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White lines, white lies: rethinking drug and alcohol policy in the contemporary era.

1. HARM MINIMISATION AND PUBLIC POLICY

Grazyna Zajdow

Notwithstanding the `zero tolerance' headlines so beloved of the tabloid press and television, Australia's official policy towards drug use and misuse, since 1985, is harm minimisation or harm reduction. Eric Single defines harm minimisation as `a policy or programme directed towards decreasing adverse health, social and economic consequences of drug use even though the user continues to use psychoactive drugs at the present time'. There is no mention of the legal status of any particular drug and this is quite deliberate. In an effort to keep the focus of the policy on helping people ameliorate their lives while in the throes of drug misuse, the issue of legal sanctions is ignored. It is as pragmatic a philosophy as any public health policy can be. This is its strength and its weakness.

The harm minimisation story is one of many strands that finally converged in the mid-1980s. Briefly, it involved academics, health professionals, bureaucrats and consumer groups. In the late 1970s, articles in public health journals around the world began appearing questioning the wisdom of policies which assumed that the ultimate goal for drugs health policy was to produce drug-free patients. Many academics from English-speaking countries wondered about prohibitionist responses to drug problems which seemed such a characteristic of these Protestant-dominated cultures. Since we had so many health and legal problems associated with drugs and alcohol misuse, problems which did not seem to appear in the more relaxed Mediterranean countries, would it not be better to follow their more relaxed policies as well?

A more realistic policy was the British model of legally prescribed heroin, which was often described as a better approach (and still is by influential writers and professionals today). It was claimed that physician-prescribed heroin produced fewer problems for British society as a whole, and for the users themselves. Popularity grew for the story that the British were forced to stop the legal prescription of heroin because of pressure from the Americans. Strictly speaking this is not true. Legal prescription of heroin disappeared because of a number of problems which undermined its effectiveness. It was most effective in the 1950s and 1960s when the market for heroin was confined to small groups of artists, musicians and others in defined subcultures. By the mid-1960s, heroin and other drug use was moving out from its subcultural hiding place to a much wider audience. The popularity of heroin meant that some patients with legal prescriptions were selling into the black market and persuading doctors to write out more prescriptions. The legal prescription of heroin was very effective while heroin use was confined to manageable groups of people, but once heroin use expanded, legal prescription in Britain became an inadequate approach. The ensuing public outcry condemned the policy and it virtually disappeared.

Harm minimisation would have remained a topic only for academic debate were it not for the HIV pandemic. Public health officials and AIDS activists saw clearly that trying to force gay men to stop having sex was a ludicrous proposition, and it was better to persuade them to change marginally their activities -- such as using condoms. By the mid-1980s, Americans were seeing a new group being infected: those using needles. Even before it was confirmed that HIV was a blood-borne virus, American heroin addicts were exhibiting very high infection rates. Policy literature of the time demonstrates that there was little regard for the health and welfare of those who used needles, but there was a great fear of this group spreading the virus to the straight, non-heroin-using population. Needle-using men generally had non-needle-using partners, and these women would eventually have children, or sleep with straight men. The same fear fed those who dealt with needle-using prostitutes. These people would become vectors for the disease into the `innocent' population and so action was required.

In Australia, especially in Melbourne and Sydney, prostitute and sex industry activists understood the necessity for quick action and persuaded brave and intelligent government ministers to set up needle exchanges so that intravenous drug users did not have to share syringes and the HIV virus. Consequently, Australia's HIV positive rates among IDUs is one of the lowest in the world, and harm minimisation became central. It was argued that if we could persuade and educate people who. put needles in their arms for fun to change their habits, then we could educate other people who used drugs dangerously to do the same. But this logic misunderstood the precise practice and cultural meanings of intravenous drug use.

For many of the children of the sixties and seventies, drug use never developed beyond smoking marijuana; joint or bong use was assumed to be the template for all other forms of drug taking. The joint was an important symbol of communion and community for many in the sixties and seventies. It was meant to be used communally and passed around. IDUs do not have the same feeling for the syringe. Syringes are generally only used communally if there is no other way of doing it. So when a supply of unused syringes was made readily available, IDUs changed their habits. This was an easy change -- but other habits are much more ingrained and have very different meanings.

Armed with the success of needle-exchanges in keeping HIV infection levels to a tiny per cent of the IDU population, public health professionals then decided that this success could be generalised to all drug use/misuse. The conversation went something like `what we need is to educate people in the safe(r) use of drugs and we will all win'. This attitude was abetted by some drug-user groups whose political agenda was to legalise or decriminalise most drug use. The philosophy was also picked up by some bureaucrats for very different reasons, such as cutting budgets. To understand how this occurred, we must first examine the utilitarian nature of harm minimisation as public health policy.

The New Public Health, which is based on notions of prevention and education rather than individual treatment, presents States with funding policy dilemmas. The decision about where best to place funds is a political decision in its broadest sense. The individual in neo-liberalist, utilitarian policies is considered rational; he/she weighs up the positives and negatives related to any particular action and decides which best suits his/her interests. This is also how individuals are considered within the harm minimisation paradigm. For example, in the evaluation of the National Drug Strategy, the authors consider that harm minimisation means that `better results can be achieved if people engaging in dangerous behaviour are treated as responsible persons who will take steps to reduce the harm they may cause to themselves (and others) if given the information and opportunity to do so'. It is admirable that government departments treat their citizens as responsible people but even the most libertarian-leaning person would recognise that many people use psychoactive drugs to undermine their psychic and social responsibilities. This also needs to be taken into account. More disturbing is the cost-benefit analysis implicit in the bureaucratic understanding of harm minimisation. From the evaluation of the National Drug Strategy, we find this description of harm minimisation:

This empirical definition of harm minimisation presumes a calculation of the net gain or loss for a given policy or program, where the net effectiveness of the policy or program is determined. Those policies which display a net gain are deemed to be harm minimisation.

