DR KERRYN PHELPS, AMA PRESIDENT, 2002 AMA NATIONAL DRUGS SUMMIT, CANBERRA
Discussion: Party drugs; herion trial; use of cannabis in medicine; PBS
PHELPS: Good morning everyone, and thank you all for taking the time to contribute to this important AMA Drug Summit. You could say that the medical profession is coming to the party on party drugs. I promise not rave on too long.
This will be an informative, through provoking and policy inspiring examination of an emerging public health challenge. The use and control of so-called party drugs. In April last year, the AMA held it's first national drug summit, where we posed the question, "Have we got the funding right for programs on tobacco, alcohol and other drugs?"
At that summit, Australia's major drug bodies united to speak out on a common issue; the need for increased funding to reduce drug related morbidity and mortality. A joint communique was released which called on all Australian governments to be more accountable and transparent in regard to the funding and outcomes of drug programs. The AMA is committed to maintaining the momentum for collective action. Once again, we're providing a forum for key groups to come together to discuss ways of minimising the harm associated with the use and misuse of drugs in our community. Today, we're focussing on the issue of party drugs. An issue that is particularly topical and relevant to the youth of Australia at this time.
When you glance at the newspaper headlines, or tune into radio or TV, you will be provided with an instant appreciation of the impact, often negative, sometimes tragic, of recreational drugs in our community. Headlines such as, Six people hospitalised for Ecstasy overdose in Queensland, or Drink spiked in a Canberra nightclub, highlight the public concern in this area.
The AMA has a strong commitment and a history of advocacy in relation to protecting and improving the health of Australia's young people. We convened a youth health summit last year and we conduct ongoing activities through the Commonwealth Bank sponsored youth health advocate program at the AMA. This is National Youth Health Week, and it's appropriate that the AMA continues it's leading role in advocating for Australia's young people by facilitating for the first time, a national forum to look specifically at recreational party drug use.
We are using the phrase, party drugs, as a general term to describe certain illicit substances, primarily synthetic ones, that are often consumed at nightclubs, bars, raves and dance parties. These substances include, but are not limited to, MDMA, or ecstasy; GHB, or liquid ecstasy; LSD, called acid; Ketamine, special K and metaphetamine, or speed. A dance culture has evolved over the past two decades with the increasing size and popularity of raves. More recently, dance parties, which were once fringe activities, have become increasingly more mainstream. Characterised by often clandestine locations, electronic music and liberal use of mood enhancing drugs, dance parties are attended by large numbers of young people. They're now being staged in more permanent legal venues, such as nightclubs.
With this dance culture now a legitimate form of popular youth culture and youth entertainment, we have seen an increase in the use of party drugs in an attempt to enhance this experience. There have also been reports that contrary to popular opinion, Ecstasy and associated drugs are increasingly being used in a variety of contexts, not just dance party related. When this information is coupled with the research indicating the increase in the use of illicit drugs, it's obvious that a significant public health issue is emerging. According to the Australian Institute of Health and Welfare, nearly half of all Australians aged 14 years or older, have used illicit drugs. Twenty three per cent report having used drugs over the past 12 months.
Now, while marijuana is the most popular illicit drug by far, there is an emerging trend of an increasing use of psycho stimulants, such as Ecstasy, amphetamines and hallucinogens. In 1998, the percentage of the population over 14 years, who had used Ecstasy was almost five per cent, indicating a doubling of users over a seven-year period. This is an alarming figure for health workers and one that by all accounts will have increased in the three years since that study. It is clear that we have an emerging major community health problem.
One of the important issues for health workers is that we don't know what are the associated health risks from taking many of these drugs. Some of the unanswered questions include, "Is there a safe level for recreational drug use? What are the short-term effects from using Ecstasy, amphetamines? What are the long-term effects? How can we most effectively prevent people from using drugs harmfully?" We can't answers all these questions today. But, together we can discuss the priorities for minimising harm through prevention, treatment, education and training initiatives.
Our speakers represent the broad range of interest groups that have a stake in the health and wellbeing of our community. I welcome Paul Dillon, Information Manager at the National Drug and Alcohol Research Centre in Sydney, Tim Waugh, General Manager of Home Nightclub in Sydney, Drew Moore, General Practitioner from Brisbane and Nicky Bath, Policy Officer from the Australian Intravenous League and Caroline Fitzwarryne, CEO of the Alcohol and Other Drugs Council of Australia.
