Not what the doctor ordered - NZ Drug Foundation
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A fair dinkum smack shortage
Putting your kids to the test
It’s how we’re advertising
The Great New Zealand Drug Driving Survey
November 2008
Not what the
doctor ordered
Recent research suggests doctor shoppers are flooding the illicit market
with prescribed pills. Just how serious is New Zealand’s prescription
drug misuse problem, and are we equipped to deal with it?
Contents
matters of substance November 2008
Vol 18 No 4
Features
ISSN 1177-200X
02 Cover story 18 Where angels fear to tread 01 Key Events and Dates
matters of substance is published by the Not what the A list of impending
NZ Drug Foundation. All rights reserved.
Neither this publication nor any part
doctor ordered conferences and events
of it may be reproduced without prior especially relevant to those
permission of the NZ Drug Foundation. interested in alcohol and
other drugs.
matters of substance invites feedback
and contributions. If you’re interested in
contributing a guest editorial or article,
21 Guest Editorial
please first contact us: Alcohol is a drug too
editor@drugfoundation.org.nz The Alcohol and other
p +64 4 801 6303 Alison Ritter reviews the
New Zealand Drug Harm Drugs Council of Australia
A full understanding of the Index and finds it useful has adopted a new theme
Brand development/graphic design
Origin Design +64 4 801 6644 seriousness of our prescription to help tackle what is now
for all its faults.
info@origindesign.co.nz a serious national problem.
www.origindesign.co.nz
drug misuse problem is only
now beginning to emerge. 22 Not all beer and skittles 24 Opinion
NZ Drug Foundation
It seems the ‘drug seeker’ This short ‘ride along’ with It’s just not cricket
3rd Floor, 111 Dixon Street is alive and unwell in ex Drug Foundation Director
PO Box 3082, Wellington, New Zealand New Zealand. Richard Boock says the
p +64 4 801 6303 Ross Henderson provides an alcohol industry’s
interesting peek into the contention that sport
08 Following the paper trail
When you have finished with
valuable work he does sponsorship isn’t about
Thailand’s new drug control around alcohol and small increasing consumption
this magazine, please recycle it.
strategy has not exactly been communities. defies common sense and
the brutal “second round of contradicts the facts.
Become a member drug suppression” many 26 Is that really how
feared… at least, so far. we’re drinking? 33 Mythbusters
The NZ Drug Foundation has been
Drinking during hard times
at the heart of major alcohol and 11 Where the bloody It’s commonly believed that
other drug policy debates for over hell is all the heroin?
18 years. During that time, we have we drink more when times
demonstrated a strong commitment get tough economically, but
to advocating policies and practices the data suggests that ain’t
based on the best evidence available. necessarily so.
You can help us. A key strength of the
NZ Drug Foundation lies in its diverse ALAC says its ads News
membership base. As a member of the accurately depict how
NZ Drug Foundation, you will receive
many New Zealanders drink, 29 New Zealand News
information about major alcohol and
other drug policy challenges. You can also but not everyone agrees
Australia has experienced an Free beer, fake IDs, waiting
get involved in our work to find solutions they’re so balanced.
to those challenges.
unprecedented heroin drought, lists and other things – our
and there’s considerable usual overview of drug news
28 The Great New Zealand here at home.
Our membership includes health debate about why. But is
Drug Driving Survey
promoters, primary health and who should get the credit the
community organisations, researchers,
most important question? The Drug Foundation wants 30 World News
students, schools and boards of trustees, to know what Kiwis think
policy makers, and addiction treatment
‘A’ for ecstasy, smoking
agencies and workers. 14 Let’s talk about pot about how drugs affect Kurt Cobain, and glad
No easy answers us when we’re behind tidings for fat smokers –
Membership and subscription enquiries Starting with his own the wheel. these are just some of the
membership@drugfoundation.org.nz international news items
or visit our website.
dear dad, Dennis O’Reilly
muses on our confusing we feature this issue.
Regulars
attitudes and behaviours
www.drugfoundation.org.nz Quotes of Substance
around alcohol and
other drugs. 01 The Director’s Cut Our usual collection of
Election debates have been drug pronouncements
16 A matter of trust dominated by the economy, from around the world
but the significant cost ranging from the wise to
Worried parents resorting
benefits of improved drug the woeful.
to drug tests may also be
testing the relationships policy appear yet again to
they have with their kids. have been overlooked.
matters of substance November 08 www.drugfoundation.org.nz
The Director’s Cut Key Events and Dates
Dangerous Consumptions 3rd International Conference on
Colloquium 2008: Manufacturing Fetal Alcohol Spectrum Disorder
Consumptions 2009
4–5 December, Auckland 11–14 March, Victoria, BC, Canada
This two-day international The conference will be a catalyst
colloquium will explore industrial for change around the globe by
relationships across the areas integrating research and policy into
of gambling, alcohol, tobacco, practice to assist governments,
pharmaceuticals, body parents, services and caregivers
enhancements, fast foods, illegal who strive to prevent FASD.
Political change has come. regarding retail sales. drug use and other areas where www.interprofessional.ubc.ca
The US has their first African- It remains to be seen how consumption of pleasurable
American President, while their coalition parties will commodities creates harm. 1st Conference of the
Labour’s nine-year tenure has influence drug policy. http://130.216.128.177/health/ Connections Project
ended in New Zealand. Both While ACT campaigned dcVI/index.html 25–27 March, Krakow, Poland
elections will impact on drug on law and order, they are
Joining the Dots: Criminal Justice,
policies. known for their criticism of 17th World Conference of Treatment and Harm Reduction
Barack Obama has spoken the current drug law and for Therapeutic Communities will aim to facilitate the
of removing the Federal their support for prevention 6–10 February, Lima, Peru development of knowledge and an
funding ban on needle and education. At this conference, experts from evidence base for how different harm
exchanges, and of expanding United Future has all over the world will explore and reduction and drug free interventions
treatment, including offering previously opposed tobacco share experiences of the range of can be incorporated across criminal
treatment as an alternative to and alcohol control policy and therapeutic community programmes. justice processes.