While the authors do not suggest that this is the only meaning of harm minimisation used, it is one which is prominent in many bureaucrats' minds. The history of harm minimisation is very similar in its outlines to the history of deinstitutionalisation for the mentally ill and intellectually disabled; what may have begun as a humanitarian and intelligent response to a perceived problem became a cause for the razor gang instead.

The meaning of harm minimisation changes depending on the drug we are talking about. For example, in relation to alcohol harm minimisation tends to include greater regulation of alcohol, rather than less.

Alcohol presents a difficult task for the health professional. It is more embedded into the economic, cultural and emotional life of all Australians. It lubricates almost all our national and personal pastimes. There is also some argument to say that moderate drinking is good for our heart health, although some evidence suggests that drinking tea has about the same effects and does not add to the domestic violence or criminal damage statistics. We have been fed an enormous amount of propaganda by the alcohol industry about the French and their low heart disease rates, but they also have the highest cirrhosis of the liver rates in the world, a fact rarely mentioned. A new study in France even suggests that there has been a general underestimation of the `negative economic and social effects of drinking: a staggering effect hardly compensated for by the low heart-disease rates. Suffice to say that harm minimisation has hardly made an impact on alcohol except with drink driving, but drink driving legislation predates harm minimisation by almost twenty years, so they can hardly take the credit for it. It is true that we consume less alcohol than fifteen years ago, but that only means that those who drank in moderation, drink even less, while the rates of harmful drinking have hardly changed at all. The alcohol industry has resisted what pressure has been brought to bear upon it. There are no warning labels, mixed drinks come in brightly coloured bottles for young people to consume, and most of our major sporting events are sponsored by alcohol companies.

Even pregnant women get mixed messages. In the United Kingdom the alcoholic drinks industry persuaded authorities to raise the recommended maximum number of drinks for pregnant women, while the US Surgeon-General recommends no drinking at all during preganancy. Both the US and UK positions present themselves as scientifically rigorous, yet different pressure groups have succeeded in each country in very different ways. In the United States, the medical, drug and alcohol professionals have been more successful than the alcohol industry, whereas in the United Kingdom, it was the alcohol industry which had its position ratified in policy guidelines. A reading of some Australian documents suggests that Australia is less interested in this particular at-risk group. The US position can be described as a moral panic (as evidenced by stories of American women being denied alcohol because they were pregnant), but the UK position is not free from the influence of prominent economic interests. Since political economy has lost its influence in academic discourse, it is easy to understand why there is so little critical comment in Australia. The alcohol industry in Australia has been a prominent supporter of harm minimisation and responsible drinking management. This may seem reasonable until it is realised that the evidence of the effectiveness of responsible drinking is hard to find.

Harm minimisation and illegal drugs

While all treatment programs are now considered harm minimisation, it does not have a straightforward or coherent meaning for all the players in policy formation. Some academics argue that harm minimisation explicitly excludes use reduction (i.e. reducing the number of drug users or eliminating drug use), while many policy makers and implementers argue that use reduction is one form of harm minimisation. Roche and Evans, writing in an academic journal, argue that `harm reduction applies to a policy position which is explicitly contrary to and a radical departure from a use reduction position'. This means that policies which support people being drug free are not considered harm minimisation.

In general, programs that exist in most states and territories include drug education, syringe exchanges, drug substitution programs like Methadone Maintenance Treatment (MMT), short-term detoxification, and some long-term rehabilitation beds. In Victoria the Kennett government did away with many beds in the 1990s in favour of short-term detoxification, expanded MMT and other such measures. New South Wales had many more medium- and long-term rehab beds, meaning that people from Victoria who wanted to become drug free often had to leave the state. Prior to Kennett, the Victorian situation to some extent resembled that of Switzerland, which has medically prescribed heroin alongside over 1000 beds in long-term residential settings based on abstinence. As with all other health, welfare and education programs under Kennett, the bean-counters won and slashed those programs deemed financially inefficient. Within these very narrow parameters, long-term drug-free rehabilitation was bound to lose out.

New South Wales has relatively recently opened a safe using room in Kings Cross. The issue of safe using rooms has been causing anguish for a number of reasons. The comparison is always made to Switzerland where, after a number of false starts (the infamous needle park in Zurich comes to mind), safe using rooms have become part of the harm minimisation furniture. However, Switzerland is committed to real harm minimisation programs and puts its money where its mouth is; Australian governments fail to do the same. As with deinstitutionalisation of the mentally ill, financial considerations overcame humanitarian arguments, leaving the victims in our streets. It is still too early to tell how successful the Kings Cross safe using room will be, though clearly it has not destroyed the neighbourhood or local businesses. Deaths from overdoses have fallen considerably in both Sydney and Melbourne, but this is much more likely to be a result of the heroin drought and rising prices than any changes in official policy. The likelihood of such a room opening in Melbourne has diminished considerably, ironically because of the silly manoeuvrings by a certain church in central Melbourne, which spent a fortune on setting up a room all the while denying this to defuse community opposition. Eventually the issue blew up in its face, the previous government decided not to back the proposal, the current government also backed down, and now no room exists. This example shows how different groups often have oppositional interests.

