Jabberwocky
Frumious Bandersnatch
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- Nov 3, 1999
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Lisa Maher was sitting at the bottom of a stairwell of a block of flats in Cabramatta on a Friday evening in 1999. She was filming three people as they injected heroin.
At about 6.30pm, a family with two young children came home.
Professor Lisa Maher watching two teenagers injecting heroin in Cambramatta in 1996. Photo: George Fetting
"They had to step over us and walk through the spoons and drugs and needles everywhere and they were apologising to us."
"These people were so fearful and confused going into their own apartment ? It was just very sad," said Maher, now a professor and program head at the Kirby Institute.
She and her colleagues would amass 143 hours of footage of people injecting drugs in Cabramatta from 1999 to 2001.
It was part of groundbreaking ethnographic research by the National Drug and Alcohol Research Centre (NDARC) that exposed the emerging heroin epidemic and the deeply flawed responses to it by authorities.
Heroin is not the headline grabber it was in the '90s. The rising rates of prescription opioid misuse have eclipsed its illicit cousin in the lead-up to codeine becoming prescription-only on February 1.
But as NDARC marks its 30th anniversary plotting Australia's shifting drug predilections, it's clear there are no clean breaks from the country's former drugs of choice.
The tears that became a watershed
In September 1984, prime minister Bob Hawke stood in front of television cameras with tears rolling down his cheeks when a reporter's questions turned to drugs and his children.
The couple's youngest daughter, Rosslyn, and her son-in-law had a heroin problem.
The prime minister's private life had come crashing into the growing public concern over illicit drug use.
It was a galvanising moment that wrenched Australia into a new reality, according to Richard Mattick, professor of Drug and Alcohol Studies at NDARC.
Policymakers could no longer afford to dismiss the growing drug problem.
"The Hawke press conference was astonishing," Mattick said.
"It came at a time when people started to realise these problems were quite pervasive. They'd see it in their children,their friends, their partners, their neighbours."
Prior to the 1980s, the medical profession had largely ignored alcohol and drugs, Mattick said.
"Research was very much moribund and the public saw these problems as aberrations; addictions that were moral failings."
"It was very much a backwater," said one of NDARC's founders, physician Dr Alex Wodak. "We had a lot of difficulty convincing anyone we needed to take this seriously."
Hawke convened a special premiers' conference in April 1985 to conceive a national drug strategy. Two years later, NDARC opened.
The 16 original staff members had to start from scratch, said Mattick, one of NDARC's first hires.
The heroin epidemic and the rise in HIV/AIDS was their main quarry.
Overdoses peaked at 1116 heroin deaths in 1999. The drug was easily found, cheap and pure. Lucrative drug markets opened up in Sydney and Melbourne, and with them came drug crime.
It was clear people who injected drugs were of critical importance to controlling the HIV epidemic.
"We all knew that putting the genie back in the bottle would be extremely difficult," Wodak said.
Their concerns were validated by policymakers but their solution was not, prompting Wodak and his fellow renegade health workers to set up the illegal pilot needle and syringe exchange program in Darlinghurst in November 1986.
Alex Wodak at the site of the pilot Needle and Syringe Program in Darlinghurst, May 1988
That act of civil disobedience drew the ire of the state health department and prompted a police investigation that was swiftly dropped. The evidence of its effectiveness was undeniable and the NSW government started rolling out an authorised program in 1988.
"We did manage to keep the epidemic under control," Wodak said.
An independent analysis found the $130 million program prevented roughly 25,000 cases of HIV and 21,000 cases of hepatitis C infections between 1991 and 2000. The savings to the health system in avoided treatment costs over a lifetime are estimated to be between $2.4 and $7.7 billion.
Australia's heroin capital
In the '90s, police dubbed the train to Cabramatta the "Junkie Express".
"That's where the vibrant and far more blatant drug market was," Maher said.
"Lots of people from all over Sydney, Liverpool, Revesby would come to Cabramatta for the day and spend weeks or months there until they were arrested or sent to juvenile detention."
She recalls teenagers as young as 14 lacing joints with heroin and rapidly transitioning to injecting drugs: "It was potentially a public health disaster."
The police's "incredibly aggressive" zero-tolerance crackdown on injecting drug use exacerbated the harms to users and alienated the community, who perceived their actions as racist and targeting their youth.
Many people were scared to call 000 when their friend overdosed. Police would routinely attend overdoses, Maher said: "So many times we'd call the ambulance and the police would come, or show up with the ambulance."