prison. He has criticised the quashed debate on cannabis Discussions will cover the therapeutic www.connectionsproject.eu
War on Drugs saying, “It’s policy. It would be a shame if community model and the latest
expensive, it’s a similar barrier stymies the scientific discoveries in the treatment International Harm Reduction
of addictions.
counterproductive, and it Misuse of Drugs Act review. Association Conference 2009
doesn’t make sense.” On the The Mäori Party is www.mundolibre.org.pe 19–23 April, Bangkok, Thailand
world stage, we may see the concerned about the health The conference theme is Harm
US promoting progressive, inequalities created by alcohol Drug Policy Symposium – Reduction and Human Rights.
balanced and health-focused and drug harm in Mäori Healthy Drug Law Asia has been consciously chosen
18–20 February, Wellington to host the conference based on
drug policy. communities. They have
What might we expect pedigree on drug policy: Pita A high-level forum for senior and many countries in the region failing
international drug policy officials, to provide vital health and harm
from the new National-led Sharples is known for his
politicians, alcohol and other drug reduction services to which drug
Government? methamphetamine work at
sector leaders and academics to users are entitled.
National have made the Hoani Waititi Marae; Tariana discuss the Misuse of Drugs Act www.ihra.net
very welcome announcement Turia is a previous associate review in the context of rethinking
to double the number of beds health minister; and Hone international drug control.
in prison Drug Treatment Harawira pulls no punches in For more information, contact
Units. The successful his attack on the hypocrisy ross.bell@drugfoundation.org.nz.
implementation of this policy between legal and illegal drugs.
will require resourcing for the There is important work to 3rd International Conference of
treatment workforce and do. Current financial priorities the International Society for the
better management within shouldn’t stop drug policy Study of Drug Policy
Corrections to ensure that the progress: the Law 2–3 March, Vienna, Austria
new beds are fully utilised. Commission’s alcohol and drug The third annual conference is being
In a letter to the Drug reviews deserve continued hosted by the United Nations Office
Foundation, the National political attention, as does the on Drugs and Crime and should be of Making it Happen 2009
Party stated their intention Supply of Liquor and Liquor interest to a wide array of disciplines 12–13 May, Fremantle,
to work for better access to Enforcement Bill inherited including anthropology, economics, Western Australia
mental health and addiction from the previous government. epidemiology, political science, Making it Happen is a unique,
treatment services. They public health and sociology. collaborative event between
Interventions to tackle
would also improve primary poverty and social exclusion www.issdp.org government and non-government
care, provide early must include efforts to reduce organisations across the AOD sector.
School of Addiction 2009 The conference will focus on the
intervention and promote alcohol and drug harm. The
4–6 March, Auckland discussion of best practice initiatives
Integrated Family Health significant cost benefit of
The biennial school, jointly hosted by to respond to clients affected by
Centres that bring together a addressing drug harm as a drug and alcohol issues.
wider range of health services DAPAANZ and the Pacific Centre for
health issue makes economic
Motivation and Change, is offered www.makingithappen2009.com
and professionals into a one sense (as well as being
to experienced clinicians and
stop shop. On alcohol, they socially just and humane). practitioners in the field of Publicise your own
support ALAC’s Culture I look forward to working addiction treatment. event online at
Change Programme and want with the new Government. www.matuaraki.org.nz www.drugfoundation.org.nz/events
to see retailers obey the law Happy reading, Ross Bell.
www.drugfoundation.org.nz matters of substance November 08 01
Cover Story
Not what the
Recent studies show that
misuse of prescription
drugs is as much a
doctor ordered problem in New Zealand
as anywhere else in the
world – possibly more
so because opioids
like heroin aren’t
plentiful here. But a
full understanding of
the problem’s seriousness
is still emerging, which
means we may not have
the structures in place
to deal with it.
Rob Zorn
02 matters of substance November 08 www.drugfoundation.org.nz
According to an International Narcotics hallucinogens (4 million), inhalants In 1990, New Zealand had
Control Board (INCB) report released in (2.1 million) and heroin (328,000) 600 people on the methadone
2007, prescription drug misuse is now a combined.
programme. Now we have
worldwide problem that is increasing Data from the UK are more patchy,
though a 2000 report appearing in the
around 4,000!
rapidly. In fact, in some regions, prescribed
medicines are being abused “in quantities journal Addiction described the size of Dr Geoff Robinson.
similar to or greater than the quantities the market for diverted prescription
of illicitly manufactured heroin, cocaine, drugs as “substantial”.
In Australia, an increasing number of
amphetamine and opioids”.
prescription medicines are being abused.
The Board’s conclusion is borne out
Data from the 2004 National Drug
by research and reports from various
Strategy Household Survey revealed
western countries. In the United States,
that 7.6 percent of Australians had
NZPA/Ross Setford
for example, statistics suggest levels of
used pharmaceuticals for non-medical
prescription drug misuse are second purposes at least once and that the
only to misuse of cannabis. The National most used substances in the 12 months
Center on Addiction and Substance preceding the survey were painkillers
Abuse (CASA) says 6 percent of and tranquillisers. In 2006, morphine
Americans (15.1 million people) was the most commonly reported
reported abusing controlled drugs in pharmaceutical used by injecting users
2003 – higher than the number of according to Australia’s Illicit Drug
those abusing cocaine (5.9 million), Reporting System (IDRS).
www.drugfoundation.org.nz matters of substance November 08 03
Of particular relevance to us is easy/very easy to get, and 50 percent of Stimulants cause increased alertness,
the Tasmanian component of the IDRS, the injecting drug users taking part in insomnia and raised heart rate and
given that state’s geographical similarity the study said opiates were the drugs blood pressure. Those sought include
to New Zealand. Heroin has not most responsible for their drug-related pseudoephedrine-containing products
generally been widely available in problems. and methylphenidate (Ritalin®).