Education has always been touted as the answer to any and all of our problems, but school drug education has spectacularly failed. Studies have shown that most school education programs, whether of the `just say no' variety, or of the `I'll give you all the facts and you can make up your own mind' school, do not stop young people taking drugs. Most drug education programs assume that teenagers are neo-liberal rational citizens; however, I would suggest that most school students are more like Pee Wee Herman -- sweet, naive, and having little concern for consequences.

The main weapon for combatting heroin is the methadone maintenance program (MMT), active everywhere in Australia except the Northern Territory. MMT originally began in the United States in the 1960s as part of an abstinence-based regime, but here in Australia it has been picked up by the harm reductionists and health department bureaucrats as cheap and easy to administer. Rather than as part of an eventual abstinence regime, MMT is considered a long-term therapy; in Victoria there are many cases of people on MMT for over twenty years. Along with the methadone, minor tranquillisers are often prescribed as part of the regimen. I have written of my problems with MMT in a previous issue of Arena Magazine, and little has changed my mind about it. The assumptions behind long-term MMT is that an addict will always be an addict and the best that can be done is to stabilise them on a legal drug of addiction. If an addict will always be so, why criticise the Twelve Step programs (like Alcoholics Anonymous and Narcotics Anonymous) for their very similar beliefs -- at least they believe that the addiction can be arrested a day at a time in a drug-free existence. More alarmingly a not-so-subtle battle is being waged against those who mention the unintended consequences of long-term MMT such as ill health, bad teeth, long-term organ damage and the possibility of an early death.

In 1998 an article appeared in a professional journal raising the issue of deaths related to methadone maintenance treatment (MMT). The author looked at the cases of fourteen deaths in the first two weeks of methadone maintenance treatment in NSW and concluded that ten of them were caused by methadone toxicity. He called these deaths `cases of iatrogenic methadone toxicity'. In the same edition of the journal were two letters criticising the original article, followed by a response from the original author. One criticism was related to the use of the term `iatrogenic' and another refuted the original findings because of the high level of benzodiazepines (minor tranquillisers) in the systems of the people who had died (never mind that most MMT patients are prescribed benzos by their doctors). This seems a highly arcane and specialised argument and even irrelevant to this article, but it is not. What the author of the original article had done was transgress one of the unwritten rules of public health campaigns -- don't mention the war (in this case the unintended consequences of public health campaigns).

An article of faith of the proponents of MMT is that it is effective; it reduces deaths (but does not eliminate them); it cuts down the amount of crime (but only acquisitive crime directly related to heroin use); it increases the amount of paid work by addicts (in this case by a miniscule amount), and so on. A critical look at the literature on the effectiveness of MMT provokes some questions in this reader, but not in the MMT advocates. One meta-analysis found that the use of illegal heroin by those on MMT fell by as much as 90 per cent in one study and only 20 per cent in another. Crime also fell, but only that considered directly involving the need for heroin; other crime stayed at the same level. Of course, this is one of the major planks in our general beliefs about illegal heroin use; that is, people only commit crime because they need to buy the high-priced heroin. Unfortunately, acquisitive crime did not fall with the fall in the price of heroin, as logic would dictate, because many more people were pulled into the heroin orbit with the fall in prices. This is the case with most recreational substances. Studies have shown that alcohol and tobacco are price sensitive -- the higher the price, the fewer the people who use them.

Given its prominence in heroin harm minimisation, any criticism of MMT provokes immediate and vicious response. In Victoria, doctors are being persuaded to prescribe methadone to young people (teenagers) without any investigation into whether they have developed an addiction to heroin or were still in the experimental stage. Government residential programs for young people in care take their charges to sympathetic doctors for this purpose. When the glut of heroin was at its height eighteen months ago, teenagers were scoring heroin as their first drug of experimentation because it was so cheap. The immediate response was to widen the MMT net. Parents were being persuaded that their children would die with a needle in their arm, so it was better to have a lifetime addiction to methadone than a dramatic early death on the streets. No matter that the person most likely to overdose and die was the experienced and older user, the moral panic was on and there was only one reasonable response. Anything else was giving in to the forces of darkness, in this case John Howard and the prohibitionists.

As I have already noted, all public policy is a series of compromises, rhetoric, promises, evidence and the eternal argy-bargy of public life. Few policies have become so readily accepted as has harm minimisation. Like the deinstitutionalisation of the mentally ill and intellectually disabled, it sounded so right on paper. It was theoretically sound, especially for those on the Left. But it became a prisoner of the economists who rationalised its humanity out of existence. We are left with pharmacologies, and little else. This is also the way that public policies on troublesome drug use are going. Pharmacologies are cheap and can be administered by GPs, nurses and pharmacists. No need for expensive rehabilitation beds, especially since almost no one gets it the first time around, or the second, or even the third. Addicts are notoriously recalcitrant, so why waste money on them?