I'd like to thank all of the speakers and the delegates for making the effort to be here today. Your deliberations and any outcomes, will be very valuable contributions to the community debate on party drugs and illicit drugs generally. Your views will also influence our community and political leaders who will inevitably develop policy in response to issues relating to party drug use in Australia.
I'd like to thank the Commonwealth Bank for their generous sponsorship of the AMA Youth Advocate Program, without which this summit would not have happened. I'm now happy to take questions. I have to my left Paul Dillon, the Information Manager for the National Drug and Alcohol Research Council and to my right, Nicky Bath. Nicky is currently employed as a policy officer at the Australian Injecting and Illicit Drug User's League and can give a user's perspective.
QUESTION: Dr Phelps, do you believe that there is a safe level though, of recreational drug use?
PHELPS: That's one of the things that we don't know. Certainly, there is unpredictability in the content of some of the drugs that are available on the street and Paul Dillon can, I think, provide more information on that technical aspect of the issue. But, there is emerging evidence that drugs that many of the users consider are probably safe in the short-term, may have adverse long-term effects and I think that we'd certainly need to encourage more research into that area so that people are able to make a more informed decision. Paul, did you want to comment on that one?
DILLON: I think it's about getting good quality information out to people and believable information. Many young people, because of the way that we do speak about drugs - and we use scare tactics, we try to frighten them. They don't necessarily believe all we tell them and I think that's what we have to try to work out: what messages are we trying to get across?
QUESTION: Why is there so little known about the effect of some of these drugs?
PHELPS: There are a lot of problems. One is getting subjects for research, and the other one is getting substances for research and, of course, there's the ongoing funding issues. But, I think with this being an emerging public health challenge, we're really only seeing the very beginnings of a public health response. Now, part of that public health's response has to be informed by evidence and it will be a matter of looking at international research and gathering what evidence that we can so that we have more predictability about the information that we're able to give to people and that it's reliable.
QUESTION: So, should the Commonwealth be funding more research in this area?
PHELPS: I think that this is an important area of research. It is, as I said, an emerging public health challenge and there's no question that along with other drug problems such as the abuse of alcohol, the use of tobacco and the use and abuse of illicit substances, that we do need to have a comprehensive approach to the use of substances by Australians. This is certainly a major issue in terms of Australia's youth.
QUESTION: How does it rank in comparison with the use of hard drugs, alcohol, tobacco? Is that a health problem?
DILLON: Well, I think we really don't know. There's a wealth of research at the moment being carried out around the world in terms of Ecstasy. But, much of that is actually on pure MDNA. Now, what the users in Australia are actually getting, is very rarely pure MDNA. So, we have to be very careful about the messages we give. So, we really don't know exactly what are the consequences of using a street drug and that's why so many of our messages are about - we simply don't know what you're taking. And so possibly, one thing that we could be looking at is, government testing of substances so that we have got messages out like an early warning network, which they have in Europe, for example, around pills. So, you always constantly know what is there and if there is anything particularly more dangerous in them.
QUESTION: How would that operate, do you know?
DILLON: Well, in Europe it's been operating for over 10 years in some countries. But, it's a very difficult thing to get up and running, of course, because some people believe that if you test pills and you're giving information on what's in it, you're condoning the use of drugs. But, I think it's something we do have to look at. It's been now evaluated in Europe and it's doing quite well.
QUESTION: Has the relatively conservative approach of drugs in Australia exacerbated the problem? Because it's seen as you're doing something wrong here, you're not meant to take them?
DILLON: I think in terms of where the messages that we put out, having incredibly conservative messages that rely upon shock tactics and trying to scare young people, all we have done is really - I use the analogy of the boy who cried wolf - you can't keep telling someone that if you use this drug it's going to kill you and it doesn't, and then you actually do have some very good information that's warning people about a real risk, they choose to ignore you because we have lied to them over a period of time. This is why we have to be very careful about the messages we give.
QUESTION: Is the best form of harm minimisation basically prevention? Is that practicable?
PHELPS: I'll ask Nicky to comment on that one?
BATH: I think that rather look in terms of prevention, look in terms of education and clearly, internationally and nationally here in Australia, the key way to do that is to ensure the involvement of drug users themselves, to disseminate information through peer education and peer support. That's going to be the most effective way in which you can disseminate accurate information. And as Paul has said, it's really important that information is put out in a way in which users actually get to see the reality of what's happening; the reality of the drugs that they're using and that the information is accurate.
