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Coming to this question from a background of nearly 30 years of working with dependent patients, I believe firmly that it should.
I want to walk you through the feelings which have brought me to the position that we ought to make a change to how we view the use of drugs of dependence. Nobody has any problems with antibiotics. We are talking about drugs which can cause dependence and lead to very inappropriate behaviours in those who use them.
Millennia of drug use
Drugs have been used by all known societies for millennia. Therefore, to proscribe the use of mind-altering drugs flies in the face of what history tells us people like to do and have been doing. With that said, it is clear that, for a long time now, drug use has also been seen to cause many problems. One only has to look at the good book which reports the problems experienced by the Jews, during their long history, with the inappropriate use of things like alcohol.
In our Judeo-Christian-based society we have tended to take a very tough line on the use of drugs which alter the mind. Alcohol, in particular, was the focus of much writing. Our societies, which have made laws very much advised by biblical writings and of course, by other writings, have taken a very strong line on the use of these agents, perhaps forgetting some of the other writings in the same book – for example the miracle of turning water into wine where Christ himself produced buckets of alcohol at the end of a wedding and didn’t seem to be particularly perturbed about that at all. Societies, in making laws about drugs, have tried to out-God Himself in being tough on those who might have developed a problem with the use of mind-altering substances.
Drug use and drug dependence
The reason for any drug use in society can get lost when we start the discussion with the problems of dependent drug use. If, instead, we acknowledge that the appropriate use of moderate amounts of alcohol or of small amounts of Valium, for example, can actually facilitate social interchange, societal interactions, conversation, communication, we might think a little differently about how we should legislate the use of these substances.
If drug use might be beneficial for a majority – and when we look at the facts, that is indeed the case – how do we keep drug use to a level which helps rather than harms individuals and their friends and associates? As a clinician, I would have to say that there is, at the moment, no single evidence-based answer to allow us to come to a clear position on that. But I do believe that by legalising these substances, de-mystifying them and being objective about their risks and benefits, we might perhaps be taking a better way forward.
Some drugs used by certain societies are less damaging than are those legalised killers in our own society at the moment – alcohol and tobacco. The safer ones used by some communities, such as kava and betel nut, are quite interesting. In India, one can go to gatherings of people and be offered betel nut, chew away at it and not get any particular harm or effects from it. I believe that, in those societies where the drugs they have chosen to use are less harmful, that society has a more rational approach to thinking about laws in association with the use of these mind-altering drugs.
Problems of drug dependence
Our current world view in the West, particularly that of the Daily Telegraph and its writers and of those who don’t “do” drugs, is that all drug use leads to harm of some sort and to a lot of harm for many who try those drugs. I suggest that that view is biased and not based on reality.
On the other hand, in talking about legalising substances, we do have to admit that continuous heavy use of many drugs of dependence and certainly acute over-use does cause medical, psychological, psychiatric, dependency and societal problems. That occurs in a percentage of users and their associates. This reality calls many to action to reduce the harm, particularly if that harm has occurred to a loved one, to an individual in our vast community.
It is a great idea to want to reduce the harm from drug use. Big use equates with big problems, so let’s reduce the use of substances. How do we do it? The easy answer is to ban the use of the drugs, make them illegal and punish those who use them. But that response neglects a huge issue that hits me every day I sit in a methadone clinic or wander the wards of Prince Alfred Hospital seeing alcoholics with cirrhosis: what is the reason for their drug use in the first place, particularly the drug use by those who end up with significant problems? This is a crucial part of the thesis I am proposing, namely legalising these substances.
Risks of dependency
The risk of becoming dependent and the risk of developing organ damage vary greatly. Drug, social and genetic factors play a significant part in determining who gets into trouble. We haven’t taken account of that in many of our laws because those facts weren’t widely known when they were promulgated. We know that the risk of becoming dependent on chemicals varies from drug to drug. The probability of becoming dependent on cannabis is about 8% to 10%, for alcohol 15%, for cocaine 17%, for opiates 23% and for nicotine – good old nicotine – 32%. When you get up to that level, people without major underlying psycho-social issues do face a significant risk of getting hooked. Society has taken that on board and has started to back off pushing nicotine and allowing nicotine to be pushed.
As a gastroenterologist, I have been fascinated when doing endoscopy lists to find that about 1 in 10 people who get their Midazolam to send them to sleep sit up and say, “What was that? I would love some more of it.” I have had two endoscopies. I remember the needle going in and nothing else until the gastroenterologist said, “It’s time to go home”. The drug doesn’t do anything to me other than send me to sleep, but about 1 in 10 are programmed to respond to this drug differently from the other nine of us. It is the same with Fentanyl. It would be great to be able to determine who is going to be at risk and who isn’t and we need to take that on board in future research work.