The National Campaign against Drug Abuse in the 1980s was intended to promote an Australian response to drug misuse, but the answers have tended to sound a bit like the European Union. We are given the examples of Holland and Switzerland by the liberals and Sweden (which has succeeded in lowering drug use substantially while recriminalising some drugs) by the right-wingers. I don't think Sweden is comparable to Australia, just as I don't think that Holland or Switzerland are. Drug use in Australia among young people is much higher than in any country in Europe. We are closer to the United States than most other countries in this respect, partly due to conditions of supply. Most European countries do not have an indigenous marijuana industry (even with hydroponics) and they are not close to the Golden Triangle, which gives us a direct supply line second to none. But demand cannot be denied as part of the problem as well, and is as intractable as supply. After fifteen years of the National Drug Strategy and with millions of dollars spent on drug education in schools, figures show that demand has not been diminished. Indeed, it has gone up. This was the opinion of the evaluation of the NDS which still supported the directions the NDS was taking. There is a cultural acceptance of drug taking of all sorts in Australia, connected to what Foucault called the uses of pleasure. Solving this problem will, I suspect, take much more money and effort than most of us are willing to pay. We have accepted, implicitly rather than explicitly, the necessity for some of us to be sacrificed to the terrors of addiction rather than the rest of us giving up our pleasures.

So one answer is to give people the information they need to make up their awn minds. This is sensible, but very few people are given all the information they need when they go on MMT -- information such as the higher than normal chance of dying early in the program, or that continuing alcohol use will exacerbate already overloaded livers. Information also that the patient will be constantly monitored by doctors, pharmacists and others. This monitoring is an integral part of the New Public Health and is fundamental to harm minimisation programs like MMT, safe injecting rooms, education programs, syringe exchanges and the like. As I have written before, prison may be an extreme case of official monitoring, but MMT seems to be the chemical equivalent of the electronic handcuffs used in some jurisdictions. And ultimately, if the patient decides on a drug-free life and needs to get off all drugs then they will probably need to hitch a lift to Sydney if they live in Melbourne because there is a dearth of publicly funded long-term rehab beds in Victoria due to the economic-rationalist mandarins in charge of health policy.

It would be sensible to institute a heroin-prescription trial, but this would only affect a small proportion of those who use heroin. It would help only those who have used for many years and are no longer attached to the street life. After many years they will be tired of the eternal chase and the possibility of an overdose death will be greatly increased. Certainly, a heroin prescription trial would be useful and advisable. But for other sections of the drug-using population, it will be immaterial and the black market will go on in tandem with the market for party drugs and amphetamines. We are part of a postmodern drug-using population, as Stephen Mugford points out, and when we work, we work long and hard and when we party, well.... But don't let us pretend that there are no negative consequences. If we are not prepared for them, they will overwhelm us as the constant example of the deinstitutionalised mentally ill shows us.

There has been an understandable revulsion from many to the rhetoric of the conservatives. The Americanised language of `zero tolerance' is hysterical and pernicious. It has pervaded all discussions about drugs strategy and poisoned any critique of the alternatives. The `war on drugs' and `zero tolerance' say nothing about effective public policy for those in trouble with chemical substances; they are a waste of time and money and have contributed to the destruction of whole societies in South-East Asia and South America. But I don't think that we should then automatically fall into the libertarian line of advocating consumption of all that we desire and allowing technology in the guise of pharmacologies to take care of the casualities. This is one of those binary polarities so beloved of postmodern critics and does not constitute good policy.

2. THE SOCIAL AND CLASS CONTEXT OF ILLICIT DRUG US

Philip Mendes

Current Australian drug policies are based on a model of individual pathology. Drug use is viewed as deviant or abnormal behaviour, rather than as a normal social activity (Lang 1998:11).

This model explicitly reflects the socially conservative assumptions of Prime Minister John Howard. Howard views substance abuse as a matter of personal morality and responsibility which requires a return to traditional social values such as the work ethic, rather than as a public health issue influenced by broader social factors and conditions (Mendes 2002).

The government's ideological message is presented in the simplistic language of binary opposites. Drug use is bad, and abstinence is good. Parents and authority figures should encourage young people to reject drugs. For example, the Federal Treasurer, Peter Costello, describes drugs as `bad and dangerous things' which `do you damage and destroy your life'. They `can't be made clean, or legal, or safe'. Young Australians `should not have anything to do with them' (Costello 2001).

A similar black and white message is expressed in official government policy statements. Illicit drug users are depicted as helpless and hopeless individuals who need professional treatment to overcome their addiction. Law enforcement methods will be used to protect innocent families, children and communities from the dangers of drugs. Predatory dealers will be tracked down and punished (Liberal Party 2000 & 2001).

Government advertisements particularly reflect this depiction of illicit drug use devoid of its social context (Rundle 2001:40-43). One brochure delivered to every Australian household assumed a middle-class nuclear family rationally conversing with their deferential children about the dangers of drug use. Parents were instructed to advise their children that they `don't want them to use illicit drugs ever' (Abetz 2000).

Most problematic users, however, are socially excluded young people who are least likely to reside in stable, supportive families, or to accept guidance from their parents. Many young people are specifically exposed to illicit drugs and the associated sub-culture by their own families. In addition, many low-income users are also involved in dealing and supply (Brotherhood of St Laurence 2000).

Simplistic pro-abstinence sentiments ignore the statistical and social reality of growing illicit drug use. For example, more than a third of adult Australians have used marijuana, and marijuana consumption appears to be growing at a faster rate than that of alcohol (O'Brien 2001). In addition, a growing number of young people are using heroin. Daily use has doubled over the past seventeen years, while the number of heroin users has almost doubled since 1995 (DPEC 2000a: 9; NCA 2001: 21).

Many young people use drugs for experimental or recreational reasons as part of their normal adolescent development (Turner 2000: 28). Only a minority become habitual users. Yet current policies potentially draw all users into the criminal justice system.

This paper offers an alternative structural explanation of illicit drug use. Part One documents the relationship between problematic drug use and broader social inequities and injustices. Part Two illustrates the social context of illicit drug use. Part Three suggests some alternative policies that reflect the social and class context of illicit drug use.

