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Key terms
and
concepts
Psychoactive drug
classification
Why people use drugs:
fulfilling specific
functions
Chapter 1
Setting the Scene
Trevor King, Alison Ritter and Margaret Hamilton
Drug-related harm
Drug use terminology:
labels matter
Theories of drug
dependence
Ways of preventing or
reducing drug-related
harm
Brief overview
1 In this chapter we define the term psychoactive drugs and provide a
system for classifying drugs according to typical central nervous system
effects (depressants, stimulants and hallucinogens).
2 We outline the reasons people consume drugs (e.g. for pleasure), and
consider the short- and long-term harms associated with drug use
(including dependence for a small proportion of drug users).
3 We summarise a number of theories of drug use and dependence, giving
particular attention to the most common: disease, neurobiological,
cognitive–behavioural and biopsychosocial theories.
4 We examine the issue of drug-related terminology and suggest that some
terms (e.g. addict, alcoholic and injecting drug user) are not benign and
can result in stigmatisation. Although psychoactive drugs is possibly the
most inclusive term for the category, in this book we have chosen to use
alcohol and other drugs (AOD) instead.
5 There is varying potential for drug-related harm in different parts of
Australian society, and we summarise issues for specific sub-populations
such as young people, Indigenous populations, women, the elderly, and
those from culturally and linguistically diverse backgrounds.
6 We conclude the chapter by introducing some of the societal responses
or controls designed to prevent or reduce drug-related harm, including
laws and regulations, policing, education and persuasion campaigns, and
alcohol and other drug treatments and strategies.
3
4
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PART ONE: FOUNDATIONS OF DRUG USE IN AUSTRALIAN SOCIETY
Introduction
Drug use: This term
This chapter provides an overview of some basic drug use issues, prior
usually refers to the
to the more in-depth analyses presented in later chapters. We explore
non-problematic use
of an illegal drug.
some of the benefits of drug use, including pleasure, coping with stress
and providing a sense of belonging. We also consider the short- and longterm harms associated with drug use (including dependence, for a small
proportion of drug users), and introduce some of the societal responses or
controls designed to prevent or reduce drug-related harm.
Psychoactive drugs:
Psychoactive drug use has been a widespread phenomenon in most
Any single chemical
societies for at least 10,000 years. Over this time, cultural differences have
compound that
interacts with the
function of our central
nervous system (i.e.
the brain and spinal
influenced the kinds of drugs used and the ways in which different societies
take drugs. Drugs clearly provide benefits, but are also associated with a
wide range of health and social problems. When we talk of psychoactive
drugs, we are referring to any single chemical compound that interacts
cord), and changes
with the function of our central nervous system (i.e. the brain and spinal
subjective experience
cord), and changes subjective experience or behaviour, or both (Muller &
or behaviour, or both.
Schumann, 2011). Psychoactive drugs are often described as mood-altering,
Also described as
as they can change the way we think, feel or act.
‘mood-altering’, as
they can change the
way we think, feel or
act. See Table 1.1 for
a list of psychoactive
drug classifications.
Classification of psychoactive
drugs
Mood-altering drugs:
Psychoactive drugs are classified according to the effects they have on the
See psychoactive
central nervous system (CNS). Although some drugs have a range of effects
drugs.
that can change the more they are taken, generally psychoactive drugs fall
into the three categories outlined in Table 1.1.
Table 1.1. Psychoactive drug classification
Depressants suppress, inhibit or decrease central nervous system (CNS)
activity. Drugs in this category include alcohol, sedatives (e.g. benzodiazepines
such as Valium), hypnotics (sleeping pills such as Rohypnol), and opioid drugs
such as heroin, morphine and methadone. Generally, if taken in small doses,
these drugs produce relaxation or drowsiness. In large doses they can lower
respiration and heart rate to the point of unconsciousness or death.
(Continues)
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Chapter 1: Setting the Scene
Stimulants enhance or increase activity in the CNS. These drugs typically
increase blood pressure and heart rate, increase respiration and generally
increase arousal. Drugs in this category include amphetamines, MDMA
(ecstasy), cocaine, caffeine and nicotine. In low doses they can increase
energy, feelings of well-being and alertness. Heavy use can result in irritability
and insomnia. Stimulants can also produce delusions and hallucinations.
Hallucinogens, sometimes referred to as psychedelics, act on the CNS to alter
perceptions, thinking, feelings, and sense of time and place. Some of the
adverse effects include unpleasant and frightening hallucinatory experiences
(‘bad trips’), post-hallucinogen perception disorder (‘flashbacks’), delusions
and paranoia. Drugs in this category include lysergic acid diethylamide (LSD or
acid), mescaline (peyote cactus) and psilocybin (magic mushrooms). Cannabis
may have hallucinogenic and/or depressant effects.
Describing
drugs
as
depressants,
stimulants
or
hallucinogens,
according to the biological effect they have, serves as a way to classify
them. However, the subjective effects may be highly variable. For example,
alcohol is a central nervous system depressant, but in low doses many
users describe it as stimulating them behaviourally. It can dull or depress
those parts of the brain that contribute to feelings of social anxiety, causing
Come down: This
most drinkers to feel more relaxed and uninhibited. Together with the
is a slang term
social context of use, this can result in drinkers being more excitable and
describing the period
gregarious. At higher doses, however, it contributes to a range of effects,
in which the effects of
including drowsiness and, eventually, sleep. If consumption continues, it
is possible to die from an overdose of alcohol, due to its depressant effect
on the central nervous system. What an individual experiences will vary
depending on their state at the time, what other drugs they are using, and
their expectations of what the drug will do, as well as the influence of
a psychoactive drug
or the psychological
high associated with
its use are gradually
reversed. This term
can also refer to
the situation they are in. Zinberg (1984) refers to this as the interaction of
the sequential use
‘drug’, ‘set’ and ‘setting’.
of drugs to reverse
The reality of drug use today is that people are not necessarily aware of
the physiological effects of the drugs that they take, and many people use
multiple drugs – sometimes at the same time (e.g. drinking and smoking,
using heroin simultaneously with benzodiazepines) and sometimes
the effects of drugs
used previously;
for example, using
cannabis to reverse
the effects of a
sequentially; for example, amphetamines followed by cannabis, to assist
stimulant drug such
with the come down.
as ecstasy.
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The extent and nature
of psychoactive drug use
in Australia
Australians have demonstrated a great propensity to consume a range of
psychoactive drugs. For many of us, drug use is part of our day-to-day
lives. Given that caffeine is also a psychoactive drug, and present in tea
and coffee, as well as cola drinks and most chocolates, it is likely that
there are very few people in this country who do not consume some sort
of psychoactive drug on occasion. Over 80% of Australians consume some
alcohol each year; 20%, or 3.7 million people, drink at a level that places
them at risk of alcohol-related injury or developing alcohol-related disease
over their lifetime. That level is more than two standard drinks (defined as
containing 10 grams of alcohol) on any single drinking occasion (National
Health and Medical Research Council, 2009). Forty per cent, or 5.2 million
people, drink at levels that place them at risk of short-term harm such as
accidental injury, at least once each year (AIHW, 2011a). A recent survey
revealed that over a third of drinkers drink specifically to get drunk (FARE,
2012). These levels of drinking also place others at risk and cause harm to
more than just the drinker.