QUESTION: There are representatives of the nightclub industry here, how important is it for them to be involved and what sort of level of cooperation do you receive
PHELPS: I think it's essential that we have the cooperation of the nightclub owners, the people who are using drugs as well. We need to have accurate information; we need to have the medical profession, other health workers involved. The more comprehensive a group we have to look at this issue, the more likely we are to come up with practical solutions. For example, there's no point in a group of health professionals coming up with, "This is what we see as the big solution."
If we haven't asked the people who represent drug users, whether that's going to be a practical approach for them: whether that's going to make sense to them and are we basing our information on accurate information from the street; accurate information from international research? The nightclub owners, where we have now legal venues operating; where we know that party drugs can be a part of that culture, I think it's important that they are involved as well. That, they can put their perspective, and the more realistic perspectives we have on this issue, the more likely our results will be realistic.
QUESTION: What sort of things could they be doing to try and minimise the problems on their premises?
DILLON: In the UK now, they've developed - the UK government has developed a series of safer clubbing guidelines. Now, they're not necessarily - the legislation hasn't been put into place to make these law. But, at least they have been created. Over a period of time in Australia, we have created a set of clubbing guidelines, but, they're not enforced. There are some clubs that do amazing work.
We know that the vast majority of Ecstasy deaths, for example, have been caused through dehydration and over-heating, over-crowding, lack of ventilation, lack of free running cold water. All of these issues need to be looked at and I think it's something that should be interesting if it's raised today and put forward as a real option that we can put pressure on governments to create these guidelines.
QUESTION: How many party drug deaths have there been, is it possible to quantify?
DILLON: Very, very difficult to quantify. Mainly because some of the deaths occur, not necessarily straight after they've used the drug. Often they don't get reported. They come out as looking like another, you know, often with a stimulant death, for example. It could be a heart attack. But, if you look at Ecstasy-related deaths, we believe about 20. If you look at the UK, for example, where tens of thousands of Ecstasy are used every weekend, they've had between 80 and 100 deaths in the last 10 years. So, in reality, death is not necessarily the usual consequence of using these drugs. There are a range of other harms that we should be looking at.
QUESTION: So, that 20, over what period?
DILLON: Since - over the past 10 years.
PHELPS: Death, as Paul said, death is not necessarily the most reliable indicator of harm from recreational drug use, because we're now looking at international research indicating, for example, with Ecstasy, that there is long-term damage to the brain and that that may lead to problems like depression.
QUESTION: These issues have been looked at a lot, particularly the New South Wales Drug Summit was fairly extensive, what's different about this forum today? What view is going to come out of it?
PHELPS: We hope that we're going to emerge from this forum with a comprehensive look to the future, that we take along with us, not only the medical profession, but drug users, the venue managers, information. As much as possible can to make sure that our responses are practical and achievable in the short-term. But, we also need to not only have short-term, but long-term objectives.
QUESTION: Are you concerned that some of the recommendations might come up with, perhaps a heroin trial? That governments are reluctant to look at those sort of issues?
PHELPS: It's very frustrating when you are blocked from trying something that might work in a pilot sense. And I think as a community, we should not be afraid of the word "trial". Because what it means is, let's see if it works? If it doesn't, in a limited sense, then you've lost nothing. If it does have gain, even though it might be quite a lateral solution, then you may well have found a solution for a sub-group of people. And I think that we need to be as lateral and as creative as we need to be, to address a problem without over-stating the problem by being realistic and being practical.
QUESTION: Do you believe that there still needs to be a heroin trial in Australia despite the plummeting deaths?
PHELPS: Heroin is not really the subject of this particular summit today. However, as I've said before, I believe that a trial is something that would be appropriate for a sub-group of patients who have failed other treatments.
QUESTION: Would that include having an Ecstasy trial?
PHELPS: Well, as Paul said, what is marketed here as Ecstasy, is - sorry, does it sound like a good idea to you, does it? Do you want to respond to that?
BATH: I just am not sure what that question means, actually. Heroin trials and Ecstasy trials is so, so separate from each other. Heroin trials - I don't even begin to answer that question. In what way would you see Ecstasy trials?
QUESTION: I'm just curious as to why you find that laughable, when you're saying that it's a worsening problem, Ecstasy?
DILLON: I think it's about issues of dependence. I mean, heroin is a highly addictive drug and has a dependent syndrome. It's yet to be really proven that Ecstasy - there is a dependent syndrome and a withdrawal from it. So, there are other issues, I think, that are important around Ecstasy, rather than trying to wean people off the drug, because they don't have those sorts of issues. It's a very self-limiting drug. So, there are other issues around it.