Part One: A Structural Explanation of Illicit Drug Use

Popular depictions of the drugs problem would suggest that heroin users come from all walks of life. Yet the reality is rather different. There is considerable historical evidence to suggest that most heroin addicts come from poor or socially disadvantaged backgrounds. There is also evidence to suggest that many of those users who do come from middle-class or affluent backgrounds have experienced significant personal trauma involving violence, abuse, and/or grief.

For example, Chein et al. (1964) found that American drug users were generally concentrated in areas characterised by poverty, low economic status, poor education and high family breakdown.

Similarly, the Swedish social-work academic Ted Goldberg (1999a) found that persons from the `lowest social stratum' were markedly over-represented among problematic consumers.

Goldberg identified factors that were likely to contribute to increased heroin use, including poverty, high unemployment, limited access to education, segregated housing, racism towards newcomers and traumatic refugee experiences. Other important psychosocial factors included parents who were alcoholics, experience of physical, sexual or emotional abuse, and poor family relations.

Local research shares many of these conclusions. The 1996 Victorian Premier's Drug Advisory Council report, for example, identified drug use as increasing with socio-economic disadvantage and emotional disorder. Marginalised young people lacking education or family support were considered to be particularly vulnerable (Premier's Drug Advisory Council 1996: 21). Similarly, Ezard (1998) quoted a study of mothers in methadone programs in Sydney which found that heroin use tended to be closely linked to poverty, unstable housing and low levels of education.

The 2000 Victorian Drug Policy Expert Committee suggested that increased drug usage and overdoses could be attributed to factors such as school withdrawal, unemployment, social isolation and economic inequality (DPEC 2000b). In addition, a submission by the Victorian Youth Substance Abuse Service to the House of Representatives Inquiry into Substance Abuse suggested that 80 per cent of the young people using their withdrawal service were traumatised through disconnection from their original countries of origin, sexual abuse, and violent or dysfunctional families (quoted in Saltau 2001).

A recent report by Hanover Welfare Services sums up the problem succintly:

Sure, there are some well-heeled heroin addicts, a smattering of upwardly mobile and celebrity users. But you won't see many of them amongst the haunted faces cruising streets in Footscray, St Kilda, Springvale, Dandenong and the CBD. We know by now that when you're addicted to heroin, your life generally becomes a cheap theatre of constant hustling and scheming ... It is a life of anguish and constant financial hardship (Middendorp 2000: 8).

Heroin use can potentially be seen by users as a solution to deep-seated social, economic and emotional problems. Just as some of the mentally ill use heroin to self-medicate, so many drug users appear to use heroin to relieve their emotional pain.

This connection is stated explicitly by Peter Norden, the Director of Jesuit Social Services (JSS). According to Norden, many of the young people involved in JSS programs have experienced considerable personal trauma including sexual, physical and emotional abuse at young ages. Norden argues significantly that young people misuse drugs `in response to pain, suffering and isolation, not because they deliberately choose to behave in a self-destructive manner' (Norden 2001: 18). Similarly, a local study of homeless young people found that problematic drug use was `usually a response to the emotional pain and anger resulting from childhood experiences and/or a mental health problem' (Szirom & Desmond 2001: 27).

The demonstrated relationship between problematic drug use and emotional pain suggests that any policy solution will need to involve positive social and emotional supports and opportunities that specifically address existing feelings of hopelessness and frustration (Brotherhood of St Laurence 2000: 3; Middendorp 2000: 9; Hamilton 2001: 6).

Part Two: The Social Context of Illicit Drug Use

Current drug policies duplicate welfare reform policies in focussing attention on the individual behaviour and character of the poor and marginalised, rather than associated structural factors and causes. Drug abuse is identified as the problem instead of being seen as the symptom of broader social abuses and inequities. It is arguably not coincidental that drug users are one of the groups most heavily penalised by the Howard government's harsh welfare breaching regime (ADCA 2000). The individual pathology model largely ignores the social factors underlying illicit drug use.

Yet there is considerable evidence that patterns of illicit drug use closely reflect social contexts of experience. Drug dependence may reflect the influence of a range of changing social factors, including gender relations, employment and finances. Conversely, particular social situations and cultural circumstances can facilitate an end to dependence (Kellehear & Cvetkovski 1998: 57-58), For example, Keenan (1998: 64-67) relates two case studies of women whose drug use varied with their social circumstances. In one of the cases, initial social and economic stresses led to increased drug use, and correspondingly, greater social and economic stability produced decreased drug use.

The social context of drug use is particularly significant for young people who make decisions primarily in relation to their peer group (Rundle 2001: 43). Young people use illicit drugs for a variety of reasons, including relaxation, fun, curiosity, and to cope with problems, anxiety or pain. Rather than being mere victims of predatory drug dealers, young people may actively seek access to illicit drug markets. Drug use may be seen as a viable and pleasurable solution to a range of emotional, physical or economic problems (Turner 2000: 28, 35).

Involvement in drug trafficking is often directly related to lack of economic opportunities in the formal economy. Some see drug dealing as a positive alternative to low-wage, dead-end jobs (Davey 1995: 137; Goode 1997: 64-65).

For example, Barbara Denton's study of female drug dealers found that the illicit drug trade offered a significantly increased income and improved lifestyle for these women. As Denton acknowledges, the women she chose to study were primarily successful dealers whose stories may not reflect the broad picture of women participants in illicit drug use and distribution (Denton 2001). Nevertheless, Denton's study does suggest that for some people, drug dealing can provide an alternative and viable career option.