In what is a continuing good news story in Australia, the number
of people smoking tobacco on a daily basis (15%) shows a continuing
downward trend that commenced in 1993, at a time when 25% of the
population smoked daily (AIHW, 2011a). However, the number of smokers
in Australia still remains too high (3.3 million) and represents an ongoing
public health challenge.
Cannabis is our most commonly used illegal drug, with over a third of
Australians using it in their lifetime and about 10% (1.9 million people)
using it in the previous year. Ecstasy is the next most commonly used illegal
drug, with 10% of people over 14 years indicating that they have tried it
and 3.0%, mostly people in their twenties, using the drug once or more in
the previous year. Heroin use is low, with 0.2% of the population (37,000
people) in 2010 reporting use in the previous year. However, it is worth
noting that the rate of heroin and other illegal drug use is under-reported
for a variety of reasons, discussed in depth in Chapter 4, Epidemiology:
analysing patterns of drug use and harms. The non-medical use of
pharmaceutical drugs such as pain killers and sleeping pills is rising. In
2010 over 4% of the population, or 800,000 people, used pharmaceutical
drugs in this way (AIHW, 2011a). This brief overview shows that many
Australians choose to use a range of legal and illegal drugs occasionally or
on a regular basis.
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Chapter 1: Setting the Scene
Why do people use
psychoactive drugs?
The literature is replete with statements and theories as to why people
initially take drugs and the reasons for continued use. These reasons are
summarised in Box 1.1.
For pleasure
We know that most people who take a psychoactive drug on a regular basis do
so because the drug produces pleasurable effects and enhances aspects of their
lives, such as social interaction or the belief that the drug will facilitate sexual
activity. Somewhat surprisingly, as noted by Kane Race, the concept of drug use for
pleasure is largely absent from contemporary public health discourse (Race, 2009).
To manage aspects of living
Box 1.1
Why people
consume
drugs
Self-medication
hypothesis: The
Some people use drugs to maintain particular roles or to assist them to work.
Examples include long-haul truck drivers or students using stimulants to
fight fatigue and exhaustion. This is sometimes called functional use (Muller &
Schumann, 2011).
use of unprescribed
medications or illegal
drugs to relieve
stress, anxiety or
other distressful
psychological states.
To manage emotions
Since psychoactive drugs can affect the way we feel, they are used to counter some
feelings and enhance others, including to calm down, relieve stress or reduce
Normative drug
use: Expectations
about drinking or
anxiety. In those experiencing distressful psychological states, drug use is a
other drug use
compensatory means of ‘self-soothing’ and is referred to as the self-medication
based on perceived
hypothesis (Khantzian, 2003).
use by peers. For
To increase the sense of belonging
person forms the
Young people still forming their own ideas and identity are often singled out as
being highly influenced by peers in both positive and negative ways (Lee & Lok,
2012). However, people of all ages use drugs because others they know, like, or
want to be like, use them. We are influenced by our peers and those we admire, and
if they use or are portrayed as using drugs, we are more likely to do so.
To do what is regarded as ‘normal’ or ‘usual’
Related to the point above, sometimes people use drugs because they think it is
normal to do so. Research has found that many young people believe their peers
are using drugs, even when the majority are not (Perkins, 2012). This builds on peer
pressure and a desire to join in, and is sometimes called normative drug use.
Trevor King, Alison Ritter and Margaret Hamilton
example, if a young
view that ‘everyone’
is using a drug, this
may increase the
likelihood that they
will also use it to
conform to what they
perceive to be the
norm. Perceptions
of use are often
far greater than
actual use.
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To expand consciousness
Hallucinogens such as LSD are used to change sensation and perception; it has
been claimed that they can increase self-understanding and self-discovery (Boys &
Marsden, 2003).
To counteract the effects of another drug
Sometimes a person who uses drugs will want to change or reverse the effects of
one drug by using another; for example, drinking caffeine to counteract the effect of
alcohol. Sometimes people use sedative or depressant drugs, including alcohol, to
‘come down’ after using strong stimulants such as ecstasy. Some people also use
drugs to manage the side-effects of prescribed medications.
To maintain physiological dependence and/or
avoid withdrawal
For those who become dependent upon drugs, it is necessary to continue use to
maintain equilibrium and avoid a withdrawal state.
This brief overview highlights that psychoactive drugs are used for
specific purposes and, for most people, this can be an enjoyable, sometimes
euphoric experience.
In addition to these psychological and social explanations of drug
use, the cultural and economic milieu in which we live is also a powerful
determinant of our patterns of drug use. Issues such as the supply and
availability of drugs, and the extent of advertising or promotion influences
drug choice, and the extent and nature of consumption.
What are the harms
associated with psychoactive
drugs?
First, the classification of psychoactive drugs as either legal or illegal is not
especially related to the level of harm that can result from their use or the
potential for dependence. Drugs such as alcohol and heroin can be used
in non-problematic ways or in ways that can lead to a range of problems
based on occasional use (e.g. problems associated with intoxication such
as impaired driving) or regular use (e.g. the development of serious health
problems). Harms can arise from both the behaviour (e.g. legal problems
resulting from the use of illegal drugs) and the short- and long-term
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Chapter 1: Setting the Scene
social and health effects associated with acute episodes of heavy use or
long-term, regular, high-level consumption. For example, a single episode
of heavy drinking is likely to result in intoxication when the drinker may
Intoxication:
experience immediate problems, including involvement in motor vehicle
A condition that
accidents, assaults, injury and domestic violence. The pattern of regular,
high-level consumption of alcohol has been causally linked to more than
sixty different long-term medical conditions, including cirrhosis of the
liver, and heart and circulatory problems. It also raises the risks for various
cancers (mouth, throat, oesophagus, breast and bowel). Four per cent or
follows psychoactive
drug use, evidenced
by disturbances
in the level of
consciousness,
cognition, perception,
approximately 2.25 million deaths world-wide in 2004 were attributable to
judgment, affect
the harmful use of alcohol (World Health Organization, 2011).
or behaviour.
Those around the drinker can also be affected; with recent Australian
research highlighting that almost three-quarters of all adults in Australia,
or around 10 million people, were negatively affected by someone else’s
drinking. The issues ranged from minor annoyance, such as street noise
Intoxication depends
on the type and dose
of a drug, tolerance
to the drug and
personal expectations
and minor property damage, to physical violence or death. It included more
about the effects of
than 70,000 Australian victims of alcohol-related assaults (24,000 were
the drug.
cases of domestic violence). In 2007–2008 approximately 20,000 Australian
children were victims of substantiated alcohol-related child abuse.
The estimated annual cost of heavy drinkers on those around them in
2007–2008 was $14 billion (Laslett et al., 2010).
Smoking continues to be Australia’s largest preventable cause of death
and disease. It has been estimated that since 1950, when clear evidence on
the dangers of tobacco first became available, more than 900,000 Australians
have died prematurely because they smoked. Over three million people, or
approximately 15% of Australians, still smoke at least weekly. The harms
associated with tobacco use have been well documented. These include
lung cancer, cardio-vascular disease, emphysema and other chronic
illnesses. In total, tobacco is responsible for 8% of the burden of disease
among Australians and costs our community approximately $12 billion
every year (AIHW, 2011a).
