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Thinking about Burdens and Harms Third Annual ACT Alcohol and Other Drugs Sector Conference All Things Being Equal: Exploring the Burdens of Harm Canberra, 24 June 2010 David McDonald Visiting Fellow, National Centre for Epidemiology and Population Health, The Australian National University Consultant in Social Research & Evaluation The drug availability/harm dilemma (John Marks/Stephen Mugford) Harm High harm Currently illegal Currently drugs legal drugs Optimal point Low harm Supply Low availability High availability The assessment of harms is … Statistical • e.g. incidence & costs of alcohol-related road crashes Statistical data [Copyrighted slide removed] The assessment of harms is … Statistical • e.g. incidence & costs of alcohol-related road crashes Social • e.g. intoxication is acceptable in some social settings Normative (i.e. judgement of ‘what ought to be’) • e.g. the death of police office, a drug trafficker or a bystander in a shootout between police and the trafficker Three key contemporary resources 1. Babor, T et al. 2009, Drug policy and the public good, Oxford University Press, Oxford. 2. Babor, T et al. 2010, Alcohol: no ordinary commodity – research and public policy, 2nd edn, OUP, Oxford. 3. National Preventative Health Taskforce, Tobacco Working Group 2008, Tobacco control in Australia: making smoking history, Technical Report No 2, [Department of Health and Ageing], Canberra (Michelle Scollo, writer). Which harms? The public health perspective: morbidity, mortality and disability The hidden harms: social harms • Goldstein’s taxonomy of the links between drugs & crime: economic (e.g. robbery), pharmacological (inhibitions lifted), drug markets (violence), lifestyles Social harms (cont.) Community amenity: public nuisance and disorder and vandalism Violence Family: divorce/marital problems, child abuse Education problems Individual & family financial problems Workplaces: injuries and other problems Loss of employment Fiscal impacts National instability – failed states Global terrorism Unintended adverse consequences of drug policies and interventions Etcetera The mechanisms through which harms are caused Source: Babor et al. 2009, p. 19. Attempts to align policies to the relative harms of different drugs International Conventions (treaties) • E.g. Convention on Psychotropic Substances, 1971 Article 4. If the World Health Organization finds: a) That the substance has the capacity to produce i) 1) A state of dependence, and 2) Central nervous system stimulation or depression, resulting in hallucinations or disturbances in motor function or thinking or behaviour or perception or mood, or ii) Similar abuse and similar ill effects as a substance in Schedule I, II, III or IV, and b) That there is sufficient evidence that the substance is being or is likely to be abused so as to constitute a public health and social problem warranting the placing of the substance under international control, the World Health Organization shall communicate to the Commission an assessment of the substance, including the extent or likelihood of abuse, the degree of seriousness of the public health and social problem and the degree of usefulness of the substance in medical therapy, together with recommendations on control measures, if any, that would be appropriate in the light of its assessment. ‘A rational scale to assess the harm of drugs of potential misuse’ Source: Nutt et al. 2007, pp. 1047-53. Different harms in different population groups For example low SES • financial strain and smoking cessation outcomes Mental illness comorbidity Aboriginal people • note confounders of poverty, access to services, mental health Different distributions of risk factors and protective factors in different population groups Policy implications of assessing harm potential It is not just the chemical characteristics of the drugs that determine harm, but also how drugs are used, drug interactions, society’s responses to drugs and people who use drugs, etc. Nonetheless, harm potential should be prominent in informing policy decision-making. Studies of the Burden of Disease and Injury Begg, S, Vos, T, Barker, B, Stevenson, C, Stanley, L & Lopez, AD 2007, The burden of disease and injury in Australia 2003, AIHW, Canberra. • Includes topline findings for each State & Territory, but not ATOD and other risk factors – these are provided for Australia only Vos, T, Barker, B, Stanley, L & Lopez, A 2007, The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003, School of Population Health, The University of Queensland, Brisbane. Begg, S, Bright, M & Harper, C 2009, Burden of disease and health adjusted life expectancy in Health Service Districts