THE INTERNATIONAL JOURNAL OF DRUG POLICY, VOL 7, NO 1, 1996


WHEN SCIENCE MEETS POLITICS: THE AUSTRALIAN HEROIN TRIAL FEASIBILITY STUDY

Gabriele Bammer, The National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia

This is a version of a paper presented at the Vlth International Conference on the Reduction of Drug Related Harm in Florence, March 1995.

Since 1991, the National Centre for Epidemiology and Population Health at the Australian National University and the Australian Institute of Criminology have undertaken an examination of the feasibility of heroin prescribing. This article deals specifically with the political aspects of the study. It begins with some information about drug use in Australia, as well as an overview of Australian government enquiries into drug use. It then outlines the history of this particular project and presents the process used in its conduct. Finally it briefly discusses the ramiflcations of both a 'yes' and a 'no' decision.

SOME FACTS AND FIGURES ABOUT DRUG USE IN AUSTRALIA

Australia has a population of around 17.5 million people. The Australian Capital Territory (ACT) is a landlocked territory surrounded by the state of New South Wales and houses the national capital, Canberra, with a population of about 300 000. In 1988 there were estimated to be 30 000-50 000 dependent heroin users in Australia (National Campaign Against Drug Abuse, 1988). Estimates conducted as part of the feasibility study vary somewhat, but suggest that there are likely to be around 1000 dependent heroin users in the ACT (Stevens et at., 199 1; Larson, 1992; Larson et al., 1994).

The tangible and intangible economic costs of illicit drug use in Australia in 1988 were conservatively estimated at $Al 441 million, which is 10% of the costs of all drug use (including alcohol and tobacco; Collins and Lapsley, 1991).

The 1993 National Drug Household Survey (National Drug Strategy, 1993) found that 34% of thoseaged 14 years or older had ever tried marijuana, with 13% having used in the last 12 months. The next most commonly used illicit drugs were the amphetamines with 8% having tried them and 2% having used in the last 12 months. Heroin and cocaine/crack use were comparable with 2% having ever tried and 1% having used in the last 12 months. Many dependent users in the ACT use a range of drugs, but for a substantial proportion heroin is the drug of choice (Crawford and Bammer, 1991; Stevens et al., 1991). Injection is by far the most common route of administration of heroin, but smoking and'chasing the dragon'also occur (Crawford and Barnmer, 199 1; Stevens et al., 199 1; Aus, tratian Bureau of Criminal Intelligence, 1995).

A national census of drug treatment service agencies conducted in 1992 identified 465 treat~ ment agencies (National Campaign Against Drug Abuse, 1992). In 1991 there were more than 9500 people on methadone programmes nationally (Department of Health, Housing and Community Services, 1992). In the ACT a range of govern, ment and non-government agencies provides treatment and/or support for illegal drug users. When the feasibility research began in 1991, the government-run oral methadone programme had 100 places (85 on maintenance and 15 on withdrawal regimens) and the waiting period for entry was about 2 months. Since then, the methadone programme underwent a period of expansion; when, as part of the feasibility research, surveys of methadone clients were conducted in 1993, there were around 260 people on the programme and now the programme has reached the projected limit of expansion with 350 clients. There are plans to increase dispensing through pharmacies and to introduce prescription throug~ private general practitioners. Other treatment services include a therapeutic community, counse Iling, detoxification centres and a range of self-help groups. There are also halfway houses and referral and information services (based on Stevens et al., 199 1, which gives a fuller description of the ACT situation in 199 1). The ACT also has active advocacy groups both for drug treatment clients and for illicit drug users outside treatment - the ACT Intravenous Drug Users League (ACTIV), the Dependency Care Foundation and Methadone Action Consumer Empowerment.

AUSTRALIAN GOVERNMENT ENQUIRIES

InAustralia, since 1971, there have been at least ten Royal Commissions, Committees of Inquiry or Parliamentary Committees which have dealt with drugs, drug use and ways of ameliorating the effects of drug use. Nick Hartland analysed these as part of the feasibility research and found that there has been a high degree of consensus between these enquiries, which have repetitively asked the same questions and produced the same answers. It is significant that they have included alcohol and tobacco as well as illicit drugs and that they have aimed to reduce harm associated with drug use, rather than the elimination of drug use. The reports have advocated a three, pronged approach: education, treatment and law enforcement. All have called for more research and for informed public debate.