The most commonly used illegal drug in Australia is cannabis,
although there has been an overall downward trend in cannabis use in
Australia since 1995. In 2010, about 10% of the population reported
using the drug in the preceding twelve months. About 21% of this group
use it on a weekly or more frequent basis. Most cannabis users do not
progress to problematic use; however, regular cannabis use is a predictor
of subsequent problems, including respiratory issues, poorer educational
performance and earlier drop-out, as well as problems associated with
driving under the influence. There is also evidence to suggest increased
Trevor King, Alison Ritter and Margaret Hamilton
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PART ONE: FOUNDATIONS OF DRUG USE IN AUSTRALIAN SOCIETY
rates of depression, anxiety and suicidal thoughts among heavy cannabis
users. Recently, there has been much scientific and public debate about the
role of cannabis in the development of serious mental illness; for example,
psychosis. It is unclear whether regular, heavy use of cannabis ‘causes’
psychosis, but it is associated with increased risk of the disease in people
who are predisposed to psychotic illness, based on family history. While
the cause and effect debate will continue, there is growing consensus
that cannabis is not a benign substance. There are risks associated with
early initiation and regular or heavy use of cannabis, particular for those
who may be predisposed to mental health issues, as evidenced by family
history.
Although the number of people using drugs such as heroin is relatively
low, the harm associated with that use, particularly if the drug is injected,
can be serious. The health consequences can include HIV, hepatitis B and
Dependence: See
hepatitis C infection. Fatal and non-fatal overdose on these drugs is also a
substance use
serious risk. Other problems are lifestyle related, including incarceration,
disorders.
financial difficulties, homelessness, and difficulty gaining and holding
Tolerance: This
refers to the way
down a job.
There are many other costs that society bears in relation to psychoactive
the body gets used
drugs. The most commonly referenced is the healthcare services cost
to the repeated
associated with drug-related illness. This includes emergency department
administration of a
drug, so that higher
doses are needed to
maintain the same
effect.
Addiction: A term
synonymous with
dependence. The
continual and
services for acute harm, and mental health and rehabilitation services for
long-term harm. The costs associated with drug-related crime are also
significant. These include costs associated with policing, courts, prisons
and customs services. Then there are general costs that accrue, such as lost
productivity, failure to achieve expected educational levels and, for some,
lack of engagement in work. There are other more hidden costs, such as
the loading on insurance premiums to cover alcohol-related motor vehicle
accidents, and other insurances covering theft and damage. The total social
excessive use of a
cost associated with legal and illegal drug use in Australia in 2004–2005
drug despite the
was over $55 billion, of which crime costs accounted for approximately
harms that it causes
$7.1 billion (Collins & Lapsley, 2008).
to the individual and
others, and repeated
failed attempts to
stop or limit use.
It is important to note that harm can be experienced at an individual
or societal level. This and the next section on dependence highlight that
individual treatment and other interventions are important. It is equally
See substance use
clear that the high levels of harm experienced by non-dependent drug users
disorders, substance
and those around them also require a range of evidence-based population
or drug dependence.
health responses.
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Chapter 1: Setting the Scene
Dependence:
one potential harm
Dependence typically involves regular drug use, increased tolerance,
experience of withdrawal when use of the drug is reduced or discontinued,
and a strong desire or compulsion to take the drug in the face of clear
evidence of harmful consequences. Dependence and related terms such
as addiction are discussed in the next section. Despite the widespread
Dependence liability:
The variable risk
of developing
dependence
belief that regular use of psychoactive drugs leads to dependence, the
associated with
epidemiological data shows that the majority of people who consume drugs
different psychoactive
which have dependence potential will not become dependent themselves.
drugs. For example,
However, it has been well established that commonly used psychoactive
drugs do carry varying risks for the development of dependence – referred to
as dependence liability. For example, epidemiological research has shown
that within the first ten years of use, 8% of cannabis users will become
dependent, as will 13% of alcohol users and 16% of cocaine users (Wagner &
Anthony 2002). It is also important to note that while dependence per se
is often associated with serious harmful health and social consequences,
this is not necessarily or obviously the case. The stereotypical picture of
health and social disintegration in a person’s life is often not the case.
at a population level,
the risk of developing
cannabis dependence
is lower than the
risk associated
with alcohol or
cocaine use.
Maturing out:
The process
whereby people
Some people experience many years of drug dependence, without it being
who experience
obvious to friends, work colleagues and others. Although many people
serious drug
associate drug-related problems with dependence, some researchers have
problems, including
estimated that up to 50% of alcohol problems are experienced by people
who do not meet the criteria for dependence.
Large-scale surveys suggest that, for the majority of people diagnosed
dependence in their
younger adult years,
reduce their drug
intake and associated
as dependent, the condition is commonly associated with adolescent onset
problems as they
drug use (Chen et al., 2009), peaks in early adulthood and has resolved
mature.
permanently, without clinical intervention, when people reach their early
Relapse: A return
thirties. This phenomenon has been described as maturing out, whereby
to drug use or
drug use decreases under pressure from age-related increases in family
drinking after a
responsibilities, or other incentives and disincentives to change behaviour.
period of abstinence,
This might include simply getting tired of a lifestyle that includes many
often accompanied
occasions of feeling unwell or getting into trouble with police. The
exception to this maturing out phenomenon is typically associated with
a combination of drug dependence and serious mental health issues,
where a pattern of drug use, treatment and relapse may continue over a
longer period (Lopez-Quintero et al., 2010). It may be that the widespread
by reinstatement
of dependence
symptoms. Some
writers distinguish
between relapse and
lapse (an isolated
professional and scientific debate about the chronic and relapsing nature
occasion of drug use
of dependence is largely based on a relatively small clinical subgroup
or a ‘slip’).
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12
Chronic relapsing
disorder: Drug
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that experiences a combination of severe dependence and a wide range of
mental health and other social issues. Most people in the general population
dependence is
who meet the criteria for dependence at some stage in their lives do not
often perceived to
behave as though they have a chronic relapsing disorder. They usually
be a long-term or
do not seek treatment, nor do they relapse to heavy drug use on a regular
life-long condition
basis and, typically, they resolve their dependence issues themselves
characterised
by periods of
uncontrolled
use, treatment,
abstinence or
(Kalant, 2010).
Terminology: labels matter
controlled use and
relapse. This is
We need to consider terminology, because inherent meaning can determine
the case for some
how our community understands and responds to drug use and associated
people, but the
problems. Commonly used terms include: drug use, drug misuse, drug
majority do not seek
treatment and resolve
their dependency
issues themselves.