In addition, the popular distinction between innocent users and evil drug dealers oversimplifies the complexity of the drug problem. In many cases, drug users are also involved in dealing either to make a living or to finance their own habit (Turner 2000: 35-36; Horn 2001: 10).

Part Three: Towards Alternative Solutions

Many commentators offer a generic structural solution to the heroin crisis based on the redistribution of wealth and income.

For example, Goldberg (1999a & 1999b) recommends a range of macro-measures to reduce long-term demand for drugs, focussed on limiting social exclusion, and devising supports to compensate for deficits in schools, families and the labour market. He argues that `to the extent we can provide as many citizens as possible with the hope of a reasonable future, we will reduce the number of problematic consumers of narcotics'.

However, such generic formulae do not specifically address the personal needs of existing and former drug users. Structural reforms may help to prevent a new generation of young people being drawn into poverty, homelessness, social isolation and potentially drug dependence, but it is unlikely that structural measures alone will help to rehabilitate those whose personal traumas are driving their drug usage.

The latter group require specific collective and personal assistance. Personal support would involve extending support well beyond the rehabilitation or withdrawal stage to offer on-going counselling that addresses underlying emotional or psychological affliction.

The collective should emphasise the role of consumer advocacy groups such as the Victorian Drug User Group (VIVAIDS) in facilitating access to material and structural assistance. VIVAIDS needs to join other consumer groups such as the increasingly influential Create Foundation (for children and young people in or leaving state care) in providing a public voice for a disadvantaged and marginalised group.

This is not just about increasing the access of current or former drug users to health care, and other community facilities and support services. It is also about drug users identifying as a collective group or community, and demanding political recognition and their fair share of community resources.

Towards a Structural Version of Harm Minimisation

Harm minimisation has been the philosophy underpinning Australia's national drug strategy since 1985. Its key goal is to reduce the adverse consequences of drug use for both the community and individual drug users, rather than to prevent drug use per se. Harm minimisation implies that drug use should be viewed as a public health, rather than a criminal or legal issue. The harm minimisation approach is value neutral and accepts that illicit drugs are and will remain part of our society, and that their elimination is impossible.

As Zajdow notes in her article, harm minimisation remains a contested term, meaning different things to different people. The current prime minister opposes many of the key components of harm minimisation. In particular, he rejects the introduction of safe injecting facilities or heroin trials, or the liberalisation of marijuana laws. Howard regards drug use as morally unacceptable, favours law enforcement over-public and social health interventions, and prioritises abstinence rather than harm reduction (Mendes 2002).

In contrast, the Federal Labor Party takes a more holistic approach to drugs. The ALP acknowledges that millions of Australians have tried illicit drugs, and that drug policies need to address the underlying social causes of drug taking. Specific solutions offered by the ALP include consideration of state trials of prescribed heroin and. medically supervised injecting rooms, and greater support for local drug strategies (Beazley 2001).

Yet it could be argued that even the more holistic interpretations of harm minimisation are based on economic rationalist as well as human rights assumptions. In addition, they can be viewed as potentially meeting interests and agendas other than the needs of drug users.

For example, the principal arguments offered in favour of safe injecting facilities are that they will reduce deaths from drug overdose, reduce the spread of infectious diseases such as HIV/AIDS and hepatitis, reduce the public nuisance associated with drug injecting in streets and parks, reduce the unsafe disposal of used needles and syringes, and provide a gateway for injecting drug users to treatment and rehabilitation (DPEC 2000a: 34).

While these arguments obviously have humanitarian implications, they also address core economic rationalist concerns. The 1998 NSW Parliament Joint Select Committee Report into Safe Injecting Rooms, for example, devotes five pages alone to economic arguments for injecting rooms (110-114). According to the report, `economic savings would be made from reducing the costs associated with treating overdoses and blood-borne infections, and by re-integrating people into society' (110).

Injecting facilities can also be seen as involving further socio-medical control of drug users. Instead of drugs being legalised and users being offered social and economic assistance, the focus is on continued professional support and intervention.

Similarly, there are both humanitarian and economic arguments in favour of heroin prescription trials. Advocates of trials regularly present evidence from the Swiss experience which suggests that trials not only improve the health and housing status of participants, but also lead to increased employment and significantly decreased crime and prostitution (Wodak 1997).

The promotion of local drug strategies can also lead to potentially positive and negative outcomes. Some local groups actively seek to include drug users in their community. For example, a number of Victorian local governments have established peer support networks for families and friends affected by illicit drug use, and assisted drug users to utilise and participate in existing community services and activities. However, other local groups influenced by Nimbyist views have attempted to exclude drugs and drug users (Mendes 2001).

In short, the harm minimisation model -- however interpreted -- may serve to meet not only the needs and interests of drug users, but also many other vested interests and agendas. It is also possible that harm minimisation will simply transform users from unhappy people using illicit drugs to equally unhappy people dependent on methadone or other substances.

Such a model will arguably only truly empower drug users when allied with measures that specifically lift the social and economic standing of users. Solutions would need to incorporate both structural supports around finances and accommodation, and personal therapeutic support around trauma and relationship issues.