Since 1979 these enquiries have considered the option of medical prescription of heroin, and although they have recommended against it (with some suggesting that such prescription may have value for a small number of dependent users), the issue has persisted (Hartland, 199 1; Hartland et al., 1992).

A BRIEF HISTORY OF THE FEASIBILITY STUDY

In 1989, the newly formed ACT Legislative Assembly established a Select Committee on HIV, Illegal Drugs and Prostitution. It had representatives from both major political parties and was presided over by Mr Michael Moore, then a member of the Residents' Rally, a minor party, and later an independent member. As part of its deliberations the committee examined the issue of controlled availability of heroin. The first International Conference on the Reduc, tion of Drug Related Harm in Liverpool was one of the influences on the committee's deliberations.

In March 1991, the Presiding Member approached the Director of the National Centre for Epidemiology and Population Health (NCEPH), Professor Bob Douglas, to discuss the possibility of a trial of controlled heroin availability. In April a group of Australian experts in drug treatment and drug policy assembled at NCEPH, endorsed the need for a study into the feasibility of controlled heroin availability and suggested a four-stage process. Each stage was to be self-contained, ending with a decision about whether or not to proceed further. The first stage was to consider the issue of feasibility in principle, the second to consider logistic feasibility, the third to pilot procedures and the fourth to be the trial itself.

Stage 1 was completed in 3 months, with a rec, ommendation to proceed to stage 2 beingmadeatthe end ofJuly 199 1. We are now approaching the end of the stage 2 research. The stage I and stage 2 research was undertaken jointly by the National Centre for Epidemiology and Population Health at the Australian National University and the Australian Institute of Criminology (AIC).

Volume 1 of the stage 1 report was reprinted infull in the Second Interim Report of the Select Committee on HIV, Illegal Drugs and Prostitution (Legislative Assembly of the ACT, 199 1), which was presented to the ACT Legislative Assembly in August 1991. Debate on the report was rapidly adjourned and the committee lapsed after the ACT Legislative Assembly elections in February 1992.

In April 1992, the then Minister for Health, Mr Wayne Berry, took the issue of the feasibility study to the Ministerial Council on Drug Strategy (MCDS). MCDS is made up of two Ministers, one each from health and law enforcement, from each jurisdiction (the Commonwealth and each Australian state and territory). MCDS noted 'the progress made by the National Centre for Epidemiology and Population Health (NCEPH) in undertaking a feasibility study, not involving the distribution of any drugs, inro heroin treatment options'and recommended that 'the results of the feasibility study be re;orted to MCDS'. In subsequent years progress reports about the study were noted and in 1994 a subcommittee of the National Drug Strategy Committee (NDSC ) was established to consider thestage 2 report when it was released. NDSC is a similarly representative committee of senior officers (public servants and police), which supports MCDS. This committee has overall responsibility for the implementation of Australia's national drug strategy.

NCEPH and AIC decided to proceed with the stage 2 feasibility research after strong support at a one-day national seminar'Heroin Treatment -New Atternatives'in November 1991 (Bammer and Gerrard, 1992). The decision was made possible by a peer, reviewed competitive grant of $A445 000over 5 years from the Australian National University's Strategic Development Fund, which aims to'identi, fy and develop new areas of research perceived as particularly fruitful, in the national interest and inadequately addressed elsewhere in the country'. A further $A1 15 000 was raised through other com, petitive peer-reviewed grants to fund a number of specific sub-projects.

The complexity of the issues and the lack of already available information on which to base decisions meant that the stage 2 research took longer than originally anticipated. Making final recommendations was postponed more than once, so that the issues could be properly considered.

THE PROCESS OF CONDUCTING THE FEASIBILITY RESEARCH

The stage 2 research into logistic feasibility had three components: an assessment of risks, development of a proposal forservice provisionand development ofa proposal for evaluation. Much of the research broke new ground.

The process was guided by a 19-member Advisory Committee which met three times in 1992 and annually thereafter. The Committee had Australiawide representation from academics, advocates for illicit drug users, judiciary, police, policy makers and treatment service providers. In order to ensure that a balance of views was represented on the Advisory Committee, it was agreed at the outset that the Committee would not be asked to formulate or endorse the final recommendations.