Tasmania, and this is one accepted In April this year, Auckland ‘Drug seekers’, as they are known to
reason why the 2006 IDRS reported it University’s School of Pharmacy health professionals, tend to come from
had higher rates of benzodiazepine released its report Prescription drug all walks of life so it is hard to generalise
injection than other Australian states. misuse: issues for primary care. about their characteristics. While
New Zealand’s National Drug Policy Researchers interviewed 51 general interviewees agreed they were
also acknowledges that our geographical practitioners, community pharmacists predominantly New Zealand European,
isolation makes it difficult to import bulk and other key experts about their
some said they tended most to be aged
quantities of heroin or raw opium into experiences with prescription drug
in their 20s and 30s while others
the country, and therefore, like Tasmania, misuse. The GPs and pharmacists
indicated they were most often over 50.
we are more likely to abuse other opioids indicated that, while it is not generally
Only two interviewees were concerned
such as prescription medicines. a major disruption to their practices,
about teenagers abusing their
Geoff Robinson, Chief Medical they are highly aware of it as an issue.
prescription medication.
Officer at the Capital and Coast District This qualitative study, led by
Males and females seemed to be
Health Board, has no doubt that Professor Janie Sheridan, provides an
excellent overview, from the coalface, as equally represented, though there were
New Zealand’s problem with prescription some general differences in approaches.
drug misuse ranks up there with other it were, of what drugs are typically being
misused, how they are being obtained, Respondents reported that males were
western countries and that a local
and what is being done – individually more likely to use standover tactics while
scarcity of heroin is one main reason why.
and collectively – to deal with the females were more successful at
“In 1990, New Zealand had 600
resulting problems. fabricating stories as to why they need
people on the methadone programme.
The sorts of drugs commonly sought the medicine. Men were more likely to
Now we have around 4,000! That’s a
fall into three main categories – opioids, claim they had physical injuries such
level similar to that of New South Wales.
benzodiazepines and stimulants – as car accidents or that they had been
The difference is that heroin is not
though interviewees differed on which assaulted. Women were more likely to
available here like it has been there,
were mainly targeted in their practices claim emotional anguish, migraines or
so these people aren’t on the programme
or pharmacies. ‘women’s problems’ in the hopes male
because of heroin dependence, but as a
doctors wouldn’t ask too many questions.
result of prescription opioid problems.”
The researchers also pointed out that
While such a massive increase in the
one emerging theme was a distinction
number of people presenting at clinics Drug seekers tend to come between two types of drug seekers.
makes it clear that prescription drugs
from all walks of life so it is ‘Abusers’ are those who seek drugs to
misuse is a serious problem, it’s not easy
to put an accurate finger on the full
hard to generalise about their use or sell for recreational purposes or
extent of that seriousness. There are no characteristics. to knowingly feed an addiction. ‘Over
published data that would provide an users’ are drug seekers who originally
overview, and even what we do know began using the drug for legitimate
is subject to interpretation. purposes such as for chronic pain or
Opioids are synthetic chemical
While the amount of opioids prescribed anxiety. However, misuse has developed
substances mainly used for pain relief.
in New Zealand has more than doubled in over time and escalated to the point of
Those sought include codeine,
the last 15 years, it is very difficult to tell dihydrocodeine tartrate, morphine addiction. ‘Over users’ tended to be
just how much of that prescribed medicine (including morphine sulphate) and considered less of a problem by
is being used legitimately and how much methadone. respondents. They were not perceived
is being diverted and used illicitly. After Benzodiazepines are a class of to be as ‘underhand’ and didn’t fit the
all, the same patient may be doing both psychoactive drug with varying ‘drug addict’ stereotype. They were also
in many cases. hypnotic, sedative, anxiolytic and thought less likely to sell their
A recent New Zealand study muscle-relaxant qualities. They were medications on the illicit market.
indicated that 14 percent of people in reported as widely sought by all The two main methods of acquiring
drug and alcohol treatment were interviewees and include diazepam prescription medications, other than
diagnosed with sedative dependence. (Valium®) clonazepam (Rivotril®) and ‘raiding grandma’s medicine cabinet’,
The 2006 Illicit Drug Monitoring System temazapam (Normison®, Somapam®, are known as ‘doctor shopping’ and
(IDMS) indicated that opiates were Euhypnos®). ‘pharmacy hopping’.
04 matters of substance November 08 www.drugfoundation.org.nz
‘Doctor shoppers’ will visit a number to patients on the programme.
of different doctors in their own area or The methadone is sold or given to
in neighbouring districts seeking someone else. One respondent said that,
multiple prescriptions that they will typically, the methadone diverter would
then present at a number of different return after half an hour claiming their
pharmacies. Sometimes, fraudulent takeaway dose was lost or spilled
IDs are used, but because it is easy in the hopes of receiving another.
in New Zealand to see a doctor on a But diversions are attempted even
one-off basis, these are often not needed. with supervised doses, with the user
Using different pharmacies, or sneaking the dose into a hidden
‘pharmacy hopping’ helps the user hide container while pretending to drink
the extent of his or her prescription it. Another method is to hold the
drug use, but ‘pharmacy hopping’ also methadone in the mouth and spit it
includes the practice of presenting a into a container upon leaving the clinic.
prescription at another pharmacy when Most doctors and pharmacists in
it is refused the first time due to a New Zealand aren’t silly and have
pharmacist’s concerns. become reasonably astute at spotting
The respondents said another prescription drug abusers. There are
way drug seekers attempt to obtain behaviours to watch for including
medication is by presenting for repeat specific requests for a particular drug,
prescriptions before they are due. a refusal to consider alternatives and
Generally, a reason is provided as to why agitated behaviour. Drug seekers are most
the medication is needed early. It has likely to visit surgeries at busy periods
been ‘lost’ or ‘stolen’, or the patient says such as at the end of the day when
they are going on holiday and needing doctors are behind schedule and more
additional supplies to take away. likely to give the benefit of the doubt to
While there are regulations around get through their day’s workload. It is
early prescriptions, pharmacists have also common for drug seekers to target Prescription drug misuse harms
discretion to fill them early. For new practices, pharmacies or doctors,
example, a 30-day repeat prescription including locums.