QUESTION: Do you think decriminalisation of these drugs might be an option to be part of a harm minimisation strategy?
PHELPS: I think all options need to be on the table and there needs to be a very broad community debate. There are aspects of criminalisation which make it very difficult to research substances, to get accurate information, to get education out to young people, it creates a black market - well, it's nature is that of a black market. It creates a number of problems with relation to people getting assistance medically. They feel that they may have to admit to an illegal activity if they run into medical problems. So, I think that there are a number of issues around these substances being illegal, that of themselves, create difficulties.
But, I think that once again, that has to be a matter for community debate and I think people ought not to be frightened of facing the fact, that these substances are being used and the only way that we can take a realistic approach to harm minimisation, is to acknowledge that they are being used and that they are part of youth culture, at the moment, and we can perhaps move forward in a constructive way. I mean, one of the reasons that, for example, a so-called Ecstasy trial would not be feasible, is that number one, it's not a drug of dependence. Number two, we, in Australia, as Paul said, don't necessarily get pure MDNA on the streets. So, if you are conducting a trial, it would be a trial on pure MDNA, not the adulterated version that people are buying in Australia.
QUESTION: I can't recall if the federal AMA have a position with marijuana as with heroin, there are sick people who should be able to use marijuana to help them with their pain. What's the federal AMA's position on that?
PHELPS: The medicinal use of cannabis is a very different issue to the recreational use of cannabis. We have serious concerns about the recreational use of cannabis, particularly by young people, because there is an association with cognitive problems, trouble with young people developing their intellectual capacity and their thinking ability and lack of motivation. In the longer term we're looking at obviously, respiratory problems with the recreational use of cannabis. Long term possibility of people who are prone to psychosis, developing psychosis when they use cannabis.
So, that is a very, very different matter from somebody who is suffering from HIV-AIDS, wasting syndrome, or who has intractable nausea from cancer chemotherapy treatment, or is in a terminal stages of cancer, using cannabis when no other substance will provide them with relief. And, I made my beliefs very clear when I was president of the AMA, New South Wales, and was pleased to see the New South Wales government proceed with an examination of cannabis for medicinal purposes in specific applications. And I think that we do need to make sure that those two issues are maintained as very separate issues.
Any other questions?
QUESTION: This is a not a drug question. Do you think Australians pay enough for subsidised drugs?
PHELPS: I haven't heard it put that way in the last 24 hours. Do I think Australians pay enough for prescription drugs?
QUESTION: Or are they getting them very cheaply...
PHELPS: Australians are getting, I think, effective subsidies under the Pharmaceutical Benefit's Scheme. The PBS is a very valuable contributor to the health of Australians. People who are the sickest and the poorest in our community, depend very heavily on the Pharmaceutical Benefit's Scheme. An increase in the cost of prescriptions to people who are, for example, on pensions, who are unemployed, who have chronic health problems, can have a very serious impact on somebody who has a fixed low income. And this is particularly a problem for elderly people, people who are on multiple medications, who have a number of serious medical conditions and to increase what they are paying for their medications, could, in fact, mean that they can't afford them and that they may not take them as prescribed and that could have long-term, and short-term, effects on their health.
I would be concerned at an increase, without - for pharmaceuticals for people in those classifications who are health care card holders, unemployed, pensioners, unless there was a increase in their welfare allowances to cover the possible costs of their medications.
QUESTION: What about people on high incomes getting them for $22 a pop….
PHELPS: I think that we have to look at the contribution that the Pharmaceutical Benefit Scheme pays to the overall health of Australians and we can't just look at a single budget cycle and say, "Look, this is expensive, it's gone up by 19 per cent in the last year, we have to slash through the PBS budget and make sure that people are paying more." We have to look at the long-term implications of increases in costs to the patients. We can't just look at the next budget cycle, we have to look at the next couple of decades, because if we control someone's hypertension today, if we control somebody's cholesterol today, if we can give somebody pain relief from their arthritis to maintain their mobility and their ability, then we could well be meaning that we are making significant cost savings, 10, 20 years down the track. So, we can't be short-sighted when it comes to looking at the PBS. And my fear is that in looking at just the next four years with slashing $2 billion from that budget, that we may be being short-sighted in our objectives there.
Thank you.
some good stuff in this. i'm not too suprised by paul's comments, just that they are on the record, so too speak.
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