NDARC researchers were among those who agitated for change, and soon every jurisdiction in the country changed its policies, only sending police to overdoses where serious crime was suspected.
"That had a huge impact. We could tell people it was safe to ring and they'd have a chance."
Local community and health department interventions have since transformed Cabramatta into a suburb touted as a fine-food mecca, but the legacy of its heroin past is still felt today.
"We've got a huge epidemic of hepatitis C that was prompted by those Cabramatta days," Maher said.
Treatment for drug dependence was almost as maligned as drugs themselves. In a world first, NDARC researchers conducted a comprehensive review of the controversial methadone maintenance treatment for heroin dependence.
"We were totally surprised to find how effectively it worked," said Mattick, who wrote the WHO guidelines for methadone treatment and put both methadone and buprenorphine - another replacement drug - on the international model list of essential medicines, cementing their treatment legitimacy.
"It was almost like a penicillin ? it doesn't make [users] perfect angels, but reduced drug and HIV risk, crime, and it keeps them alive for longer."
The golden half-hour
Overdose deaths often conjured the image of a young and naive user injecting themselves in a back alley with heroin laced with impurities.
"It's absolute rubbish," said Professor Shane Darke, who has been an NDARC researcher since 1988. "Pretty well everything we thought we knew about overdose was wrong."
Older people in their 30s and 40s who were long time heroin users accounted for the bulk of overdose deaths, which usually involved some other substance, most notably alcohol, and more often than not occurred inside their homes.
"People were astonished when every time they heard of an older person dying of a heroin overdose. Well, welcome to my world," Darke said.
The veteran drug and alcohol researcher spent countless hours trawling through thousands of death certificates, coronial reports, police and medical records over the past three decades to discover who dies from overdose.
"If we can understand why people are dying of overdose, we can start to intervene."
He discovered that with most overdoses there was a precious window of time - a golden half-hour - in which a person's life could be saved through medical intervention.
"In the early days we thought everyone dropped dead immediately, but fewer than one in seven die straight away. Some will survive for hours."
Further research confirmed the drug naxolone effectively reversed overdoses.
Heroin drought, meth deluge
By the time the heroin drought had dried up supply in the early 2000s, methamphetamine use had been steadily climbing for a decade.
Australia was a very attractive marketplace for meth labs opening in Asia, and local bikie operations were also making and flogging their own product.
Methamphetamine use seemed to follow a predictable pattern of steadily increasing rates of use before a steeper drop-off every decade, said NDARC principal research fellow Professor Louisa Degenhardt.
The reports of violence and the highly addictive quality of crystal methamphetamine (ice) tended to take the focus away from other drugs that were a much more steady and sustained issue, like prescription opioids, Degenhardt said.
"It can be incredibly scary for friends and family when someone is in the midst of a drug-induced psychotic episode. But the fact of the matter is the sustained rate of opioid overdose deaths has been an increasing problem in recent years," she said.
Roughly 40 per cent of deaths linked to ice, speed and other stimulants were from "natural disease", including heart attacks and stroke or violent methods of suicide, found a recent analysis.
"Everyone talks about meth violence, but no one really talks about the irreversible heart disease," Darke said.
The prescription problem
These days, prescription opioids can be easier to come by on the streets than heroin.
More Australians are dying from accidental prescription opioid overdoses than heroin, accounting for two-thirds of the fatalities, figures from the Australia Bureau of Statistics show.
The problem in Australia hasn't reached the "opioid epidemic" proportions of the US, but it has been trudging dangerously down the same route for the past 15 years, Wodak said.
About 20,000 doses are prescribed for every 1 million people in Australia every year, the latest data shows.
Opioid-related hospitalisations among people aged 30 to 59 have steadily increased over the past five years, and many deaths were caused by multiple drug toxicity, which increases the risk of a fatal overdose, according to NDARC research.
The rise of prescription opioid dependence creates a new, complex patient profile.
It is a cohort of "street junkies" shooting up oxycodone and upper-middle-class parents taking 90 codeine tablets a day after being prescribed opioids for their wisdom teeth extractions.
Since 2012, Degenhardt and her colleagues have been tracking 1500 chronic pain patients prescribed schedule 8 pharmaceutical opioids like oxycodone.
Those affected predominantly fell into two groups: injecting drug users mixing drugs, and people with chronic non-cancer pain with no significant history of drug use.