Drug misuse: This
refers to use of a
drug in a way that is
likely to cause harm,
usually associated
abuse, harmful drug use, drug dependence and drug addiction. In general,
drug use refers to non-problematic use; however, it is usually reserved
for drugs that are illegal. The term misuse has been introduced because
many people use alcohol, and we are only concerned here with those who
misuse it. Terms such as abuse, harmful use and dependence fall under a
general category of substance use disorders, as defined by two separate
classification systems: The World Health Organization: International
Statistical Classification of Diseases and Related Health Problems: Tenth
with legal drugs, and
Revision (ICD-10) (WHO, 1992); and the American Psychiatric Association:
differentiates non-
Diagnostic and Statistical Manual: Fourth Edition (DSM-IV) (American
problematic from
Psychiatric Association, 2000). While the two systems classify the less
problematic use.
serious conditions of ‘harmful use’ and ‘drug abuse’ differently, both
Drug abuse: See
classification systems describe ‘dependence’ in a similar way. Features
substance or drug use
include preoccupation with the behaviour, diminished ability to control the
disorder.
behaviour, tolerance, withdrawal, and adverse psychosocial consequences
Harmful drug
(Cunningham & McCambridge, 2012). The very inclusion of substance use
use: A pattern of
disorders within ICD and DSM demonstrates one prevailing view, which
drug use that is
is of drug problems as medical problems, with defined diagnostic criteria.
causing physical
The term addiction has been largely replaced by the notion of dependence,
or psychological
but it has a long history and persists, especially in media coverage and
damage to health
(such as hepatitis
from injecting
or depression
associated with
general community discourse. With revisions to the two classification
systems currently underway, there is considerable debate about definitions
taking place among medical and scientific experts which might yet see
the term addiction return (O’Brien, 2011). In this book, consistent with the
alcohol use). It also
terminology used in the major classification systems, we use dependence
often results in social
rather than addiction. While it may be argued that the meaning of these
consequences.
terms can be differentiated, we treat them as synonymous. Importantly,
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Chapter 1: Setting the Scene
we have a strong preference not to use terms such as alcoholic and addict,
as these terms refer to the whole person, rather than their drug using
Substance or drug
behaviour. This is the same as using the term schizophrenic rather than
dependence: A
referring to someone with schizophrenia. For the same reason, there has
maladaptive pattern
been a recent trend to refer to people who inject drugs (PWID) rather than
injecting drug users. This demonstrates the importance of language and its
capacity to increase or decrease stigmatisation.
of substance
use leading to
clinically significant
impairment
or distress, as
Theories of drug use
and dependence
Numerous theories have been offered to explain drug use and dependence.
manifested by a
need for increasing
amounts of the
substance to achieve
intoxication, the
need to continue
The value of any theory is determined by its capacity to describe behaviour,
to take the
explain relationships between variables of interest, predict future
substance in order
behaviour, and provide guidance on assessing and effectively modifying
to avoid withdrawal
the behaviour. Theories of drug use and dependence can be broadly
grouped as: disease theories; biological theories that consider matters of
genetics, neurobiology and physiological adaption; psychological theories,
including those derived from psychoanalytic, personality, behavioural
(such as classical and operant conditioning), cognitive–behavioural and
motivational perspectives. Others draw on sociology, anthropology and
social systems approaches, including family, peer groups and social
influence. There are also theories that adopt cultural, social, economic,
philosophical and other approaches in describing dependence as a socially
symptoms,
unsuccessful
attempts to stop or
cut down the drug
use, and continued
use despite harmful
consequences.
Substance use
disorders: The
term used by the
constructed phenomenon. It is not our intention to provide an account of
American Psychiatric
each theory but rather to describe the biopsychosocial theory that captures
Association (2000)
the multi-faceted nature of drug use and dependence by drawing on a
in the Diagnostic and
range of other theories. Some consideration will then be given to disease
and cognitive–behavioural theories, both of which tend to feature in any
discussion about drug dependence. None of the current theories can be
regarded as proven, and they are not necessarily mutually exclusive, with
each contributing some part of an explanation of who develops problems
with drug use, including dependence. More discussion on frameworks and
theories can be found in Chapter 3, Frameworks for understanding drug
use and societal responses, and elsewhere (e.g. Lee, 2004).
Statistical Manual
IV to describe a
condition that
includes substance
abuse and substance
dependence.
Alcoholic: A term
consistent with a
disease theory of
dependence that
Biopsychosocial theory
describes a person
experiencing alcohol
While there is no universally accepted theory of dependence, most experts
dependence. See
agree that complex and multi-faceted interactions are involved. There is
alcoholism.
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Addict: A person
abundant evidence to support this conception of dependence whereby
who is addicted to
psychological, social, economic and specific situational factors combine
or dependent on a
psychoactive drug
(usually illegal). It
implies a lack of
control over use of
the drug.
Disease theories:
Theories of drug
with genetic and other biological factors to explain why some people who
use psychoactive drugs develop dependence. This is typically referred to as
the ‘biopsychosocial theory’ of dependence. This theory suggests that there
are biological factors such as predisposing genetic factors that contribute
to drug use and dependence. In addition to biology, psychological factors
such as personality, coping styles, learning and the impact of factors such
as emotional difficulties and mental health problems also contribute to
use and dependence
drug use and dependence. Over and above both biology and psychology,
that emphasise
social factors such as the availability of alcohol or drugs, and the cultural
the primary nature
context of drug use play a role in determining patterns of use. Where experts
of the condition
tend to disagree is the extent to which any of these aspects contributes
(i.e. the disease or
abnormality that
precedes the use of
a drug).
Substance or drug
abuse: A maladaptive
pattern of substance
use leading to
clinically significant
to dependence. Privileging any aspect to explain dependence may result
in other important aspects being neglected, and this has flow-on effects
in terms of future research, the nature of interventions that are funded,
and perceptions about drug users and the extent to which they may be
stigmatised in society. This multi-factorial theoretical perspective has
resulted in calls for appropriate integrative, multi-disciplinary approaches
to the study of dependence and responding to people who experience drugrelated problems.
mental or physical
impairment or
distress. It is
characterised by
a failure to fulfil
obligations, drug
use in situations that
Disease theories
Disease theories have their origins in much earlier times (see Chapter 3,
Frameworks for understanding drug use and societal responses) and
are broadly based on the view that dependence is experienced by some
are hazardous, and
people and not others due to biological vulnerabilities or the effect of
persistent use.
these drugs on a person’s physical and mental processes. This is usually
Biological theories:
Theories of drug
seen as either a genetic predisposition for dependence or biochemical
abnormalities that pre-exist or occur as a result of psychoactive drug use.
use or dependence
In the articulation of disease theories from the middle of last century,
that emphasise the
dependence was classified as a psychiatric disease, partially due to the
genetic predisposition
influence of Alcoholics Anonymous, which commenced in the mid-
to drug dependence,
1930s. ‘Alcoholics’ were deemed to be different from other people in that
or the neurobiological
changes and
physiological
adaptation that result
from drug use and
their brain chemistry was not the same as others or had changed because
of chronic alcohol use causing impaired control over their drinking.
That is, they were seen as rational and in control prior to drinking
and irrational and out of control once drinking commenced. A similar
can impact on the
disease concept has been applied to the users of other psychoactive drug
long-term course of
classes, reflected in the teachings of self-help groups such as Narcotics
the condition.
Anonymous.