Alcoholic cirrhosis and lung cancer
Today at RPAH, I saw two patients with alcoholic liver disease who are facing transplants. Both have been heavy drinkers – but that complication only occurs to about 20% of truly good imbibers. There are genetic and other factors which predetermine who is going to end up with cirrhosis. Only the minority get into trouble.
Carcinoma of the lung doesn’t occur in every smoker, although the risk is greater in all. In thinking about how we should now be handling our drugs and putting them into a legal framework, we need to admit all of these facts and take them on board, with information from further studies, and free up our attitude towards the drugs themselves.
The results of keeping drugs illegal
What has been the effect of keeping these drugs illegal till now? We have lived with this approach for many years. Many of us who grew up through the 1940s and 1950s through to the 70s probably avoided the use of these drugs because they were illegal. It wasn’t tempting to me to use heroin because I would have copped it from the law and from the family if I were found out. The law did have an effect on me. However, a lot of people did dabble during the 60s and 70s – now we have a hepatitis-C epidemic, thanks to the fact that those who dabbled in heroin had to do it under cover, sharing injecting equipment. Our society now faces the fact that 250,000 people have hepatitis-C, 20% to 30% of whom will end up with cirrhosis and need liver transplants. So our keeping the drug illegal in the 70s, all based on good thinking, led to consequences we just had no idea about but are now having to deal with.
Keeping drugs illegal gives government something to focus on as they fight the war on drugs rather than the war on dismay, despair, isolation and fear which has driven the drug use in the first place. This approach gives work to Customs agents, Federal Police and others, resulting in great news stories, such as large quantities of drugs being shown in people’s underwear or in condoms which they hold up and say, “I wonder where they inserted this?”. People think that is wonderful and get a chuckle out of it, but these drugs kill people. The people who are bringing them into the country are making millions of dollars at the expense of young people’s lives. Despite the war on drugs, we are now seeing more heroin back in Sydney than ten years ago, thanks to the war on drugs and the war on terrorism which has allowed Afghanistan to now start producing more heroin than ever before.
The Stateline program on 4 February said it all, I think, sadly and innocently in some ways. We saw the story of a man who had committed suicide on the front lawn of some young people in western Sydney because these young, unemployed, under-engaged drug using teenagers had just heckled him and heckled him to the point of his killing himself – an extraordinary tale. Cannabis and other drug use were blamed to a significant degree for this outcome, whilst the issues of poor parenting, lack of work or social support systems were addressed far less clearly. The current system completely failed that man. If the kids who caused him to take his life were charged with his death and sent into the penal system, is there much hope that they would be rehabilitated? My answer is “No, there is not a lot of hope that they would come out of it better people.” Our system failed everybody in that story – yet it was presented as a very intense, thoughtful look at drugs in our society.
Our current system criminalises the drug use that makes life bearable for some; it hardens the minds and hearts of those who do end up in the penal system; it ignores the bleedingly obvious societal factors which lead to dysfunctional drug use in the first place; and it allows this system to run beneath the surface of the law, out of reach of the police for much of the time, making millions of dollars and ending hundreds of tragic lives.
Why legalise harmful drugs?
As these drugs do cause harm, why legalise them? I believe that we should, because keeping them illegal marginalises the users and the clinicians involved in their care. There is nothing worse than walking onto a ward and having the nurses or another doctor saying, “Your patient over there is causing harm”, and you say, “They’re not my patient. They are the obstetrician’s patient or the surgeon’s patient. They just happen to be drug users and we have been consulted.” It also marginalises the research agenda to a degree that renders the ‘keeping these drugs illegal’ approach harmful rather than helpful.
Decriminalisation or legalisation?
So if the current system is not the way forward, what are the options? The two always trotted out are decriminalisation or legalisation. I suggest that decriminalisation is the wimp’s way forward. Laws still have to be in place, people still end up in gaol, albeit fewer of them. Decriminalisation advocates speak as though it were a rational and profoundly risky step to take, whereas it has already happened in a number of countries, and even here for some drugs in certain quantities. Is this not enough?
I think no, it is not enough, because decriminalisation is usually only applied to a couple of drugs, leaving the rest as attractive alternatives to young, risk-taking people, the very people we are dealing with a lot of the time. Not only are they young and risk-taking, but they are often highly damaged – sexually, physically abused, with no hope of a life as we imagine life should be.