"People can find themselves getting into some pretty extreme levels of opioid use and others have the opposite experience," she said.
"It was very clear that there was a real need to be vigilant about prescribing prescription opioids and monitor their use so we don't find ourselves in a situation where it gets out of control," Degenhardt said.
Ahead of codeine becoming prescription-only on Thursday, Federal Health Minister Greg Hunt also announced $20 million for a trial program to help pharmacists find alternatives for managing patients with chronic pain.
Last week the Therapeutic Goods Administration also flagged the possibility of banning GPs from prescribing schedule 8 drugs, including oxycodone and fentanyl - a highly potent opioid responsible for an increasing number of accidental overdoses. It's a proposal the Royal Australian College of General Practitioners opposes.
The focus on prescription opioids was warranted, Darke said, but there was always a risk that a fixation on one class of drugs obscured others.
"Just because a lighthouse isn't shining on the rocks, doesn't mean they're not still right there," Darke said.
"After the heroin peak in the '90s a lot of people said 'Oh we've solved the problem, now we're down to 350 [deaths per year].' Well, that's nice. Those 350 who died must be pleased they're part of the solution."
Through the years of the heroin epidemic and the methamphetamine mania dominating the headlines and the soundbites, tobacco and alcohol were the far greater health burdens.
"Alcohol use is the leading cause of disability in young adults, which is astounding. The single leading cause among people aged 10 to 24 years old," Mattick said.
Synthetic drugs would be the next challenge for doctors, researchers, law enforcement and policymakers, Mattick said.
"Why would you bother growing [poppies for opiates] when you can create new drugs in a warehouse? We already know how much easier it is to transport fentanyl. You can send a kilogram of the stuff rather than 100 kilograms of heroin," he said.
For Wodak, the challenge is drug law reform.
Now president of the Australian Drug Law Reform Foundation, Wodak said it would take another national event as galvanising as the Hawke press conference and the drug summit to propel Australia into the next phase.
"We have to redefine [drug use] and shift from a law enforcement problem to a health and safety problem," Wodak said, arguing Australia's harm-minimisation policies have not pushed the pendulum far enough away from punitive responses.
"Until we make that switch, we are always going to be struggling with this issue."
Source: http://www.smh.com.au/national/heal...f-australias-drug-misuse-20180125-h0ole9.html
At about 6.30pm, a family with two young children came home.
Professor Lisa Maher watching two teenagers injecting heroin in Cambramatta in 1996. Photo: George Fetting
"They had to step over us and walk through the spoons and drugs and needles everywhere and they were apologising to us."
"These people were so fearful and confused going into their own apartment ? It was just very sad," said Maher, now a professor and program head at the Kirby Institute.
She and her colleagues would amass 143 hours of footage of people injecting drugs in Cabramatta from 1999 to 2001.
It was part of groundbreaking ethnographic research by the National Drug and Alcohol Research Centre (NDARC) that exposed the emerging heroin epidemic and the deeply flawed responses to it by authorities.
Heroin is not the headline grabber it was in the '90s. The rising rates of prescription opioid misuse have eclipsed its illicit cousin in the lead-up to codeine becoming prescription-only on February 1.
But as NDARC marks its 30th anniversary plotting Australia's shifting drug predilections, it's clear there are no clean breaks from the country's former drugs of choice.
The tears that became a watershed
In September 1984, prime minister Bob Hawke stood in front of television cameras with tears rolling down his cheeks when a reporter's questions turned to drugs and his children.
The couple's youngest daughter, Rosslyn, and her son-in-law had a heroin problem.
The prime minister's private life had come crashing into the growing public concern over illicit drug use.
It was a galvanising moment that wrenched Australia into a new reality, according to Richard Mattick, professor of Drug and Alcohol Studies at NDARC.
Policymakers could no longer afford to dismiss the growing drug problem.
"The Hawke press conference was astonishing," Mattick said.
"It came at a time when people started to realise these problems were quite pervasive. They'd see it in their children,their friends, their partners, their neighbours."
Prior to the 1980s, the medical profession had largely ignored alcohol and drugs, Mattick said.
"Research was very much moribund and the public saw these problems as aberrations; addictions that were moral failings."
"It was very much a backwater," said one of NDARC's founders, physician Dr Alex Wodak. "We had a lot of difficulty convincing anyone we needed to take this seriously."