As discussed in more detail below, there was emphasis on an open, consultative process. As sub, projects were completed, the results were published as working papers, so that they were available for scrutiny and discussion. Newsletters summarising the research results and providing updates of political events surrounding the feasibility considerations were publishedfrom time to time. Keydecision-makers, locally, nationally and internationally, were briefed about results and asked for input. The media were kept informed about the study and there were numerous radio, television and newspaper reports. The ABC current affairs series Atdtude produced a programme about the feasibility study which was screened in June 1994. Papers were also presented at national and international conferences and are being published in peer-reviewed journals. One of the study aims is to facilitate informed debate about the issues.

There is also considerable interchange of information with Swiss policy makers, health professionals and researchers who are involved in the trials of heroin maintenance prescribing which began in 1994. The Swiss trials strongly influenced the proposal for service provision.

Three principles guided the conduct of the investigation:

The research should have intrinsic value, so that regardless of whether or not a trial goes ahead, the research should be of value to treatment services or to drug policy generally.

Research should be conducted in all relevant dis, ciplines and the disciplinary findings should be integrated to address the central problem.

The process should involve to the greatest extent possible the key interest groups: illicit drug users, service providers, police, policy makers and the community.

The first principle meant that research questions were framed broadly, so that the issues relevant to the feasibility investigations were embedded in a wider context, which provided valuable information in itself, but also enriched the information needed for the feasibility considerations.

The second principle involved integratinga multidisciplinary approach. Academic colteagueswith a range of disciplinary skills donated time to the project-the disciplines covered included anthropology, clinical science and health care, criminology, demography, economics, epidemiology, law, pharmacology, philosophy, political science, policy analysis, psychology, sociology and statistics.

The third principle was to involve the relevant interest groups. Martin (1991) analysed the role of interest groups in shaping debates about drug policy and indetermining the issues and arguments brought to bear. The aim here was primarily to use interest groups to ensure that all potential issues, especially risks, had been identified and to determine the level of support for a trial of controlled heroin availability. Both formal and informal consultation processes were used. The formal processeswere surveys, areference group and workshops. The informal process was discussion, both oneto-one and small group. The key interest groups consulted were the general community, the police, illicit drug users, service providers, ex,users and policy makers.

ACT community surveys were conducted in 1991 and 1994; Sydney and Queanbeyan residents were surveyed in 199 1; and a national survey was conducted in 1995. There were also informal discussions with individuals and particular community interest groups.

The police were surveyed in 1991, were involved in a workshop about drug markets in 1992 and in a workshop specifically on policing issues for a trial in 1994. There were regular discussions with the ACT Drug Squad and the Australian Bureau of Criminal Intelligence. There were also discussions with the Australian Federal Police Association (the police union) and individual ACT and interstate police.

Illicit drugusers in and out of treatment were sur, veyed in 1991 and 1993. A reference group of people who are advocates for illicit drug user interests (without necessarily being users or ex-users themselves) was also consulted regularly and there were many informal discussions with individuals and advocacy groups, locally and interstate. There was also part ic, ipation in public meetings organised by the ACT Intravenous Drug Users League (ACTIV) and the Dependency Care Foundation.

Service providers were surveyed in 1991 and attended workshops on medical issues in 1994, service provision ina trial in 1994, and the contribution of childhood sexual abuse to alcohol, heroin and other drug problems in 1993. There were a number of discussions with staff from the ACT Health Drug and Alcohol Service and staff from non~government organisations, particularly Assisting Drug Dependants Inc. and the Alcohol and Drug Foundation of the ACT. There were also discussions with the Australian Medical Association, the Australian Salaried Medical Officers Federation and individual doctors, pharmacists and other health professionals.

Some service providers are also ex-users and so contributed to both perspectives. Other ex-users were surveyed in 1991 and 1993 and there were also informal discussions.

YES OR NO?

The final assessment of whether or not it is logistically feasible to make heroin available to dependent users in a controlled manner will weigh the benefits and risks of so doing.

If the decision is that it is not logistically feasible, there are unlikely to be major political difficulties,
However, there is a general feeling that something new needs to be done about the problems resulting from heroin dependence, so that there will be an opportunity for something else to be tried.
If the decision is that a trial of controlled heroin availability is logistically feasible, there are likely to be political difficulties in getting the recommendationa ccepted and implemented. The keyplayers will be the ACT and federal governments and the Ministerial Council on Drug Strategy.

