Case against harm minimisation in drug fight
Don Weatherburn
October 26, 2007
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When it comes to illicit drugs, the goal of harm minimisation seems sensible enough, perhaps even trite. But whose harm are we trying to minimise and how do we compare different types of harm? Is it possible to compare the harm done by injecting drug users when they discard needles in a public park with the harm done to injecting drug users when they are unfairly harassed by the police?
It used to be thought that if efforts to reduce the supply of heroin ever succeeded, this would push up prices and force users to commit more crime to fund their addictions.
Thanks to the heroin shortage we now know that pushing up the price of heroin substantially reduces consumption. Higher prices produced a fall in heroin-related crime and fatal overdoses. Police would argue that it also produced a big improvement in public amenity in places like Cabramatta.
But reducing the supply of heroin increased some types of harm. The risk we take when we push up the price of one illicit drug is that consumers will switch to another. Evidence is now emerging that the heroin shortage may have increased the demand for methamphetamine and cocaine.
Demand reduction is often put forward as a less harmful policy than supply reduction, on the grounds that if we reduce demand, the excess supply will drive down prices, reducing profits to dealers and the scale of the blackmarket. And, of course, if consumption falls, most of the health harms can also be expected to fall.
One of the things that makes demand reduction so appealing to public health advocates is that its symbols are doctors, nurses and teachers, rather than police, courts and prisons.
But let's think about what drives drug users into treatment. Some experience an epiphany and go voluntarily but many are like Tom Waits in the song Bad Liver and a Broken Heart, in which he said he didn't have a drinking problem except when he couldn't get a drink. People who try heroin, cocaine or amphetamines are not generally prompted to stop using because of adverse pharmacological effects.
The most common reasons given by injecting drug users for entering treatment are trouble with police, the cost of drugs and the lifestyle associated with dependence - endless scamming, theft, violence and risk of imprisonment. To maximise the attractions of treatment it helps to make life without it fairly unpleasant. If we want to get the most out of demand reduction, in other words, we have to inflict some harm.
Some argue we should concentrate on reducing the harm suffered by drug users rather than reducing drug use.
The two best-known examples of this strategy are the needle and syringe program and the medically supervised injection centre in Kings Cross. There is no evidence that either of these initiatives have caused any harm. But part of the difficulty in evaluating the harm reduction as a general policy is that we really just tinker at the margins.
If you doubt this, just think for a minute about what you could do if you were really serious about limiting the harm illegal drugs do to those who use them.
We could remove criminal sanctions altogether from personal drug use or possession so drug users would not end up with a criminal record and find their career prospects ruined.
To avoid compromising the education of schoolchildren, we could adopt a policy of not expelling students caught with drugs. We could establish a medically supervised injection centre in every neighbourhood.
Why don't we do these things? The most commonly heard reason is that we will ultimately end up with more users and higher levels of harm. It is customary in some circles to scoff at this argument, but it may not be quite as silly as it sounds. Our policies towards alcohol and tobacco rely heavily on stigmatisation and measures designed to increase the cost of use.
Harm minimisation was from its inception less a policy goal than a political fix, designed to ensure that illicit drug use was not viewed solely through the prism of law enforcement.
Harm minimisation might be a worthy goal in the United States, which still places too much emphasis on drug law enforcement and not enough on treatment. Australia, though, no longer needs the goal of harm minimisation.
All it really does is confuse the public and gloss over tensions in drug policy that are better brought to the surface and debated.
Everything we do in the name of drug policy carries risks, costs and benefits. They cannot be added up in a way that would tell us what policy best minimises drug-related harm.
Instead of committing ourselves to harm minimisation we would be better off simply listing specific problems we wish to reduce, such as heroin-related crime, fatal heroin overdoses, hepatitis C and amphetamine psychosis.
Then we can have an open and frank debate about what harms, risks and benefits matter the most.
Dr Don Weatherburn is the director of the Bureau of Crime Statistics and Research.