Hawke convened a special premiers' conference in April 1985 to conceive a national drug strategy. Two years later, NDARC opened.
The 16 original staff members had to start from scratch, said Mattick, one of NDARC's first hires.
The heroin epidemic and the rise in HIV/AIDS was their main quarry.
Overdoses peaked at 1116 heroin deaths in 1999. The drug was easily found, cheap and pure. Lucrative drug markets opened up in Sydney and Melbourne, and with them came drug crime.
It was clear people who injected drugs were of critical importance to controlling the HIV epidemic.
"We all knew that putting the genie back in the bottle would be extremely difficult," Wodak said.
Their concerns were validated by policymakers but their solution was not, prompting Wodak and his fellow renegade health workers to set up the illegal pilot needle and syringe exchange program in Darlinghurst in November 1986.
Alex Wodak at the site of the pilot Needle and Syringe Program in Darlinghurst, May 1988
That act of civil disobedience drew the ire of the state health department and prompted a police investigation that was swiftly dropped. The evidence of its effectiveness was undeniable and the NSW government started rolling out an authorised program in 1988.
"We did manage to keep the epidemic under control," Wodak said.
An independent analysis found the $130 million program prevented roughly 25,000 cases of HIV and 21,000 cases of hepatitis C infections between 1991 and 2000. The savings to the health system in avoided treatment costs over a lifetime are estimated to be between $2.4 and $7.7 billion.
Australia's heroin capital
In the '90s, police dubbed the train to Cabramatta the "Junkie Express".
"That's where the vibrant and far more blatant drug market was," Maher said.
"Lots of people from all over Sydney, Liverpool, Revesby would come to Cabramatta for the day and spend weeks or months there until they were arrested or sent to juvenile detention."
She recalls teenagers as young as 14 lacing joints with heroin and rapidly transitioning to injecting drugs: "It was potentially a public health disaster."
The police's "incredibly aggressive" zero-tolerance crackdown on injecting drug use exacerbated the harms to users and alienated the community, who perceived their actions as racist and targeting their youth.
Many people were scared to call 000 when their friend overdosed. Police would routinely attend overdoses, Maher said: "So many times we'd call the ambulance and the police would come, or show up with the ambulance."
NDARC researchers were among those who agitated for change, and soon every jurisdiction in the country changed its policies, only sending police to overdoses where serious crime was suspected.
"That had a huge impact. We could tell people it was safe to ring and they'd have a chance."
Local community and health department interventions have since transformed Cabramatta into a suburb touted as a fine-food mecca, but the legacy of its heroin past is still felt today.
"We've got a huge epidemic of hepatitis C that was prompted by those Cabramatta days," Maher said.
Treatment for drug dependence was almost as maligned as drugs themselves. In a world first, NDARC researchers conducted a comprehensive review of the controversial methadone maintenance treatment for heroin dependence.
"We were totally surprised to find how effectively it worked," said Mattick, who wrote the WHO guidelines for methadone treatment and put both methadone and buprenorphine - another replacement drug - on the international model list of essential medicines, cementing their treatment legitimacy.
"It was almost like a penicillin ? it doesn't make [users] perfect angels, but reduced drug and HIV risk, crime, and it keeps them alive for longer."
The golden half-hour
Overdose deaths often conjured the image of a young and naive user injecting themselves in a back alley with heroin laced with impurities.
"It's absolute rubbish," said Professor Shane Darke, who has been an NDARC researcher since 1988. "Pretty well everything we thought we knew about overdose was wrong."
Older people in their 30s and 40s who were long time heroin users accounted for the bulk of overdose deaths, which usually involved some other substance, most notably alcohol, and more often than not occurred inside their homes.
"People were astonished when every time they heard of an older person dying of a heroin overdose. Well, welcome to my world," Darke said.
The veteran drug and alcohol researcher spent countless hours trawling through thousands of death certificates, coronial reports, police and medical records over the past three decades to discover who dies from overdose.
"If we can understand why people are dying of overdose, we can start to intervene."
He discovered that with most overdoses there was a precious window of time - a golden half-hour - in which a person's life could be saved through medical intervention.
"In the early days we thought everyone dropped dead immediately, but fewer than one in seven die straight away. Some will survive for hours."
Further research confirmed the drug naxolone effectively reversed overdoses.
Heroin drought, meth deluge
By the time the heroin drought had dried up supply in the early 2000s, methamphetamine use had been steadily climbing for a decade.