Harms resulting from prescription medicine
may be collected after 20 days if the Under their codes of conduct, both abuse are similar to those associated with
dispensing pharmacist believes there doctors and pharmacists are bound to act substance abuse in general.
is sufficient reason. within the law and withhold medicines
■■ Physical harms are mainly from
Often, fabricated medical conditions from those who would abuse them.
injecting such as venous thromboses,
are used to fool GPs and hospital clinics, The guidelines may well be very clear, vascular and tissue damage, ulcers
such as invented pain symptoms or fake but respondents indicated the reality and gangrene.
psychological states (e.g. grief) – the is often much less straightforward.
■■ General harms include having unsafe
‘patient’ relying on the fact that most Even when they are suspicious, there
sex, driving while under the influence
doctors would prefer to err on the side of is an understandable reluctance to act. of drugs and the risk of blood-borne
caution and not deny medication, even if Where doctors don’t know a patient, diseases from sharing injecting
they suspect the symptoms are phoney. it can be difficult to be certain they are equipment.
Prescription forging is also faking it without direct evidence, and
■■ There is always the risk of overdose,
reasonably common. This can involve most would prefer to prescribe a small which increases when differing
altering an authentic prescription by amount of medication than make a substances are taken together.
adding drug names to it or by changing mistake and leave someone suffering.
■■ Social harms include isolation and
the amount of the medication prescribed Pharmacists say they can find
a lack of connectedness, loss of
– for example, by inserting an additional themselves in a similar situation. employment, family and relationship
digit to the correct dose. Computer- They are entitled to refuse a prescription breakdowns and engagement in
generated fake prescriptions have also if they are in doubt, and it is common criminal activity to fund addiction.
been used, sometimes even verified with for them to call the prescribing doctor
■■ Financial costs to society can also be
stamps stolen from hospitals or surgeries. to check that a prescription is legitimate. substantial in terms of lost productivity,
The respondents also discussed Even where the pharmacist disagrees a drain on medical and pharmacy
specific diversion methods relating to with the doctor, there is an practice resources, and time spent
obtaining methadone. Most diversion understandable reluctance to question by treatment professionals.
occurs when takeaway doses are given that doctor’s professional integrity or
www.drugfoundation.org.nz matters of substance November 08 05
Recognising signs of
drug seeking and misuse
*from Best Practice Journal, September 2008 competence, especially when the that can be turned to for help or
pharmacist does not have access to the guidance such as drug treatment
Many GPs believe they can easily identify
drug seekers, but they will not all fit the patient’s history or reasons for diagnosis. agencies that may have specific
expected stereotype. Ministry of Health figures suggest knowledge about individuals or the
that, while reckless or criminal general drug scene in the locality.
Drug seekers may be known patients or Methadone providers are particularly
prescribing does occur, it is not
casual attendees to the practice. They may
widespread. Medicines Control, the valuable in this regard.
be dependent on the drug themselves or
sourcing it for illicit sale. Anyone, regardless Ministry’s drug abuse containment arm, GPs and pharmacists are able to
of gender, income, ethnicity, health or actively monitors prescription rates check a register of known drug seekers
employment status, can be a drug seeker. and investigates where a doctor is published in print form by Medicines
prescribing unusual amounts of Control, but this is only useful when the
And not all drug seekers are faking
addictive medicines, either in general drug seeker is using his or her real name.
symptoms. They may have a legitimate
or to the same persons. Around three or Looking up the booklet during a
complaint and, over time, have become
dependent or tolerant and require larger four doctors are approached each month consultation with a suspected drug
doses to function in their daily life. Patients nationwide, but of these, only a few seeker is also considered impractical
with chronic pain, anxiety disorders and would be referred each year to the Police by many doctors and pharmacists.
attention-deficit disorder are at increased or Medical Council.
risk of addiction co-morbidity. Medical Officers of Health in
Some indicators of drug seeking behaviour are: conjunction with Medicines Control If it seems that our
■■ presenting near closing time without make these decisions on a case-by-case institutional response
an appointment basis, unless there is direct Police mechanisms to prescription
intervention.
■■ reporting a recent move into the area, drugs misuse are under-
making validation with a previous According to Geoff Robinson, the
practitioner difficult threshold for what is considered
developed, that is probably a
■■ requesting a specific drug and refusing aberrant prescribing may be too low. reflection of the fact that our
all other suggestions – the patient may “While there can be legitimate understanding of the scale and
claim other medications don’t work, reasons why some doctors prescribe complexity of the problem is
they have an allergy to them or a high more addictive substances than others, still emerging.
tolerance to drugs or report losing the fact is that an incredible amount is
prescriptions diverted to illicit use, and we need
■■ inconsistent symptoms that do not tighter controls on what is given out
match objective evidence or physical Medicines Control can be contacted
and to whom.”
examination directly for advice on what to do about
He says that, while there are some a drug seeking patient or if there is
■■ manipulating behaviour, which may doctors willing to supplement their
include comparing one doctor’s concern about the prescribing habits
incomes by selling unnecessary of a doctor. Suggested additions to the
treatment opinions against another’s,
prescriptions, the majority who over register of known drug seekers can also
offering bribes or making threats
prescribe would be motivated by a be made.
■■ use of multiple doctors
“foolish altruism” where they somehow If it seems that our institutional
■■ assertive personality, often demanding believe they are helping their patient,
immediate action response mechanisms to prescription
or that the patient’s situation would be drugs misuse are underdeveloped,
■■ unusual knowledge of medications worse if their addiction was not fed. that is probably a reflection of the fact
and symptoms, or evasive and vague
As with most professional that our understanding of the scale
answers to history questions
communities, doctors and pharmacists and complexity of the problem is
■■ reluctance to provide personal
have their own unofficial support still emerging.
information such as address or name
networks and liaise with their peers on Respondents to the University of
of regular doctor.
issues around prescription drug misuse. Auckland prescription drug misuse
Many drug seekers will target doctors who This can involve consulting nearby study identified three broad areas in
are new to a practice or doctors who are colleagues about suspected drug seekers which developments could be made to
sympathetic and dislike confrontation.
and the sharing of advice between more better manage prescription drug misuse
A usual patient/doctor relationship is based
and less experienced or knowledgeable in the future.