Specific recommendations include:

1) formal recognition by government that the drug problem cannot be addressed in isolation, but must be viewed as part of a holistic set of generic social and health problems to be tackled by social health strategies;

2) policies that break the nexus between the illicit drug market and criminality. At the very least, governments should decriminalise the use and possession of small amounts of heroin;

3) formal inclusion of consumer voices in decision-making bodies. Drug users should have at least a couple of representatives on the Australian National Council on Drugs, the peak body which provides advice to government on drug policy and service issues;

4) public drug interventions, including advertisements, should target the peer and cultural networks within which socially excluded young people operate. They also need to offer specific training and employment alternatives to involvement in the illicit drug trade.

3. ADDICTION AND POSTMODERN SOCIETY

Guy Rundle

Two hundred years since morphine was first synthesised from poppies, three hundred since `geneva wine' or `gin' was introduced to the burgeoning populace of London, and four hundred since Europeans and Indigenous Americans introduced each other to the pleasures of tobacco and alcohol, addictive substances have become a central feature of our social life, and a focus -- real or imagined -- of our social dilemmas. Indigenous communities across the world are reeling from the impact of a range of substance-abuse problems, as are many people of all origins, impoverished or excluded in the industrial and post-industrial heartlands. For the powerful and wealthy, the cycle of addiction, dependence and rehabilitation has become a frequent -- and in some professions, virtually de rigeur -- life event, a parable to be retold in a thousand glossy magazines. Lurid ad campaigns warn of the dangers of illicit drugs, using the same techniques employed to sell alcohol by the caseload. Zero tolerance regimes, with worksite drug tests, have become a feature of everyday life -- often in parallel with `harm minimisation' programs; and vast networks of government social services are employed to deal with substance abuse or the immediate effects thereof. Looking around, one wonders if we have not vanished down the same hole as the bulk of Coleridge's Kubla Khan, when the arrival of a visitor from Porlock woke him from his opium-induced reveries. Is our society uniquely structured by substance abuse?

The answer is yes and no: no if we are talking about recent `modern' life: yes if we are talking about the sort of society that has existed for three hundred or so years -- urbanising, scientific, caught in the process of development, tending towards the creation of modern classes and individuals. For thousands of years, addictive substances have been a part of those cultures within the bounds of which they have grown -- coca in pre-Columbian America, peyote for Indigenous Americans, hallucinogenic mushrooms for the Uralic peoples, and so on. To a degree these peoples were shielded from the effects by the smaller doses available in natural form, but they also lived in societies where meaning and practice were framed by tradition and ritual. Excessive (in the sense of psychologically disordering) use was either employed for specific shamanic purposes or confined to ritual periods for the whole of the social group. (Even so, most societies had some understanding of moderation -- for example, those who partook of coca would choose the smaller leaves, the equivalent of smoking ultramilds.)

Modernity -- in the expanded sense of the term -- began with a series of multiple events, all of which created the basis for contemporary drug and alcohol use and abuse. Exploration and conquest introduced new substances to cultures that had developed little tolerance for them, either physical or cultural; trade and commerce established the commodity circuit and the reach of luxury and desire; the artist moved from the court and the church and into a space where Art, Truth and Experience became goals in their own right; the agricultural revolution created a surplus population which drifted to the cities; the rise of chemistry and engineering made distillation and synthesis possible. From the cities came a new market for alcohol, and gin licenses became hot property -- King William and Queen Mary had the first for London, a few decades prior to Hogarth's `Gin Lane'. From trade came empire, the discovery of Indian poppies and the manufacture of the Chinese opium market -- the most extraordinarily blatant extension in history of market by military means. From opium came morphine, and from morphine and modern wars, addiction. And from addiction came morphine's two great `cures' -- cocaine and heroin. From Art came the search for wisdom via the road of excess, and the addict as culture-hero. US alcohol prohibition created organised crime on a global scale; the coincident US-inspired global narcotic prohibition (designed to wipe out the European empires' lucrative trade) set the pattern for the confused moral-medical-punitive discourses around today. In the 1960s the rise of a `class' of `individuals' -- the fully educated, increasingly autonomous `intellectually trained' -- created a dominant culture oriented to obtaining individual deep Experience, the final victory of the Romantic Revolution. Once it connected to the South-East Asian heroin market that the US military had established to help fund warlord bands in the Vietnam conflict, the contemporary heroin market was pretty much in place.

In the modern era, substance abuse follows the flows of power -- empire, conglomerate, dominant cultural form -- and tends to come from the outside in. It also has a degree of autonomous power -- the power to wholly addict the user, who then becomes a carrier for further addiction -- which tends to vary with the degree of Synthesis (morphine and related opiates having the greatest autonomous sway, naturally occurring herbs the least). Substance abuse in different social and cultural forms will carry addiction in different ways. As Zajdow notes here, there Is a kind of triage operating in contemporary society whereby access to substances includes the implicit understanding that a minority will die or fall into total social exclusion because of them. Furthermore, as Mendes notes, different social classes have access to different forms of social power -- wealth and power make it far easier to manage an addiction that would destroy the life of someone whose status was already marginal. Noel Pearson, in the Arena Magazine accompanying this paper, notes the manner in which alcohol connects with the collective ethic still present in Aboriginal society, and the manner in which such addiction becomes general and unrelated to particular circumstance. Pearson is scathing about the tendency to see substance abuse as merely a symptom of social malaise, rather than an autonomous process; while Mendes corrals an array of impressive evidence to show that there are strong links between social exclusion and substance abuse. Who is right?

The answer I would suggest is not only that both are, but that the whole idea of substance abuse covers territories too vast to be taken in by a single term. Part of the confusion in addressing the problems of substance abuse in Indigenous communities and in inner city contexts is that we are talking about wholly different processes. They are mediated by identical objects -- the bottle, the syringe -- but the social meanings of these vary and can often be contrary.