Not so long go Portugal took the radical step of decriminalising drug use. Other countries have done the same for a range of drugs. Cannabis is usually the one they start with. But when one goes to the literature to find hard data on what happens, the first thing we can say is that where decriminalisation has happened, drug use tends to stabilise or go down, it doesn’t go up. But when you look for research publications, here’s a summary statement:
In relation to cannabis consumption, following decriminalisation in certain States, a range of studies with varying methodologies show that the effect of decriminalisation is rather small, not significant, not present at all or at least not present for last month’s use or for youngsters.* The studies have been frail they haven’t been solid, large studies looking at the population and we are still saying: “What happens when you make drugs more available?” The data would suggest they don’t get used in larger amounts.
Are there any data supporting the legalisation of drugs? I suggest that any data which do exist, and they are sparse, are there to be interpreted and re-interpreted in a thousand ways, depending on your mood on the day and on your position on drugs at the time. Perhaps China with opium is the place to go, where the drug was readily available before the British came in and wanted to change things around, take control and control the people. It was available, used by many and by some it was totally destructive, but the reality was that many people could use it and contribute very positively to their society.
What about data against the idea of legalising drugs? Certainly, where drugs such as alcohol and tobacco have been made legal, use seems to become very common. The problem with looking at that without looking further is that we forget that these are drugs that have been flogged for a profit and that governments make money out of them. For governments to give up the taxation revenue from the sale of these products is something they just can’t bear to think about. So the drugs are not there in their own simple right, being chosen by people because they feel they would like a drink or a smoke. We are told we should drink and we used to be told we should smoke. My argument is that if drugs were to be legalised, nobody should make any money from their availability. Governments would have to supply them.
How would legalisation work?
How would my plan work if I am going to make drug use legal? All drugs would have to be covered. I wouldn’t want any drugs sitting out there as an attraction because they are the illegal ones and therefore something that I can flout society by taking. The process would have to be introduced after a lot of preparatory work had been done. It would have to be introduced nationally, with clear goals and objectives. A statement about drugs could be that any drug which alters the mood of a person is not a harmless and fully safe product that can be used by everyone, at all ages, in all concentrations without any risks or problems in the short or long-term.
We would also have to say to communities that the majority of people who do use drugs of addiction do so for a limited period of time, with few or no negative consequences and that criminalisation has not led to a cessation of use of any of the older or very new drugs which appear on the market from time to time. Public education, and not the sort of public education we have had around Hepatitis C and B – which is always half-cocked, not national, not done with a real vision about what we should be saying -would have to be done by the government if this were ever going to work. Drugs would have to be declared to be chemicals with various levels of danger or risk associated with their ingestion, just as we do with rat poison, Draino and other things which kill you a lot quicker than most of the drugs we are worrying about.
The plan would need to be established such that nobody makes a profit from these agents. The public would have to be informed that harm can occur, but the public lives with that. We kill more people on the roads than we do with heroin each year, but we don’t take cars off the road. We have adapted to the fact that some behaviours cause harm. The public accepts that if they are informed appropriately.
Efforts would need to be put in place to understand who was at more risk of harm in the community. To help reduce the risk of people needing to use these drugs, every effort would need to be directed towards assisting those people and the social circumstances leading to drug use being attractive to them.
Could this be done in Australia?
Could all this be done in a society such as ours? I suggest with certainty that it could, but it couldn’t be done in a hurry and certainly not with the systems which helped us to have the home insulation program from hell.
Would there be a risk? Of course, there are risks. Perhaps drug use would become passé because it is no longer illicit and those most damaged individuals who now abuse drugs might turn to some even more sociopathic behaviour. I can’t image that might be, but I am sure that they would come up with something. We might then have to think about whether or not that was made illegal. New and more dangerous drugs might be developed, but I suggest that, if there were no profit to be made, the drive to do so would quietly disappear.
In conclusion, I do believe, based on the principles of justice for all, but particularly for the oppressed, the mentally ill, the sociopathic and the genetically predisposed, legalisation needs to be changed. We do need to base the decisions on facts as we have them. Unfortunately, a lot of our present rules do not sit well with the facts we have before us. We need to move, having the courage of our convictions, but to move at an informed, appropriately paced and reasonable rate. We need to acknowledge the desperate need for more research data.
Given that, there is a true need for us to recognise that the vast majority of those who become dependent and harmful drug users, the people who steal our videos and DVDs, do have a background that is disastrous. We need to address this much more effectively as well – compassionately and urgently. Drugs are a distraction in this debate. I suggest that legalising them is the way to move forward.
*These references are available on request from Professor Batey: Robert.Batey@sswahs.nsw.gov.au
Professor Robert Batey AM, FRACP, FRCP, MD, trained at Sydney Hospital, Royal Prince Alfred Hospital and the Royal Free Hospital in London in hepatology and addiction medicine. As well as working at Royal Prince Alfred Hospital and in various regional centres, he is currently clinical adviser to NSW Health in addiction medicine. He recently accepted a Chair of the Academic Board of the Sydney Institute for Traditional Medicine.