on mutual respect; however, a drug seeker
has a stronger relationship with the doctors and pharmacists. Some have The first was training and education
prescription than with the doctor. Some even set up fax trees to quickly so that all GPs and pharmacists had a
doctors who are pressured for time would disseminate information about minimum level of understanding around
rather ‘write than fight’. drug seeking activity in their area. prescription drug misuse issues, not just
There are also professional bodies those with knowledgeable colleagues in
06 matters of substance November 08 www.drugfoundation.org.nz
their support networks. The training the drug addict mould most AOD “The National Drug Policy
would include which medications were services are geared towards. contains exactly nine lines on diverted
most targeted and innovations in drug Interestingly, the Medical Council pharmaceuticals and contains no
seeking behaviour (such as forgery of New Zealand’s report Strategies for discernable plan for reducing what
techniques), how to identify and manage Action on the Misuse of Addictive has become an epidemic.”
drug seekers and who to contact when Prescription Drugs made many of the Robinson would like to see the
issues arise. same recommendations back in 1991. Ministry of Health conduct a formal
The second area was access to As Sheridan et al. point out, this indicates review of the issue in conjunction with
electronic information such as an up-to- that “whilst action may have occurred in relevant parties such as The Royal
date national database of known drug the intervening period, the problems New Zealand College of General
seekers/restricted persons, and community remain broadly similar and unresolved”. Practitioners, the treatment sector
databases across pharmacies and practices So what action has occurred in the and the Police.
that would identify a person sourcing intervening period, particularly on the He concedes, however, that getting
potential medicines of abuse from more part of the Ministry of Health? the balance right between optimal pain
than one location. Such a system would One thing that has been done is the control and over prescribing is always
have immense ethical, privacy and misuse introduction of electronic monitoring of going to be difficult and suggests doctors
of data implications, however. controlled drug prescribing, which has need more training and better guidelines
The third concern was for improved made surveillance much easier. Plans to increase their awareness and help
support systems such as national or are afoot to bring in e-prescribing based them get it right more often.
regional standard protocols to guide the on a Swedish model, which will mean “You can put all the prescribing
management of prescription drug prescriptions are no longer given out to controls in place that you like, but it’s
misuse. A targeted specialist support patients. Instead, they will reside in an pretty hard to regulate what happens to
body was also suggested, made up of key online database where they can be the drugs once they’re in the hands of
prescription drug misuse stakeholders accessed by pharmacists according to the the user.
such as the Police, AOD treatment patient’s unique identifier. It is uncertain “It’s essential, therefore, that
representatives and knowledgeable GPs when this will be a reality. prescribing doctors make good decisions
and pharmacists. Lastly, improved Regulations have also been altered so based on a sound understanding of the
support for prescription drug misusers that drugs with a high level of addictive nature and extent of the problem, and
was seen as necessary. Once a potential, such as morphine and Ritalin®, we’re only going to get that across all
prescription has been denied, what can only be given out in 10-day amounts. sectors if all parties work together.”
then? This is especially relevant to “But actually, there’s not been a lot
‘over users’ with legitimate prescribing of change or progress at all,” says Rob Zorn is a Wellington-based writer.
indications who do not necessarily fit Geoff Robinson.
The price on the street
These were Police Prescription drug Quantity Street value
estimates of tablet
Morphine sulphate (30mg) $40–$60 per tablet
prices in 2007.
Morphine sulphate (60mg) $80–$100 per tablet
Morphine sulphate (100mg) $120 per tablet
Halcion (0.25mg) $5–$6 each
Ritalin $10–$15 each
Diazepam (10mg) $5 each
Valium (10mg) $6 each
Rivitrol (2mg) $5 each
Temgesics (0.2mg) $20–$40 each
Duromine (30mg) $5–$20 each
Doloxene (100mg) $5–$10 each
Codeine phosphate (15mg) $10 each
Codeine phosphate (30mg) $15 each
Codeine phosphate (60mg) $30 each
www.drugfoundation.org.nz matters of substance November 08 07
Following the paper
trail – drug control
in Thailand
In the May 2008 Matters of Substance, Martina Melis
provided readers with an overview of the situation of
Thailand’s drug users during the 2003 war on drugs.
“Same same, but different” highlighted worrying signs
that the Thai government’s launch of a new drug
control strategy in 2008 was, in fact, a second round of
drug suppression in the Land of Smiles. In this article,
Pascal Tanguay presents an overview of recent
developments and opportunities in harm reduction
in Thailand.
On 2 April 2008, the Royal Thai drug dependence as a health issue, it is
Government announced a new six-month heavily influenced by the Rehabilitation
drug control strategy effective until 30 Act of 2003 and focuses on short-term
September 2008. The strategy focused on rehabilitation through compulsory
reducing the number of traffickers, drug treatment and incarceration. It
users and vulnerable people, as well as on encourages blacklisting through
increasing and intensifying drug control ‘community support’, and definitions of
efforts. It also sought to increase the role target groups are fluid and ill-defined.
of civil society in response to drugs. Further approaches presented point to
The strategy was to be supported by an increased law enforcement responses
action plan that was never produced. and the intensification of their efforts
In the six months during which the through capacity building and increasing
manpower.
strategy was implemented, local
It is important to note that the
organisations in Thailand working
strategy includes provisions that could
with drug users reported human rights
open the door to harm reduction
Kirk Hargreaves/The Press
violations on a much smaller scale than
implementation and policy support.
during the 2003 war on drugs. In that
In addition, collaboration with civil
sense, the second chapter of the much
society is highlighted in several areas
feared war on drugs has yet to start.
outside blacklisting – although the
Piyabutr Nakapiew, manager of the proposed role of civil society seems to be
Piyabutr Nakapiew is the manager of O-zone, a O-zone drop-in centre in Bangkok says,
Bangkok drop-in centre for injecting drug users.
“There was [a war on drugs] but perhaps
less aggressively implemented than the I think lessons were learned
previous one. I think lessons were from 2003 when 2,500 people
learned from 2003 when 2,500 people
who used drugs were killed.
who used drugs were killed.”
Significantly, the strategy is silent on Piyabutr Nakapiew.