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Chapter 1: Setting the Scene
A perspective based on genetic inheritance is receiving increased
attention and potentially re-ignites an emphasis on physiology as the
basis of dependence. This can then be more readily linked to a disease
or disability conception of dependence. While the precise contribution
of genetic inheritance remains contested, there are increasing claims,
consistent with the disease theory, that up to 50% of the risk of developing
dependence may be inherited (Goldman et al., 2005). More recently,
the study of neurobiology has developed neuro-imaging techniques
demonstrating drug induced brain circuitry changes. It has been argued
that these circuitry changes explain the transition from drug use to
dependence (Kurti & Dallery, 2012). This research has identified the
Psychological
theories: Theories
of drug dependence
that arise from
psychoanalytic,
personality,
behavioural
or cognitive
perspectives.
Biopsychosocial
theories: A
multifaceted theory
dopamine-enhancing effects of various drug classes that result in a user
proposing that
experiencing feelings of well-being or feeling high, therefore placing
drug dependence
dopamine at the heart of the dependence process. This has reinforced the
arises from a range
disease theory, consistent with the biological basis for dependence.
While the neurobiological research has provided greater understanding
of brain function, the disease conception of dependence is considered too
of interacting
factors, including
characteristics of
the drug, the person
reductionist for those who understand addiction as having complex social,
using it and the
psychological and biological roots (Cunningham & McCambridge, 2012).
environment in which
the use occurs.
Cognitive–behavioural theories
Cognitive–behavioural theories posit that behaviours are learned and
based on thoughts and beliefs. These cognitive processes (comprising
meanings, judgments and assumptions) are often established core beliefs
Generic inheritance
or predisposition:
Refers to the
evidence, mainly
from twin studies,
showing that genetic
about how we interpret the world. They determine how we feel and act
factors contribute
in various circumstances. Dysfunctional behaviour often arises due to
to dependence
dysfunctional or irrational thinking. Problematic drug use is understood
vulnerability
in cognitive–behavioural terms as a mechanism to cope with stress and
that is over and
emotional states, accompanied by beliefs that the drug use will assist.
In the context of treatment for drug dependence, cognitive behavioural
approaches are designed to tackle high-risk situations, learn better coping
strategies and increase self-efficacy to resist drug use. Cognitive behaviour
therapies often teach reframing strategies designed to address irrational
beliefs that lead to dysfunctional behaviours. This may include teaching
strategies to increase self-efficacy and self-confidence to resist drug use, to
cope with life stressors and to effectively deal with situations where the
potential for relapse is high. These issues are discussed in Chapter 8, Drug
treatment: psychological and medical interventions.
Trevor King, Alison Ritter and Margaret Hamilton
above general
environmental
factors. Despite this
evidence, no single
gene has been
identified.
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PART ONE: FOUNDATIONS OF DRUG USE IN AUSTRALIAN SOCIETY
Alcoholics
Drug-related harm in specific
populations
Anonymous (AA): A
worldwide self-help
As we have discussed, psychoactive drug use has potential benefits
movement that
and potential for harm. This harm potential differentially affects parts
originated in America
of our community and warrants closer examination. All drug users are
in the 1930s. The
primary purpose of
AA is to achieve and
maintain sobriety
through mutual
assistance and
following a twelvestep program.
Narcotics
Anonymous: A selfhelp movement that
potentially vulnerable to the harms as well as the benefits of these drugs.
However, there are particular groups, as summarised below, who may be
at higher risk of harm.
Young people
Many young people like to experiment with drugs and engage in other
risky and potentially harmful activities, making them at disproportionate
risk of short- and long-term harm. In 2010, 38 per cent of 12–17 year-olds
consumed alcohol. It is frequently offered to them by friends and family,
commenced in the
and most will accept the offer. This is not surprising, given that alcohol is
1950s in America
a legal drug in Australia which is culturally sanctioned and aggressively
and is based on AA.
promoted through advertising. Young people are more likely to binge drink,
It follows the same
with 20% reporting that they deliberately drink to get drunk (AIHW, 2011a).
twelve-step program
and provides
mutual support to
abstain from drug
use. See Alcoholics
Anonymous.
Binge drinking:
While there is no
consensus on what
Drinking in this way can cause injury or disease over the longer term. For
example, alcohol accounts for 13% of all deaths among 14–17-year-old
Australians, and more than 60 are hospitalised each week from alcoholrelated injuries and other related causes (Chikritzhs and Pascal, 2004).
Alcohol consumption in adolescence is also associated with risky sexual
behaviour and academic failure. In addition to the harms associated with
intoxication, there is also evidence that alcohol may cause damage to
young people’s developing brain. Early initiation, currently at 17 years on
constitutes binge
average in Australia, with some much younger, is associated with episodes
drinking, it usually
of memory loss and problematic drinking patterns, including dependence
refers to drinking
later in life (Hingson et al., 2006).
on a single occasion
(or on a number of
occasions if blood
alcohol concentration
Experimenting with tobacco appears to be attractive for many
adolescents, with initiation commencing around 16 years of age on average.
Some (almost 4%) will use occasionally, while 2.5% report smoking daily.
does not reach zero
It is very concerning that, of this group, the daily smoking rate for girls is
in between) at levels
almost twice that for boys (AIHW, 2011a). There is evidence that smokers
that put a person at
who commence early are less likely to give up than those who start later
high risk of harm.
in life (British Medical Association, 2007). Therefore, many are likely to
experience the now well-known health and social consequences of smoking.
Approximately one in five young people aged 14–17 years have used an
illegal drug at some stage. Two-thirds of this group have tried cannabis,
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Chapter 1: Setting the Scene
with less than one in ten of this group reporting use in the past 12 months.
The numbers using other illegal drugs is very low (AIHW, 2011a).
The vulnerability of young people to the immediate and long-term
harms associated with drug use provides compelling grounds for
introducing evidence based strategies to prevent or delay the uptake of drug
use or reduce the associated harms (see Chapter 6, Primary prevention:
preventing uptake of drugs, for a detailed analysis of these strategies).
Socio-economic
disadvantage: The
concept is neither
simple nor well
defined. Broadly,
‘disadvantage’ refers
As Wayne Hall so eloquently puts it, ‘individual choices about drug use
to the limitations of
are not always made wisely by young people with temporal myopia, a
people’s access to
sense of personal invulnerability, skepticism about their elders’ advice
material and social
and an exquisite sensitivity to adult hypocrisy about drug use’ (Hall, 2006,
p. 1531).
resources, and their
ability to participate
in society.
Indigenous peoples
Burden of disease:
The use of psychoactive drugs, combined with high levels of Indigenous
that combines years
A statistical measure
socio-economic disadvantage, results in a high disease burden, and is a
major contributor to the longevity gap of 12 years for males and 10 years for
females compared to non-Indigenous Australians (AIHW, 2010). Indigenous
people experience almost double the burden of disease associated with
alcohol use than the general population. The burden comprises long-
of life lost due to
premature mortality
and years of life lost
due to time lived in
states of less than
full health. WHO
term harms such as strokes and cancer; and others, including homicide,
developed a metric
violence, suicide and road traffic accidents. The proportion of Indigenous
in 1990 called the
people who abstain from drinking has been consistently shown to be
‘disability-adjusted
higher than the general population. This may be partly explained by the
numbers who have given up due to the harmful consequences of their use.
The proportion of Indigenous Australians who drink in a risky manner
may be at least double that of the general population (Wilson et al., 2010).
