challenge to governments, asserting that health and social policy makers were lagging in what was in reality a deadly race against time.

Policy makers had in fact by this time begun to act. The Ministerial Council on Drug Strategy, the major joint federal-state government drug policy body in Australia, had moved to establish a committee to develop an effective response to the problem. Victoria, the state hailed as'the amphetamines capital of Australia', took a lead role in this process, although the problem was clearly recognised as a national one requiring a coordinated national response.

The committee's approach was to develop strategies in law enforcement, education and treatment simultaneously to ensure a consistent and mutually reinforcing response. The framework for this response was the National Campaign Against Drug Abuse, complemented by state-level structures such as the Victorian DrugStrategy, whichhad developed a strongemphasis on demand-reduction and community development approaches, as well as highly regarded HIV preveption strategies. The committee also linked up with national groups set up by police and road transport authorities to address specific aspects of the amphetamine problem.

POLICY DILEMMAS

The emphasis on developing an integrated action plan was significant, because it was immediately apparent to the committee that the amphetamine issue blurred a number of traditional policy boundaries. First, the split between supply control and demand reduction was challenged in view of the connection between amphetamines and legal stimulants such as ephedrine. Supply control efforts had to encompass these drugs as precursors to amphetamine manufacture, while recognising that misuse of these licit drugs is a problem both in itself and as a factor increasing the risk of progression to amphetamine use. This muddying of the line between licit and illicit drug problems, together with the special difficulties of policing the local manufacture of amphetamines, were key factors in leading the police to a firmer acknowledgement of the role of demand reduction and in creating closer cooperation between health and law-enforcement authorities.

In addition, allegations that the heavy control of marijuana production was increasing the demand for speed forced law-enforcement authorities to consider seriously the interaction between their supply-control policies on different drugs and theneed toredirecttheir efforts to those drugs causing the greatest harm in the community. The amphetamine problem has, in fact, led to a considerable resurgence of community debate about decriminalisation of marijuana use.

The second traditional element of policy to be challenged was that of linking specific drugs to recreational, occupational or dependent use. Amphetamines bridge the gap between these categories. Evidence suggests that, in distinction to heroin, speed is used predominantly either for social enjoyment or for occupational reasons and that the vast majority of users never develop true dependence (although, of course, dependent use may develop from either of these categories). Hence, whilst speed 'addicts' as such are certainly a problem, they are far from being the main issue. One important implication of this is that education campaigns need to target occasional recreational users and specific occupational groups (neither of which have been specific components of previous demandreduction campaigns) and that a range of different approaches may be needed within the same groups. With truck drivers, for example, demand-reduction strategies need to involve employees, unions and employers at workplace level in order to change workimtures to reduce the pressures to use stimulants. At the same time, lower profile HIV prevention campaigns targeted to this group need to be conducted discrete way to reduce the immediate risk of infection without exposing employees to the fear of sanctions from employers.

AMPHETAMINES AND HIV PREVENTION

This raises the third and perhaps most significant challenge - the relationship between demand reduction and HIV prevention, both of which have been important elements of national drug strategy. The Australian experience has been characterised by broad coordination between these two objectives, with a gradually increasing degree of integration at service level. Yet while drug policies have continued to develop a wide range of demand -reduction approaches, HIV strategies tended to be developed in parallel, taking a conscious decision to be non-drug-specific in approach. Sensitive to criticism of early campaigns which tended to alienate !! users by presenting negative images of drug users, [recent HIV campaigns have focused very narrowly on behaviours that transmit HIV. Although these campai gns have indirectly targeted amphetamine users, by trying to dispel myths about intravenous drug users and accessing recreational users, there has been no specific focus on amphetamines.

Two questions in relation to this have arisen over the last year. First, can the risk of HIV infection to amphetamine users be reduced by explicitly raising the profile of amphetamines in HIV education, and second, can the broader dangers associated with amphetamine use be promoted in the same context? We do not, as yet, have clear answers to these questions but we have recognised the need for both aspects to be considered in a more integrated way and there has been some valuable crossfertilisation of ideas.

The experience of HIV campaigns has been invaluable in developing innovative ways to contact drug users outside treatment services, particularly young recreational users. These campaigns have developed successful low-key community development approaches, characterised by careful targeting of distinct subculturesI and have advanced the application of health promotion strategies and'health belief'theories to illicit drug use. In doing this, they have shown the importance with some groups of avoiding an anti-drug message even at an implicit level. On a more practical level, the HIV issue has produced a netwerk of services such as needle-exchange outlets whic~ may play an important role in a campaign focused on amphetamine use. HIV campaigns have also produced a wealth of data on intravenous drug use, much of which contains valuable information on amphetamine use. Further analysis of the data specifically in terms of amphetamines will be critical in testing the hypothesis that amphetamine users are at greater risk of HIV infection.

Conversely, the process of developing an action plan on amphetamines has prompted us to focus on a numberof gaps in our HIV strategies. One of these is the issue of truck drivers and similar occupational drug users. Although it was known that stimulants were widely used in these groups, it had been tacitly assumed that this was oral use. Recent reports of injecting practices among truck drivers have alerted HIV strategists to a potential threat of HIV transmission which they had not targeted. More generally, the publicity about the extent of amphetamine use has prompted a concern that HIV campaigns have been too general and that a specific focus on amphetamines may also be needed in order to persuade intravenous amphetamine users that they too are at risk. At the same time, community awareness of the dangers of amphetamine use, quite apart from HIV, raises the question of whether current HIV prevention campaigns are misleading young people into the tacit assumption that amphetamine use is, in itself, not harmful.

A final aspect of the amphetamine problem relevant to HIV campaigns is the apparent ease of the progression from oral to intravenous use and the reported recency of this phenomenon. Actively promoting a shift from intravenous injection to safer modes of administration has not been attempted in Australia as an HIV prevention strategy. However, if amphetamine users are the main focus, such a strategy may warrant serious consideration (especially in view of evidence that some intravenous users will change to snorting; oral use as a'giving up'strategy). This approach would, of course, need to take care that it did not result in recruitment of new users and that the significant risks involved in intranasal use, for example, are not underestimated.

CONCLUSION

In summary, then, the focus on amphetamines is proving to he a potent catalyst in bringing HIV and other drug strategies closer together. On a practical level, there is now an acknowledgement of the need for closer linkages in planning, and a greater appreciation of the relevance of targeted community development approaches to both demand reduction and HIV prevention. There is also a growing appreciation that harm minimisation is much broader than HIV prevention ~ and that campaigns cannot afford to ignore other types of harm associated with use of a specific drug. The amphetamines issues has done much to breakdown the stereotyped image of the illicit drug user and to broaden our concept of an illicit drug problem. At the same time there has never been closer cooperation between law enforcement and health authorities as both recognise the real threats posed by amphetamine use and the fact that these will only be addressed by broadening traditional approaches to illicit drug use.

M.P. Turnbull, Victorian Drug Strategy Unit, Health Department Victoria, Australia