of Queensland Health, 2006, Queensland Health, Brisbane. Zhao, Y, Guthridge, S, Magnus, A & Vos, T 2004, 'Burden of disease and injury in Aboriginal and non-Aboriginal populations in the Northern Territory', Medical Journal of Australia, vol. 180, no. 10, pp. 498-502. VicHealth, Burden of Disease (BoD) - LGAs and regions 2001, http://www.health.vic.gov.au/healthstatus/bod. ATODs as risk factors for the BoD Disability-Adjusted Life Years (DALYs) 2003 • Combine mortality, morbidity & disability • Do not cover the ‘hidden harms’, i.e. social harms Tobacco, alcohol and illegal drugs: 12.1% of the total burden • tobacco: 7.8% of the total burden of disease & injury • alcohol: 2.3% in net terms • illicit drugs: 2.0% ATOD only • tobacco: 65% of the drug-related burden • alcohol 19% • illicit drugs 16% Not available for the ACT by risk factor (Source: Begg et al. 2007 & presenter’s calculations) Taxonomy of drug-related harms/costs Type of harms/costs, e.g. Who bears the harms/costs Sources of harms/costs Users, dealers, intimates, employers, neighbourhood, society, etc. Drug use, legal status, interventions, etc. Health Social & economic functioning Safety & public order Criminal justice system Source: adapted from MacCoun & Reuter 2001. Conclusion ‘Harm’ is a complex concept ‘Where we sit determines what we see’ Thinking about the ACT’s drug-related burden of harm • • • • The facts and figures on health & social harms The community’s values and expectations The sources of drug-related harms Who in our community bears the drug-related harms Sources and notes (1) Babor, T et al. 2010, Alcohol: no ordinary commodity - research and public policy, 2nd edn, OUP, Oxford. Babor, T et al. 2009, Drug policy and the public good, Oxford University Press, Oxford. Bennett, T & Holloway, K 2009, 'The causal connection between drug misuse and crime', British Journal of Criminology, vol. 49, no. 4, pp. 513-31. Goldstein, PJ 1985, 'The drugs/violence nexus: a tripartite conceptual framework', Journal of social issues, vol. 15, no. 4, pp. 493-506. Kendzor, DE et al. 2010, 'Financial strain and smoking cessation among racially/ethnically diverse smokers', American Journal of Public Health, vol. 100, no. 4, pp. 702-6. Kleiman, MAR 1992, Against excess: drug policy for results, Basic Books, New York, NY. Kleiman, MAR 2009, When brute force fails: how to have less crime and less punishment, Princeton University Press, Princeton. MacCoun, R, Reuter, P & Schelling, T 1996, 'Assessing alternative drug control regimes', Journal of Policy Analysis and Management, vol. 15, no. 3, pp. 330-52. MacCoun, R & Reuter, P 2001, Drug war heresies: learning from other vices, times, and places, Rand Studies in Policy Analysis, Cambridge University Press, Cambridge, UK McKie, J & Richardson, J 2003, 'The rule of rescue', Social Science and Medicine, vol. 56, no. 12, pp. 2407-19. Mrazek, PJ & Haggerty, RJ (eds) 1994, Reducing risks for mental disorders: frontiers for prevention intervention research, National Academy Press, Washington DC. Mugford, S 1991, 'Drug legalization and the 'Goldilocks' problem: thinking about costs and control of drugs', in MB Krauss & EP Lazear (eds), Searching for alternatives: drug-control policies in the United States, Hoover Institution Press, Stanford, Calif. Mugford, S 1993, 'Harm reduction: does it lead where its proponents imagine?' in N Heather, A Wodak, EE Nadelmann & P O'Hare (eds), Psychoactive drugs and harm reduction: from faith to science, Whurr, London. National Preventative Health Taskforce, Tobacco Working Group 2009, Tobacco control in Australia: making smoking history, Technical Report No 2, including addendum for October 2008 to June 2009, [Department of Health and Ageing], Canberra, writer: Michelle Scollo. Nutt, D, King, LA, Saulsbury, W & Blakemore, C 2007, 'Development of a rational scale to assess the harm of drugs of potential misuse', The Lancet, vol. 369, no. 9566, pp. 1047-53. Roche, AM 1997, 'The shifting sands of alcohol prevention: rethinking population control approaches', Australian and New Zealand Journal of Public Health, vol. 21, no. 6, pp. 621-5 . Rose, G 1981, 'Strategy of prevention: lessons from cardiovascular disease', British Medical Journal (Clinical Research Ed.), vol. 282, no. 6279, pp. 1847-51. Rose, G 1992, The Strategy of Preventive Medicine, OUP, Oxford. David McDonald’s contact details Director Social Research & Evaluation Pty Ltd 1004 Norton Road, Wamboin NSW 2620 Phone: (02) 6238 3706 Mobile: 0416 231 890 Facsimile: (02) 9475 4274 Email: [email protected] Online: www.socialresearch.com.au Visiting Fellow National Centre for Epidemiology & Population Health The Australian National University Canberra ACT 0200 Email: [email protected]