HIV/AIDS. Although it acknowledges
08 matters of substance November 08 www.drugfoundation.org.nzRecommendations from Thai civil
society groups at the UNAIDS
Programme Coordinating Board
Thai civil society groups consider the use of
punitive measures, especially violence, in
drug control efforts to be ineffective and
counterproductive to HIV/AIDS prevention,
treatment, care and support.
They encourage the Thai government to
consider implementation of a national
harm reduction policy and to review
carefully the drug control strategy issued
on 2 April, including revising laws and
policies that create barriers to treatment.
Thai civil society groups also recommend
that a comprehensive health scheme
delivered in a friendly environment,
focusing on prevention, treatment, care
and support, be accessible to vulnerable
communities (including intravenous drug
users, migrants, sexual minorities, prisoners,
sex workers and so on) in order to achieve
Universal Access before 2010.
Civil society groups, particularly people
who are using or recovering from drug
dependence, recommend they be involved in
development and implementation of policies
to endorse law enforcement responses. reduction, the 12D, with representatives and interventions that affect their lives and
When promoting rehabilitation, the from a number of civil society groups livelihoods, especially in the areas of drug,
strategy stresses reduction of stigma and including the Foundation for AIDS health, social care and sustainable financing
to ensure support for building their capacity.
discrimination, and social reintegration, Rights, the Thai Drug Users’ Network
especially for recovered drug users. and the Asian Harm Reduction Network. Civil society group representatives consider
Over the course of the past six In mid-October, the Global Fund that their rights – sexual and reproductive
health rights and rights to treatment,
months, efforts have been made by many announced that Thailand’s Round 8
shelter and work – should be respected
stakeholders to work alongside the Office proposal had been accepted, with a strong
regardless of gender, citizenship, lifestyle
of the Narcotics Control Board (ONCB) harm reduction component. In addition, and so on.
and other government agencies to lobby an independent proposal was approved
Civil society group representatives
for a balanced action plan to support the in August supporting local NGOs to
recommend that relevant government
drug control strategy. The UNAIDS deliver harm reduction services. agencies work to change popular attitudes
Programme Coordinating Board (PCB) Meanwhile, AHRN has been lending in order to reduce stigma and discrimination.
meeting set the stage with a support to the ONCB by building
demonstration organised by the Thai technical capacity and generating greater THAILAND
Network of People Living with HIV/ awareness about harm reduction among MYANMAR
LAOS
AIDS (TNP+) and the Thai Treatment drug control officials and by providing
Action Group (TTAG). Demonstrators exposure to effective models and key
from several civil society groups had stakeholders in the region. In parallel, THAILAND
banners highlighting key advocacy the Asian Consortium on Drug Use, HIV/
issues discussed in previous consultation AIDS and Poverty has invited the ONCB BANGKOK
CAMBODIA
meetings supported by AHRN. and other Thai parliamentarians to play INDIAN
OCEAN
Recently, the Thai government important roles in regional platforms
GULF OF
included methadone in the universal around drug use and HIV/AIDS. THAILAND
healthcare scheme, a decision influenced While the latest drug control strategy
by months of advocacy work by several has significant shortcomings, it does 0 200 miles
leading local NGOs. This also led to the provide an interesting backdrop for MALAYSIA
0 200 km
formation of a working group on harm considering the future of harm reduction
www.drugfoundation.org.nz matters of substance November 08 09in Thailand and analysing salient
developments. Indeed, some recent
events and the level of engagement of
all key stakeholders – including the
Thai government – are pointing to
growing interest in harm reduction
and in addressing drug use through
evidence-based approaches. Yet, to
reduce trafficking and drug use, the
latest policy document proposes
approaches and mechanisms that are
not supported by evidence.
“The Thai government still believes
that forcing people who use drugs into
rehabilitation programmes will lead to
abstinence,” says Mr Nakapiew. “This
approach systematically ignores the fact
that, to achieve sustainable abstinence,
drug users must want to quit drugs and
that forcing treatment upon people will
not achieve expected outcomes.”
Although a greater number of
This approach decision and policy makers are
systematically ignores increasingly exposed to harm reduction
the fact that, to achieve approaches, without strong commitment
sustainable abstinence, drug from the highest levels of political
leadership, the integration of HIV/AIDS
users must want to quit drugs
alongside drug demand and supply
and that forcing treatment reduction in Thailand’s drug control
upon people will not achieve efforts will remain elusive, and outreach
expected outcomes. workers will remain without legal
Piyabutr Nakapiew. protection for delivering HIV/AIDS
UNAIDS officials meet Thai health advocates
prevention services to people who use
drugs. Meanwhile, Thai civil society
groups are preparing for the April 2009
International Harm Reduction
Conference in Bangkok to ensure further
discussion on harm reduction and drug
control strategies in Thailand.
In the context of the current political
changes and tensions in Thailand, it is
difficult to assess when the next drug
control strategy will be released or to
predict what approaches will be
proposed by the Thai government.
The recommendations formulated by
Thai civil society groups at the outset
of the 2003 war on drugs and those
formulated at the PCB are indeed more
important than ever in guiding policy
changes in drug control in Thailand.
Pascal Tanguay is Communications Manager
at the Asian Harm Reduction Network (AHRN)
Thai Police in Thailand, www.ahrn.net.
10 matters of substance November 08 www.drugfoundation.org.nzExpecting grains – the Australian
heroin drought debate
Australians have lamented low rainfall for most of this century. But the
Lucky Country’s population of heroin users has experienced a different kind
of drought; that of their drug of choice. The Big H has been thin on the
ground since 2001, and many commentators say this is Australia’s most
severe and long-lasting heroin drought, but also the best documented ever in
the world. The causes behind this phenomenon have sparked a lot of interest,
research and opinion pieces. Media reports and policy makers generally
accepted that the heroin drought resulted mostly from law enforcement
efforts, but as Martina Melis describes, there were multiple factors involved.