Tobacco contributed to the deaths of one in five Indigenous people in
2003. They experienced high rates of cardiovascular disease, stroke and
chronic respiratory tract diseases. It is concerning that the downward
trend in smoking seen in the general population is not replicated in
life year’ (DALY) to
assess the burden of
disease consistently
across diseases, risk
factors and regions.
Kava: The active
ingredient in the root
of the pepper plant
Piper methysticum.
Indigenous populations. In 2004–2005, half of adult Indigenous people
It is used in Pacific
were daily smokers compared to about 19% of non-Indigenous Australians
countries for
(ABS & AIHW, 2008). Indigenous Australians are also much more likely
to use cannabis than the general population (AIHW, 2011a). In some of
the more remote parts of Australia, Indigenous people are also vulnerable
to the harmful use of other psychoactive drugs such as kava, introduced
from the Pacific Islands over the past thirty years. The consequences
ceremonies and for
social occasions. It is
also used in northern
parts of Australia in
much the same way
as alcohol, acting
also go beyond health, with the role of alcohol and drug use in offending
as a sedative and
being of particular concern. Although Indigenous people make up only
muscle relaxant.
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2.6% of the Australian population, they are over 17 times more likely to
be imprisoned. One study showed that, of those imprisoned, almost 70%
were under the influence of alcohol at the time of arrest, compared to 27%
of non-Indigenous prisoners (Putt et al., 2005). These figures show what
Indigenous people and public health practitioners already know: there are
serious public health challenges for this population that warrant specific
and urgent attention.
Women
Women are exposed to greater risk because they suffer greater levels of
personal drug-related harm after fewer years of drinking or drug use,
compared to their male counterparts. For example, when consuming
Standard drink:
alcohol at high levels (between two and eight standard drinks per day),
Refers to any drink
the risk of alcohol-related disease increases more quickly for women than
containing 10 grams
men (NHMRC, 2009). Another alcohol example shows that women are more
of alcohol; for
example, a 30 ml
nip of spirits (40%
alcohol per volume)
affected by the third-party harms, including interpersonal violence and
sexual victimisation. They also spend more time caring for people who
misuse alcohol (Laslett et al., 2010). It has been estimated that alcohol is
equals one standard
involved in between 25% and 50% of domestic incidents (Leonard, 2001).
drink, or a 375 ml can
The experience of violence is particularly the case for Indigenous women,
of beer (4.8% alc. Vol)
where alcohol-related assaults are 33 times higher than for women in the
equals 1.4 standard
general population (AIHW, 2008). It should be noted that violence against
drinks.
women is a complex issue and alcohol involvement does not equate with
causation. In terms of drug use trends, there is evidence that, in Australia
between 1995 and 2005, the proportion of women drinking at risky levels
increased from around 6% to 12%. As mentioned earlier, we also know
that adolescent girls are smoking at almost twice the rate of their male
counterparts. This trend is a matter for great concern.
Elderly people
The proportion of elderly Australians (65+) is increasing as our population
ages. Consequently, in coming years we can expect an increase in the
numbers using various psychoactive drugs and an associated increase
in net drug use harms. An analysis of the 2007 Australian National Drug
Strategy Household Survey (AIHW, 2008) showed that elderly people were
more likely to misuse alcohol and prescription drugs than illegal drugs.
The rate of daily drinking for those 70 years and over is higher than for
any other age group. Over 12% of the elderly drink alcohol at levels placing
them at risk or high risk of long-term harms (AIHW, 2011a). These harms
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Chapter 1: Setting the Scene
include accidents and injuries which, for this age group, carry a higher
risk of permanent disability or death. In the 65–74 age group, almost
600 die every year from injury and disease caused by drinking above
recommended levels, and a further 6,500 are hospitalised (Chikritzhs &
Pascal, 2005). Tobacco is used by approximately 8% of this group on a daily
basis and is the drug most associated with serious harm. There is also
evidence that 3% of this group take analgesics for non-medical purposes
(Hunter & Lubman, 2010). An additional complication in this age group
is that an estimated 25% consume up to five prescribed medications at
any given time (AIHW, 2007). There is increased risk of falls related injury
associated with drug interactions, particularly when combined with
alcohol or unprescribed medications. Chronic pain and anxiety disorders
are conditions that increase in later life, and therefore the number of people
seeking prescription and non-prescription analgesics and benzodiazepines
is expected to increase (Nicholas et al., 2011). Psychoactive drug use by the
elderly is an under-researched area and will need greater attention as we
face the challenges of an ageing population.
People from culturally and linguistically
diverse backgrounds
Twenty-five per cent of the Australian population (5.3 million) was born
overseas and, for 16%, English is not the language spoken at home (ABS,
2007). The health status of most migrants is as good as, if not better than,
that of the Australian-born population (AIHW, 2010). People from culturally
and linguistically diverse (CALD) backgrounds in Australia have different
drinking cultures and behaviours, which result from their differing
circumstances. People whose main language spoken at home is not English
are more likely to either abstain from alcohol or to be ex-drinkers (43%)
compared to English speakers (15%). However, certain CALD groups show
higher rates of risky consumption than others. For example, people born in
Pacific Island nations have slightly higher rates of risky alcohol consumption
than people born in Australia (ABS, 2010a). There may be specific factors
that contribute to riskier drinking among some CALD populations; for
example migration, isolation and post-traumatic stress. Although smoking
is on the decline in Australia, there is evidence that Australian men born in
Europe, North Africa and the Middle East, and women born in New Zealand,
the United Kingdom and Ireland are more likely to smoke than Australianborn men and women (Weber et al., 2011). Public health messages need to
be tailored to CALD sub-groups. This goes beyond merely translation into
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languages other than English and includes understanding the culturally
specific determinants of harmful alcohol and other drug use.
Gay, lesbian, bisexual and transgender people
One of the sub-populations identified as being at high risk for the
development of problems with psychoactive drugs has been those
of minority sexual identity: gay, lesbian, bisexual, transgender and
transsexual people (GLBT). In relation to tobacco, numerous studies have
found significantly higher rates of tobacco use among GLBT populations.
A number of studies have shown that bisexuals in particular (of both
sexes) had the highest rates of tobacco use. Alcohol consumption rates are
generally higher in GLBT populations than in heterosexual populations
and, concomitantly, higher rates of alcohol use disorders are found.
However, this finding appears to apply strongly for females (lesbian and
bisexual women) and is less so for homosexual men (Cochran & Mays,
2000). For illicit drugs, across both drug use and diagnosed drug use
disorders, a majority of studies showed significantly higher prevalence
among GLBT compared to heterosexual populations (e.g. Bolton & Sareen,
2011). There are a number of factors that can go some way to explaining
why GLBT individuals use drugs to a greater extent, and face higher rates of
dependence than other groups. Factors that may account for higher alcohol
and other drug problems include: self-identification; relationship status;
relationships with family and friends; residential context; ‘coming out’;
abuse and victimisation; and stigma, minority stress and discrimination.
Many of these factors are likely to be interrelated; for example the process
of ‘coming out’ may have implications for relationships with family and
friends. Many, but not all of these risk factors (for instance, victimisation)
can apply equally to GLBT and heterosexual groups. However, in many
cases these factors are experienced to a greater extent by the GLBT
population. Preventing discrimination and stigma is an essential aspect
of any comprehensive approach to reducing psychoactive drug problems
among GLBT. There is a small but compelling literature that demonstrates
that recognition of same-sex marriage is associated with lower alcohol
disorders. Measures that reduce the stigma and discrimination against
GLBT people are likely to have powerful public health impacts.