POSTSCRIPT

The assessment at the end of the Feasibility Study was that there should be a trial to evaluate expansion of maintenance prescribing to include heroin as well as methadone and that the benefits of conducting such a trial outweighed the risks. The final stage 2 report with 12 recommendations (Bammer, 1995) was presented to the ACT Minister for Health, Mrs Kate Carnett (who is also the Chief Minister), on 27
June 1995. The primary recommendations were that two pilot studies should be undertaken (stage 3) before conducting a full,scale trial (stage 4). Another of the report's recommendations 'that the* ACT government institutes a three-month consultation period in which the results of the feasibility study are widely disseminated and discussed'was implemented immediately. The consultation was undertaken by a 29-member Task Force chaired by Mr Kevin Waller AM. In its January 1996 report the Task Force recommended that the ACT government undertake the first pilot study and supported the overall research protocol (Heroin Pilot Task Force, 1996).
The ACT Legislative Assembly has yet to decide whether or not to proceed. In addition, the Chief Minister has made it clear that a trial will not
go ahead unless financial assistance is provided to the ACT government and unless there is support from other Australian states. The MCDS is likely to be a crucial forum for deciding on these conditions.

Dr Gabriele Barnmer, National Centre for Epidemiology and Population Health, The Australian National National University, Canberra, ACT 0200, Australia.

REFERENCES

Australian Bureau of Criminal intelligence (1995).1994Australian Illicit DrugReport. Canberra: ABCI.

BammerG (1995). Report and Recommendations of Stage 2Feasibility Research into the Controlled Availability of Opioids. Canberra: National Centre for Epidemiology and Population Health and Australian Institute ofCriminology.

Bammer G, Gerrard G (eds) 0 992). Heroin Treatment - New Alternatives. Proceedings of a One-day Seminar, Becker House, Canberra, November 1991. Canberra: National Centre for Epidemiology and Population Health and Australian Institute of Criminology.

Collins DJ, Lapsley HM (199 1). Estimatingthe Economic Costs of Drug Abuse in Australia. National Campaign Against Drug Abuse Monograph Series No. 15. Canberra: Australian Government Publishing Service.

Crawford D, Bammer G (1991). Attitudes to a trial. In: Feasibility Research into the Controlled Availability of Opioids, Vol. 2, pp. 187-27 S. Canberra: National Centre for Epidemiology and Population Health, Australian National University.

Department of Health, Housing and Community Services (1992). Statistics on DrugAbuse inAustralia 1992. Canberra: Australian Government Publishing Service.

Hartland N (1991). The political context. In: Feasibility Research into the Controlled Availability of Opioids, Vol. 2, pp. 53-82. Canberra: National Centre for Epidemiology and Population Health, Australian National University.

Hartland N, McDonald D, Dance P, Bammer G 0 992). Australian reports into drug use and the possibility of heroin maintenance. DrugandAlcohol Review 11: 175-82.

Heroin Pilot Task Force (1996). The Report of the Heroin Pilot Task Force. Canberra: Department of Health and Commu, nity Care.

Larson A ( 1992 ). Estimating the numbers of heroin users in the ACT. Feasibility Research into the Controlled Availability of Opioids Stage 2 Working PaperNumber 1. Canberra: National Centre for Epidemiology and Population Health and Australian Institute of Criminology.

Larson A, Stevens A, Wardlaw G 0 994). Indirect estimates of 'hidden' populations: capture-recapture methods to estimate the numbers of heroin users in the Australian Capital Territory. Social Science and Medicine 6: 823-3 1.

Legislative Assembly for the Australian Capital Territory, Select Committee on HIV, Illegal Drugs and Prostitution (199 1). Second Interim Report. A feasibility study on the controlled availability of opioids.

Martin B (1991). Interest groups and social controversies. In: Feasibility Research into the Controlled Availability of Opioids, Vol. 2, pp. 83-6. National Centre for Epidemiology and Population Health, Australian National University.

National Campaign Against Drug Abuse 0 988). National Drug Abuse Data System Statistical Update: How Many Heroin

National Drug Strategy (1993).1993 National Drug Household berra. In: Feasibility Research into the Controlled Availability of
Survey. Canberra: Australian Government Publishing Opioids,Vol. 2, pp. I-IS.Canberra: National Centre for Epi
Service. demiology and Population Health, Australian National

StevensA, Dance P, BammerG (1991). Illegal druguse inCan- University.