In August 2008, the International The most sensible conclusion a
Journal of Drug Policy devoted a special critical reader will come to is that
issue to an interesting discussion of the there is clearly insufficient evidence
possible causes and consequences of supporting any single factor as the
Australia’s 2001 heroin drought. critical one behind the drought. As is
A number of articles analysed four often the case in drug matters, multiple
possible collections of causes and rated factors must be considered for a useful
them quite differently in terms of and sensible explanation to be found
likelihood: and so lessons can be learned.
1. Successful drug seizures, the
progressive switch from heroin to Let’s step back to the beginning. Martina
ATS production and the increased In the 1990s, Australia’s heroin Melis
consumption of heroin en route market grew rapidly. Data from the
to Australia. Australian National Household Surveys
2. Law enforcement’s disruption of that time show heroin use in the
of large trafficking syndicates. 1990s was doubling every two or three
3. A crackdown on opium producers years. Figures on heroin purity, price
in source countries. and opioid overdoses – the latter rising
4. Adverse climatic conditions causing four-fold between 1990 and 1999 –
a prolonged reduction in opium supported the idea that Australia was
availability. experiencing a heroin ‘glut’.
www.drugfoundation.org.nz matters of substance November 08 11In 2001, the scene changed government accountability has increased declined at about the same time.
dramatically. Reports from Sydney first, pressures on policy makers to justify Another common argument used
and from other parts of Australia soon policy investments and provide in support of law enforcement relates
after, indicated a drastic reduction in scientific-based evidence in support of to actions aimed at disrupting drug
heroin availability and purity, and an policy decisions. In the case of funding trafficking structures and operations.
increase in price for all major heroin for supply reduction efforts, this has It refers particularly to the arrest of key
markets. The number of deaths caused been difficult to achieve.” players in the heroin supply chain and
by overdoses dropped from 1,116 in One wonders whether the bold the possible impacts this has on the
1999 to 357 in 2003 – a change largely attempts to attribute the shortage to amount of heroin imported into
and credibly attributed to the heroin improved law enforcement were Australia.
shortage. somehow influenced by the need to This may well have had some effects.
Law enforcement and ‘tough on justify increased law enforcement However, we’ve learned from Colombia,
drugs’ champions were quick to claim funding in 1998 as a result of the Panama and even Myanmar (the
credit for these changes, asserting that National Illicit Drug Strategy. retirement of drug lord Khun Sa)
increased intensity of law enforcement Secondly, the claim ignores the that, where large cartels are disrupted,
operations was the fundamental cause of essential climatic changes that were reduction in supply tends to last only
reduced heroin availability. Comparative happening in the countries of origin. as long as it takes for drug trafficking to
statistical data on seizures and estimates Australia’s almost exclusive heroin reorganise and new players to enter the
of the heroin market pre- and post- supplier is Myanmar. In 1999, severe game. In addition, and to add some more
seizure sizes were used to prove the droughts in Myanmar’s poppy growing complexity, it should also be noted that
drought was caused primarily by the areas caused a significant decline in the drought happened at a time when
interception of drug supplies at production and cultivation for the third the production of amphetamines was
destination (Australia). year in a row. Wodak writes, “It seems sharply increasing in Asia. The
Two comments can be easily made in entirely plausible that a reduction in possibility of heroin traffickers switching
response to such claims. Firstly, the very heroin production in a source country to the amphetamines business therefore
nature of this illicit business means data may result in a reduction with different cannot be ruled out.
and figures related to how accurately timing and severity in different The discussion goes on, and many
seized quantities represent a particular destination countries.” other issues are raised by different
percentage of the overall drug market or And although some reject the climate authors. However, it is also time to note
the overall number of drug users are argument because reduction in heroin that, while there is an abundance of
only ever ‘best guesses’ and hard to supply only affected Australia, it theses and antitheses on the causes of
prove as facts. appears that availability in Canada the heroin drought, comparatively
De Beck and Wood point out in their – where there had not been any change little research and analysis has been
contribution that “the effort to promote in law enforcement funding – also undertaken to investigate its effects.
12 matters of substance November 08 www.drugfoundation.org.nzQuotes of Substance
Today in France, the sight of
a bottle of wine has become as
offensive as a picture of war
or pornography.
Daniel Lorson, from an industry body of
champagne producers, after a French court
ruled the internet should be included in
strict laws regarding alcohol advertising.
We’re not trying to encourage
drinking, but the cathedral has to
find ways of meeting people on
their territory. Cathedral wine
bars should be seen as a potential
commercial operation with profits
going into the upkeep of the
building and paying for
evangelistic work.
Mark Hope-Urwin, Director of Hospitality
Some studies on effects have been done, to one single factor is of little use. and Welcome at Birmingham Cathedral on
and they do offer important insights and Instead, it is clear that far too little space plans to raise the cathedral’s profile with a
possible lessons for the future. For example, has been allocated to investigating the chain of wine bars.
although heroin prices increased consequences of the heroin drought,
significantly, a large proportion of how a change in supply affects drug
injectors did not stop injecting drugs. users’ behaviours and whether supply Under the thin veneer of
They simply switched to the injection reduction is an effective strategy to
sophistication that 20 years of
of more readily available cocaine and reduce drug use.
liberalised licensing laws gave us,
methamphetamines. Correspondingly,
we’re a state steeped in
Ultimately, the understanding and
service providers found themselves
wowserism.
learning from the effects of the drought
having to quickly perform treatment might have been the lesson for policy and Michael Hardin on a 2am lockout imposed
switching. Used to providing services to practice that should have been debated. on Melbourne bars and clubs, which began
heroin users, they were suddenly asked in October.
to deal with stimulant users, their Martina Melis is a senior policy analyst at the
increased violent behaviour and an New Zealand Drug Foundation.
overall steep rise in amphetamine- This is another one of those
related psychosis. Very often, they pretty shonky industry surveys.
were not prepared for this. AUSTRALIA AND MYANMAR I mean, shock horror that the
If the heroin drought impacted spirits industry asks bottle shop
positively on heroin use and heroin- owners what they think of an
related deaths, it is reasonable to wonder alcohol tax, and they say they
if positive impacts did indeed stretch
MYANMAR don’t like it – well, there are no
across the whole drugs scene. One might YANGON
surprises there.
also question the narrow focus of Australian Health Minister Nicola Roxon
rejoicing at the suppression of one dismisses research by the Distilled Spirits
substance when another one – with its Industry Council of Australia showing,
characteristics, dangers, associated 88 percent of liquor retailers believed
harms and differing response strategies INDIAN tax increases had not reduced alcohol
OCEAN
– waits just around the corner to take or consumption.