Sometimes our community acts as though the above groups are the
only ones who have trouble with particular drugs, and this view can lead
to stigmatisation, prejudice and inappropriate interventions. It is clear
that psychoactive drugs cause a range of health and social problems in all
sections of society, albeit more pronounced in some specific sub-groups.
How do communities respond to or attempt to control these issues?
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Chapter 1: Setting the Scene
Controls to prevent or
reduce drug-related harms
All communities make judgments about what behaviours require some
level of response or control. The basis for these decisions can include
public expectations, ideology, religious belief, scientific research evidence
and many other factors (see Chapter 3, Frameworks for understanding drug
use and societal responses, and Chapter 6, Primary prevention: preventing
uptake of drugs). Consumption of psychoactive drugs is no exception,
with all societies implementing some measures to prohibit or restrict use.
These measures, often in the form of drug laws, differ between countries,
between states and over time. For example, the possession of up to 50 grams
of cannabis in Victoria (Australia), although illegal, will be dealt with
by a police caution and referral to a cannabis education program. In the
Netherlands, cannabis use is illegal but tolerated in small amounts that can
be bought in ‘coffee shops’. In California and many other states in America,
the use of cannabis for medical purposes is legal. In Singapore there are
severe penalties for cannabis possession and trafficking, outlined in the
Drug Misuse Act. Possession of up to 30 grams can result in up to 10 years’
imprisonment; over 30 grams is considered to be a trafficable amount, with
penalties that can include life in prison; amounts of over 500 grams attract
the death penalty. Similarly, alcohol is a legal drug in Australia but in
some countries it is regarded as equivalent to the way in which Australian
jurisdictions treat cannabis; as an illegal drug, with varying levels and
types of penalty for possession and use.
Our society has interesting ways of thinking about acceptable and
unacceptable drug use. The vast majority of Australians consume alcohol,
and it is often not thought of as being a problematic drug. Illegal drugs
are usually associated with marginalised sectors of the community and
it is easy to stereotype and condemn these users. Control measures are
often very broad in their application, focusing on behaviour rather than
the causes of that behaviour. For example, a drink-driving conviction may
arise from a single drinking occasion and associated poor judgment, or
the detection of a regular, persistent behaviour pattern associated with
chronic alcohol use and dependence. How we as a society treat people
who experience serious problems or are dependent on drugs depends on
whether we view their condition as a disease over which they have little or
no control, or whether we consider it a moral failing whereby people simply
make poor (often self-destructive) choices and need to be held to account
Chronic alcohol
use: A pattern of
regular, high-level
consumption over a
long period, usually
associated with
for those choices. Although this is a fairly simplistic dichotomy applied
serious health and
to a complex issue, it shows how a community response can vary; the
social harms.
Trevor King, Alison Ritter and Margaret Hamilton
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PART ONE: FOUNDATIONS OF DRUG USE IN AUSTRALIAN SOCIETY
International drug
provision of treatment, or the application of the full force of the law. You
conventions: Since
only need to read the opinion page and other sections of a newspaper on
1912, various United
Nations conventions
have been developed
to regulate the
any day to see that there are very strong and conflicting public views on
these issues.
Drug control at the highest level comes with international drug
possession,
conventions, such as the Single Convention on Narcotic Drugs, 1961
use, production,
(WHO, 1961). As Australia signed this convention in 1967 it, along with
distribution and
most other countries, is bound to prohibit the production and use of
sale of various
psychoactive
substances.
These conventions
establish a system of
drugs such as heroin, cannabis and cocaine, except when the purpose is
medical or scientific. Recent reviews of the effectiveness of this convention
highlight how ineffective it has been, with illegal drug use contributing
to a substantial and increasing burden of disease (Room & Reuter, 2012).
regulation whereby
Further discussion of the international treaties can be found in Chapter 9,
only medical and
Drug laws and regulations). National- and state-level laws are also used
scientific uses
to control drug use for specific groups or behaviours. This includes
are permitted.
restricting alcohol and tobacco use for people under 18 years; restricting
Conventions require
signatories to
take measures
against illicit
drug production,
hours of access to licensed premises; restricting allowable levels of alcohol
consumption and banning some other drug use in association with driving;
restricting areas in which tobacco can be smoked; and, somewhat more
controversially, restricting alcohol sales in some remote communities.
trafficking, and other
These legislative controls are typically introduced with the intention of
provisions against
limiting the harms associated with the use of various drugs.
money laundering
and the diversion of
precursor chemicals
(chemicals used in
the manufacture of
drugs).
Narcotic: A term that
initially referred to
drugs with sleep-
Policing occurs at a number of levels, including overseas intelligence
operations, customs controls and border inspections of incoming goods, as
well as local street-level efforts at detecting and intervening in the supply
of these products, all aimed at preventing the availability of illicit drugs.
Overall control of illegal drugs is based on efforts to prevent or restrict their
availability and largely relies on active policing of illicit drug use, dealing,
sale and supply, manufacture and trafficking. Policing can use a number of
mechanisms, targeted at different levels of the illegal drug supply chain.
inducing properties
At its most common, police arrest illicit drug users and drug dealers. The
such as opioids,
numbers of users arrested significantly outnumbers the arrests of suppliers
but is now used
(known as ‘traffickers’ when larger quantities are involved) of illicit drugs.
(particularly in
At higher levels of the illegal drug market, police target known criminal
America) to describe
any illegal drug.
networks that manufacture and supply illegal drugs. The evidence base
for law enforcement is relatively small, compared to what we know about
treatment approaches (see Chapter 10, Drug law enforcement: reducing the
supply of drugs).
Control is also sought in other ways, often through education and
persuasion campaigns. Social marketing campaigns, including televisionbased public health advertisements, are designed to change some aspects of
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Chapter 1: Setting the Scene
drug use behaviour; most often directed at reinforcing the disinclination of
Education and
those who have not yet tried using illicit drugs and curbing any inclination
persuasion: These
toward misuse of licit drugs, such as binge drinking. In-school education is
also designed to influence the drug choices of young people (these strategies
are examined more fully in the Chapter 6, Primary prevention: preventing
uptake of drugs). Other control mechanisms include the provision of
treatment interventions of varying intensity, provided in a wide range
strategies include
school-based
education, safe
drinking guidelines
and labels on alcohol
beverages. They are
of settings. This might include simple advice from a general medical
designed to influence
practitioner to stop smoking because it is harmful, through to coerced and
drinking or drug use
voluntary treatment for more serious problems associated with chronic use
decisions.
of psychoactive drugs (see Chapter 8, Drug treatment: psychological and
Social marketing:
medical interventions). Other measures include the provision of advice,
Applies commercial
services and equipment designed to address the harms associated with
marketing concepts
drug use, rather than the drug use as such. Examples of this include the
and technologies to
provision of needles and syringes to control the incidence of individual
and community-level hepatitis and HIV transmission. The provision of
widespread opioid maintenance programs using medications such as
methadone also has a control function. In addition to improving health,
such programs are effective in reducing drug-related crime, with obvious
individual and community benefits. These issues are explored in the harm
reduction and treatment chapters (Chapter 7, Harm reduction: reducing the
harms from drug use, and Chapter 8, Drug treatment: psychological and
medical intervention).
influence voluntary
behaviours so
the wellbeing of
individuals and
society is improved.