Within the inner-city context, and within the class predispositions that Mendes has outlined, the subgroup of substance abusers and addicts is to a degree self-selected -- although, of course, when other factors such as childhood abuse are taken into account, the level of determination is very high indeed. Addiction follows the lineaments of social and cultural divisions -- the relief from pain, the road of excess, the uses of pleasure, or all three together. The individual seeks in the context of a society in which one's identity must be put together piece by piece within the bewildering contemporary flux. Of course networks of users form, and people may become users because their partners are users, but it may still strike one person and not another for a variety of reasons that may have more to do with personal psychology, and even a degree of biological predisposition than with other factors. Areas in which drug use does become general -- prisons for example -- can be taken as rule-proving exceptions, because they are total institutions in the midst of the open, atomised system of contemporary life. Addiction -- especially that of opiates -- becomes a multi-layered phenomenon, a form of self-medication in the context of a society where the ecstatic experience that drugs offer is reproduced as the vocabulary of advertising of standard commodities.

Those in contemporary urban society who self-medicate with drugs, usually do so at least in part out of loneliness or its associated conditions -- depression, despair, psychological pain. In Indigenous societies caught in the net of substance abuse, according to Pearson's account, the problem has more to do with the reciprocal and obligational nature of social life: `grog circles' take the same form as did the obligation to share food originating from a hunter-gatherer economy, and thus open-ended drinking spreads throughout the whole society. Pearson's interpretation of the process by which this occurs is not the only one, but let us take it as a major part of the picture. The process is thereby the reverse of the addiction that occurs in urban society. Instead of isolation, the trigger is the form of subjectivity which places obligation and connection to the `other' at the centre of one's experience of `self'. To step out of the circle is thereby to go against the grain -- not only of the social whole, but also of one's selfhood.

In that respect the difference is more than merely that between social processes. The contemporary urban addict or substance abuser, like all contemporary urban persons, lives in a world of impermanence, where other persons, objects and images form part of a universe of connections to be made -- or to fail to. This form of selfhood is more reflexive -- people have the capacity to recontextualise themselves, to `make new lives' -- but it is also less `grounded'. That is, the features of one's self (and of one's context) that one can feel sure of, are much fewer and weaker than they are in the structures of a society based on obligation. The modern urban individual and the person from a traditional culture live in social worlds in which the nature of `being', of existence itself, of objects and others, is very different -- it is far more than the mere difference of social habits, or roles, or practices. What can be described on the basis of external appearance as the one practice of `substance (ab)use', is in fact two very different social practices, one based on a certain form of the social, the other as often as not compensates for its absence. Even the communal practices that Zajdow notes -- based around marijuana use -- are but a shadow of the obligational processes at work in traditional or even partially traditional societies.

What policy implications can we read off all these factors? The most important is that to address problems of substance abuse in a complex `postmodern' society -- that is, a society in which every kind of social life is present, from the information-age worker to the traditional Indigenous culture -- there can be no single policy, because there is no single thing called `substance abuse'. Instead there are different cultural expressions of desire and need, based around common objects, which may have acquired utterly opposite meanings, and therefore opposite dangers. In the context of Indigenous cultures with major problems, such a position would lead one to think more favourably of a range of policies such as blanket prohibition (by the community itself) which are unworkable in other contexts. However, such a policy would run into problems if there was a coincident attempt to introduce a culture which loosened the social bonds that supported such prohibition. It would only work if these connections were simultaneously reinforced.

In atomised urban society, this leads to the reflection that very different types of addiction can exist within the one social framework -- especially in the case of opiate abuse and drugs such as `crack' cocaine which have the ability to transform the physiology of the user. In the worst cases, the `junkie' has entered a third type of personhood, in which desire has become centred on a single commodity, and any obligational connection to others has absolutely ended. Government drug campaigns which seek to portray drugs as something outside of any context of reasonable social use will fail not only because they are at variance with the lived reality of the majority of adolescents and young adults, but because their ideal audience is the `radical protestant' subject -- the teetotaller, who gains a meaningful existence by taking the pledge. Every aspect of contemporary culture takes people in the opposite direction: it batters them with the idea that selfhood is to be found, not merely in consumption, but on the wilder shores of experience. Only when we recognise that urban, modern substance abuse is not an aberration but a pure expression of the forces that drive consumer culture, will we be able to minimise its impact.

REFERENCES

p. 3 1. Harm Minimisation and Public Policy

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p. 7 2. The Social and Class Context of Illicit Drug Use

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Grazyna Zajdow has taught sociology at Deakin University for over fifteen years. She has researched and written in the areas of self-help groups, women's experience of drug addiction, and drug addiction policies. A monograph entitled Someone Actually Remembered My Name: Stories and Narratives from a Self-help Group will be published by Greenwood Press in 2002.

Philip Mendes teaches social policy and community development in the Department of Social Work at Monash University. His articles on the illicit drugs debate include `Nimbyism vs Social Inclusion: Local Communities and Illicit Drugs' (Youth Studies 2001). He is currently preparing a book for the University of New South Wales Press entitled Australia's Welfare Wars: The Players, the Politics and the Ideologies.

Guy Rundle is a co-editor of Arena Magazine, the author of The Opportunist: John Howard and the Triumph of Reaction (Australian Quarterly Essay 3) and a frequent contributor to the Age, the Sydney Morning Herald and the Bulletin.
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Date:Dec 1, 2001
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