AUSTRALIA
share the central stage.
In conclusion, it is clear that the CANBERRA
heroin shortage was caused by a number
of interrelated factors and that
continued on page 20
attempting to attribute it solely or largely
www.drugfoundation.org.nz matters of substance November 08 13CAYAD worker Denis O’Reilly has spent a lot of time My dad, Dinny O’Reilly, was a kind
and hardworking man who raised his
around either alcohol or drugs in one way or another. six kids to be good and contributing
In this short life story, he muses on the confused citizens. We had a family business in
Timaru, a service station that was open
nature of our attitudes towards legal and illicit drugs. seven days a week. It was not only the
focus of our family’s life, it also served
as the fulcrum for an Irish Catholic
community of neighbours and friends.
The link of the ‘Faith’ was one thing,
but there were others too – a love of
horseracing and a genetic predisposition
towards alcohol in all its forms, but
preferably good whisky. The tyre room,
where dad repaired punctures and
vulcanised tyres, was a de facto bar.
The big tank where we tested tubes for
leaks served as a useful beer chiller, and
Dad’s friends and relatives would pop in
14 matters of substance November 08 www.drugfoundation.org.nzand chat to him whilst he worked, children and a wife to care for, and my The drivers to our drug taking are
and generally a beer or two would earnings were not enough to adequately essentially psychological, which
be consumed. care for their increasing needs. suggests we need health-based strategies
We’d always be well stocked with Ten o’clock closing had just been to drive down demand. I don’t think
crates, and in the days of six o’clock introduced, and Jake the Muss stalked there is much debate about that. But
closing, it would not be unknown for the streets. Large-scale drunken brawls when it comes to controlling drugs – that
one of his mates to come down to the were standard fare. Marijuana was is, reducing supply – we lose consensus.
garage and grab a crate or two for starting to be used socially, and it didn’t There are powerful lobbies around
replacement the next day. Dad would take a degree in sociology to observe the continued sale of legal drugs such as
have bridled at the accusation of being that some people were a lot nicer to alcohol and tobacco. That’s because
a ‘sly grogger’, but I’m pretty sure that deal with when they had been toking as some people make lots of money out of
a licensing inspector may have come them. Few people would argue about the
opposed to drinking. In fact, when there
to that conclusion. harm done by consumption of alcohol
was no dope around, we knew we were
Timaru is a port town, and many and cigarettes but both are currently sold
going to have a very heavy and violent
‘wharfies’ were amongst his customers at corner dairies.
night on the door.
and friends. Every now and then, there’d Despite the fact that 4,700
Fast forward from the 1970s to the
be conspiratorial discussion in the tyre New Zealanders are said to die annually
new millennium and the widespread use
room with one of the wharfies. The lube from smoking, a major political party
of methamphetamine. For the past five
bay doors would be opened, a hulking has recently rejected the move to keep
Chevy would be driven in, and boxes of years, driven by the death of friends,
I’ve worked really hard to build cigarettes out of sight on the basis that
whisky would be unloaded. this would be an interference by
community resilience against this
‘Nanny State’.
particular substance. In some quarters,
Yet, when it comes to those
there are now ‘P free’ zones where
substances we deem illicit, regardless
It didn’t take a degree in groups won’t tolerate the presence of
of any balanced scorecard assessing
sociology to observe that some methamphetamine.
their respective harm impacts against
people were a lot nicer to deal A couple of weeks ago, there was a
alcohol and tobacco, we simply turn
with when they had been toking party amongst such a group. Because
to prohibition, despite its proven
booze is legal, readily available, cheap,
as opposed to drinking. ineffectiveness. The accelerating
strong and so easily drinkable in the
prison population reflects that fact.
form of RTDs, it has again become the
Do illicit drugs cause harm?
primary drug of choice.
Once, I can remember Dad, having Absolutely. Do they cause worse harm
The partygoers over imbibed, and
consumed some of the ‘holy wather’ as than legal drugs? On balance, I’m not
a nasty fight broke out. People were
he called it, putting bottles of whisky in too sure. I don’t have any easy answers
injured, and property was damaged.
a wheelbarrow and delivering orders to the conundrum of legalisation or
Moreover, family turned against family, decriminalisation of particular
to neighbours up and down the street.
and it has taken a lot of körero to calm substances. But I am my father’s son,
It was all done with a twinkle in the eye
things down. In reviewing what had and for some reason, my particular
and the celebration of rebelliousness
gone down, one of the peacemakers – poison is legal and comes in a bottle.
that is a mark of our race.
a non-drinker – said to me, “Bro, this
If you had accused him of being a
is getting like the 1970s again. I’m
‘drug smuggler’, he would have roared
committed to our (no P) kaupapa but
with outrage. He hated drugs and all that
they seemed to represent. When I was don’t you think we should just go back
18, I managed to score a little bit of hash. to smoking dope and lay off the booze?”
He found out, and the furore that The received wisdom is that we take
followed made the current concern drugs for a variety of reasons: to cope, to
around the collapse of Wall St pale in self medicate, to forget our troubles and
comparison. I could have said Hail woes, to find structure, to give some
Marys forever and crawled around the theme and purpose to our lives, and for
Stones of Knock for the rest of my life status – to be part of the scene.
and it would not have assuaged my guilt. At a societal level, we try to control
Denis O’Reilly is a social activist, coach,
If only it had been whisky! drugs because of intoxication, addiction,
businessman and a Community Action Youth
Later in life, and living in Wellington, impaired decision making, the potential
and Drugs worker with Consultancy Advocacy
I moonlighted as a bouncer for some to harm others and the need to look after and Research Trust and Mokai Whänau Ora.
Greek nightclub owners. I had two ourselves.
www.drugfoundation.org.nz matters of substance November 08 15You can also read