Opioid maintenance
programs: One of
the many terms
describing programs
that treat opioid
Control strategies are not always based on good evidence. Sometimes
the very things that seem like common sense can result in unintended,
negative consequences for individuals and for the overall community. The
best evidence of this is where countries have introduced laws to prevent
dependence with
another opiate drug
such as methadone
or buprenorphine.
illicit drug use and severe penalties for those who break them. In countries
such as the United States, this has resulted in large numbers of people in
prisons or, as is the case in some South-East Asian countries, in compulsory
Injecting equipment:
treatment centres or labour camps. Not only is there no evidence that such
All items used for
measures have any long-term impact on illicit drug use or re-offending,
injecting drugs that
but they can also be associated with significant public health costs and
are a potential source
negative consequences for people beyond those directly involved in
drug use. An example is the in-prison exposure to HIV and hepatitis
through needle-sharing and subsequent spread in the broader community.
At times the laws designed to restrict drug use produce drug using practices
of contamination or
infection (such as
hepatitis C). This
includes needles,
syringes, spoons,
that are especially risky, including hurried use of large amounts of a drug
swabs, filters,
to avoid detection and inappropriate disposal of injecting equipment such
tourniquets and
that it poses a risk to other community members.
water.
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The extent to which new control policies can be introduced is often based
on community-level support. The Australian National Household Survey
includes measures of support for various policy options. For example,
in 2010, support for policies aimed at reducing harm caused by tobacco
received very high levels of support (89% supported stricter enforcement of
the law against supplying cigarettes to minors; and 87% supported stricter
penalties for the sale and supply of tobacco products to minors). There was
also high-level support for more severe penalties for drink-driving (86%).
Legalisation: Refers
to making drug
use, possession,
Other alcohol measures supported included monitoring late night venues
(80%) and restricting late night alcohol trading (64%) (AIHW, 2011a).
Since some of the harms associated with the use of illicit drugs are
production and
due to their legal status, there is a case to be made for change to this status
distribution legal.
and the theoretical possibility of aligning these currently illicit drugs more
Like other legal
closely with licit or legal psychoactive drugs. This would allow them to be
substances, other
controls may be
introduced, for
example, to restrict
sales to people under
certain ages or to
restrict the ways in
which the products
are marketed.
controlled and regulated like tobacco and alcohol. Taxation could then be
used as a powerful government control lever that can be varied to change
prices and, through this, strongly impact on consumption patterns, as has
occurred with tobacco. This issue is addressed in detail in Chapter 9, Drug
laws and regulation.
Examining Australians’ views about decriminalisation and legalisation
of currently illegal drugs, most people do not support full legalisation of
drugs such as cannabis, heroin or methamphetamine. At the same time,
Mephedrone:
however, there is strong support for various versions of decriminalisation
A synthetic stimulant
of drug use – such as cautions, fines and referral to drug treatment (Ritter &
with effects similar
to ecstasy (euphoria).
One street name is
meow, meow. See
also synthetic drugs.
Khat: Comes from
the plant Catha
edulis. The fresh
Matthew-Simmons, 2012). While high-level public support does not
guarantee that policies will change, low-level support almost guarantees
that they will not. Debate about the most appropriate response to the range
of different psychoactive drugs waxes and wanes and, from time to time,
this captures public attention. (See the history and policy chapters of this
book for some examples of this.)
A new challenge to our capacity to control drugs is the rapid development
or dried leaves or
of new synthetic psychoactive chemicals such as mephedrone (also
buds of the plant
referred to as ‘meow, meow’). This drug, chemically related to the khat
are chewed for
plant, received a great deal of media attention when it was legally available
their stimulant
effects (common in
some countries of
east Africa and the
Arabian Peninsula,
(prior to changes to laws in many countries that banned the substance). This
issue is discussed in Chapter 9, Drug laws and regulations. It is not only
the ongoing rapid development of new drugs but also the efficient purchase
and distribution system that the internet provides (see Chapter 11, Drugs
where it is part of
and the internet: modern technology) that are challenging policy-makers
social and cultural
to consider whether prohibition or some other strategy may be most
tradition).
appropriate.
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Oxford University Press ANZ
Chapter 1: Setting the Scene
25
Summary
People in all societies use a variety of drugs for pleasure, to manage emotions, to
be like others, for ceremonial occasions and many other reasons. There are obvious
benefits from drug use, but there are also many associated harms. All societies
struggle with the issue of psychoactive drug control and this brief overview highlights
the complexities involved. We can point to great successes in areas such as the
reduction in tobacco use and drink-driving in Australia. We can also point to strategies
such as some international conventions that appear to have made no difference, while
most certainly leading to increased harms in some countries.
This introductory chapter has been designed as a general primer to the following
chapters, which will address a range of drug issues in far greater depth. The aim
of the book is to provide a broad overview of the role of drug use in Australian
society; the benefits we derive from such use and the short- and long-term harmful
consequences that may be associated with their use. We wrote the book with
specific target audiences in mind: students studying drug and alcohol subjects in
tertiary level courses; health practitioners who encounter drug and alcohol issues
in their day-to-day work; and readers who have a general interest in this area.
• A number of reasons are given for why people use drugs. Can you think of any
additional reasons? What is the connection between the reasons people use drugs
and how we as a community respond?
• There are a number of contrasting theories of drug dependence – disease theory,
neurobiological theory, social theory – how do different theories influence the way
we think about and respond to dependence?
• There are many terms used to describe people who consume psychoactive
substances – can you list as many as possible and identify how they might be
stigmatising?
Trevor King, Alison Ritter and Margaret Hamilton
Food for
thought…
26
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PART ONE: FOUNDATIONS OF DRUG USE IN AUSTRALIAN SOCIETY
Further reading
Australian Institute of Health and Welfare. (2011a). 2010 National Drug Strategy
Household Survey report. Catalogue Number PHE 145, Canberra: Commonwealth
of Australia.
Lee, N. (2004). Psychological theories of drug use and dependence. In M. Hamilton,
T. King & A. Ritter (Eds), Drug Use in Australia: Preventing Harm (Second edition)
(pp. 75–88). Melbourne: Oxford University Press.
Muller, C., & Schumann, G. (2011). Drugs as instruments: A new framework for nonaddictive psychoactive drug use. Behavioral and Brain Sciences, 34, 293–347.
National Health and Medical Research Council. (2009). Australian Guidelines to Reduce
Health Risks from Drinking Alcohol. Canberra: Commonwealth of Australia.
Race, K. (2009). Pleasure Consuming Medicine: The Queer Politics of Drugs. Durham:
Duke University Press.
Useful websites
Australian Government: National Drug Strategy:
http://www.nationaldrugstrategy.gov.au/
Australian National Council on Drugs: http://www.ancd.org.au/
National Cannabis Prevention and Information Centre: http://ncpic.org.au/