Australia was a very attractive marketplace for meth labs opening in Asia, and local bikie operations were also making and flogging their own product.
Methamphetamine use seemed to follow a predictable pattern of steadily increasing rates of use before a steeper drop-off every decade, said NDARC principal research fellow Professor Louisa Degenhardt.
The reports of violence and the highly addictive quality of crystal methamphetamine (ice) tended to take the focus away from other drugs that were a much more steady and sustained issue, like prescription opioids, Degenhardt said.
"It can be incredibly scary for friends and family when someone is in the midst of a drug-induced psychotic episode. But the fact of the matter is the sustained rate of opioid overdose deaths has been an increasing problem in recent years," she said.
Roughly 40 per cent of deaths linked to ice, speed and other stimulants were from "natural disease", including heart attacks and stroke or violent methods of suicide, found a recent analysis.
"Everyone talks about meth violence, but no one really talks about the irreversible heart disease," Darke said.
The prescription problem
These days, prescription opioids can be easier to come by on the streets than heroin.
More Australians are dying from accidental prescription opioid overdoses than heroin, accounting for two-thirds of the fatalities, figures from the Australia Bureau of Statistics show.
The problem in Australia hasn't reached the "opioid epidemic" proportions of the US, but it has been trudging dangerously down the same route for the past 15 years, Wodak said.
About 20,000 doses are prescribed for every 1 million people in Australia every year, the latest data shows.
Opioid-related hospitalisations among people aged 30 to 59 have steadily increased over the past five years, and many deaths were caused by multiple drug toxicity, which increases the risk of a fatal overdose, according to NDARC research.
The rise of prescription opioid dependence creates a new, complex patient profile.
It is a cohort of "street junkies" shooting up oxycodone and upper-middle-class parents taking 90 codeine tablets a day after being prescribed opioids for their wisdom teeth extractions.
Since 2012, Degenhardt and her colleagues have been tracking 1500 chronic pain patients prescribed schedule 8 pharmaceutical opioids like oxycodone.
Those affected predominantly fell into two groups: injecting drug users mixing drugs, and people with chronic non-cancer pain with no significant history of drug use.
"People can find themselves getting into some pretty extreme levels of opioid use and others have the opposite experience," she said.
"It was very clear that there was a real need to be vigilant about prescribing prescription opioids and monitor their use so we don't find ourselves in a situation where it gets out of control," Degenhardt said.
Ahead of codeine becoming prescription-only on Thursday, Federal Health Minister Greg Hunt also announced $20 million for a trial program to help pharmacists find alternatives for managing patients with chronic pain.
Last week the Therapeutic Goods Administration also flagged the possibility of banning GPs from prescribing schedule 8 drugs, including oxycodone and fentanyl - a highly potent opioid responsible for an increasing number of accidental overdoses. It's a proposal the Royal Australian College of General Practitioners opposes.
The focus on prescription opioids was warranted, Darke said, but there was always a risk that a fixation on one class of drugs obscured others.
"Just because a lighthouse isn't shining on the rocks, doesn't mean they're not still right there," Darke said.
"After the heroin peak in the '90s a lot of people said 'Oh we've solved the problem, now we're down to 350 [deaths per year].' Well, that's nice. Those 350 who died must be pleased they're part of the solution."
Through the years of the heroin epidemic and the methamphetamine mania dominating the headlines and the soundbites, tobacco and alcohol were the far greater health burdens.
"Alcohol use is the leading cause of disability in young adults, which is astounding. The single leading cause among people aged 10 to 24 years old," Mattick said.
Synthetic drugs would be the next challenge for doctors, researchers, law enforcement and policymakers, Mattick said.
"Why would you bother growing [poppies for opiates] when you can create new drugs in a warehouse? We already know how much easier it is to transport fentanyl. You can send a kilogram of the stuff rather than 100 kilograms of heroin," he said.
For Wodak, the challenge is drug law reform.
Now president of the Australian Drug Law Reform Foundation, Wodak said it would take another national event as galvanising as the Hawke press conference and the drug summit to propel Australia into the next phase.
"We have to redefine [drug use] and shift from a law enforcement problem to a health and safety problem," Wodak said, arguing Australia's harm-minimisation policies have not pushed the pendulum far enough away from punitive responses.
"Until we make that switch, we are always going to be struggling with this issue."
Source: http://www.smh.com.au/national/heal...f-australias-drug-misuse-20180125-h0ole9.html
