10 Dec 2010
Submission by Burnet Institute (Burnet Institute)
Introduction and Mission
The manner in which the introductory material is framed suggests satisfaction with earlier strategies and an ongoing commitment to incremental change. The strategy would be strengthened by an explicit statement that this is indeed the preferred approach or by providing further clarification on the overall direction if this is not the case.
If Australia wishes to remain a leader in responding to drug related harms then the strategy should include clear articulation of past successes to build on, persistent gaps/challenges and a commitment to innovative responses to address these. The attempt to better integrate illegal drugs and other drug (e.g. prescription drugs alcohol and tobacco) use is a positive development and may lead to better capacity to maximise policy research and learning across different drug types (e.g. tobacco policy is relatively advanced and may provide insights for other drugs.
A more accurate description of how responses are operationalised and the tensions associated with health/law enforcement interactions in actual settings may increase potential for genuine partnerships than the current formulation that does not reflect these issues of competing tensions and prioirities adequately. With respect to this issue, there is no mention of corruption and how this impacts on performance of the strategy especially in relation to law enforcement.
The Pillars: Supply Reduction
Even though the strategy refers to ‘balance’ it still reflects an over-investment in supply reduction strategies. Commitment to this approach persists despite the absence of research evidence in support of effectiveness; community based policing is an exception here and provides an example of why commitment to trialling new approaches and commitment to gathering evidence of effectiveness is essential.
There needs to be an explicit acknowledgement that evidence in the area of supply reduction is lacking, a commitment to developing new and innovative approaches, development of performance indicators, not activity indices, and programming in response to what the evidence demonstrates works.
The Pillars: Demand Reduction
There needs to be increased commitment to collecting evidence for program effectiveness in the suite of demand reduction activities. The NDS refers to social marketing campaigns which have limited evidence for effectiveness outside of the tobacco programs (see Wakefield et al, Lancet, 2010). At a minimum, further research on developing effective social marketing strategies for other drugs should be undertaken before significant investments are made in programs using this approach. The section on participation needs to indicate that the evidence of effective programs in this area is very weak, and therefore further work is needed.
The strategy should allow for the development of consistent national structures for providing some of the mainstay treatments such as pharmacotherapy as a mechanism of demand reduction. This is especially important in relation to the costs of pharmacotherapy treatment which vary dramatically across the country.
The role of taxation as a supply or demand reduction tool with respect to alcohol is not represented in the strategy.
The Pillars: Harm reduction
For Australia to regain its position as a world leader in harm reduction significant innovation and vision not apparent in the current document are required. Examples of programs that may be explored/trialled include NSP in prisons, injecting rooms, improved substitution therapy programs, take home and peer naloxone. Other initiatives which could be supported under the strategy could include party safe initiatives, user-friendly health centres, peer education, 24 hour service provision, use of new and as yet underutilised technologies such as vending machines. Services scale-up should be among the objectives and can be reflected in process indicators around harm reduction services e.g. waiting times for pharmacotherapy, access to NSPs.
Despite strong evidence supporting substitution programs they receive little attention in the strategy. There is a clear opportunity for the Commonwealth to demonstrate leadership in this area to make programs more accessible and affordable for clients, an estimated 50% of people who inject drugs who would benefit from treatment are not currently accessing it (Ritter and Chalmers 2009).
The inclusion of workforce issues is a positive development but a number of improvements may be made:
• A broader definition of AOD workforce could include trainers and researchers essential to skills building and continuously updating the evidence base.
• The increasing complexity of improving outcomes for AOD service users is recognised in the strategy but the difficulties associated with attracting and retaining a suitably skilled/qualified workforce particularly in the NGO sector needs to be addressed – this is linked to SACS award paying up to $20,000 less pa when compared to government services.
Evidence base and Performance measures
Ongoing commitment to evidence informed programming is admirable but the strategy must also embody the same principles for data quality and use. For example, the strategy refers to data from 1998 data (NDS p11 re illicit drugs) which is an outlier due to survey errors and cannot be compared with later data to provide an accurate description of trends (2001 survey data is the earliest available comparison).
A minimum standard for program evidence must be consistent across the three pillars of harm minimisation. This is usually done well for drug treatment and other health indicators but should be replicated across all areas. In particular, a shift from activity indicators to valid and reliable performance indicators focussing the harms in the area of demand reduction and supply reduction (interruption) need to be identified. The number/volume of seizures alone cannot be a measure of success and using prevalence data to attribute success to supply and demand reduction programs is tenuous. Issues of this type arise with respect to law enforcement and many other previously funded programs.
There should be scope within the strategy to revisit activities within the suite of responses where the evidence has improved/changed to ensure effective responses are not excluded from consideration e.g. Sydney MSIC
The NDS strategy should be a big-picture consensus document with a clear indication of where we aim to be 5 years hence. The draft NDS identified 16 relevant but separate sub-strategies at various stages of implementation in Appendix A. However, it does not articulate how these interact with the overarching NDS. As many of these have already or are about to expire, the Drug Policy Modelling Program proposal for a series of workplans to replace the sub-strategies is advocated. Workplans with detailed measurable performance indicators and resource allocations by subject area should report against the overarching objectives of the NDS and still allow sufficient flexibility to accommodate the reality that plans are implemented at state and local level and in a range of settings.
NDS governance arrangements need improvement to ensure key stakeholders (e.g. public, service providers and consumers and experts) remain engaged with implementation. The IGCD needs to achieve a balance between using in-house resources and drawing on external expertise especially in areas such as engaging the alcohol and other drug sector in significant health sector reform processes (e.g. Medicare Locals). The draft strategy hints at approaches for improved governance (e.g. linking AOD to the social inclusion agenda, establishment of working groups for development of research and workforce development strategies) but the public and service users remain unrepresented.
The two National research Centres should broaden their scope to reflect the fact that most of the spending is in law enforcement. There is also a need to make the funding mechanisms for these entities more competitive.
The membership of the national drug research data working group needs to be broadened.
Use of the term “drug” to include both licit and illicit is a positive development. However, the terminology throughout the document should be alcohol and other drugs and drug use.
Words such as misuse and abuse contribute to stigmatisation of individuals and risk groups and undermine program implementation. If misuse must be used then it requires definition/explanation.
The shift in approach from individual and population group risk to risk “settings” should be applauded and ideally will translate to incorporation of international best practices many of which have emerged in international HIV prevention programming.
The increased emphasis on disadvantage is appreciated but the new document does not adequately recognise the important role individuals and communities including people who use drugs, have in the development of effective responses. The strategy needs to go beyond recognising needs exist (e.g. among remote and rural communities) and outline strategies for improved access and affordability.
The challenges section (p12) partially recognises the scale of harms/costs but would be improved by a statement of prioritised responses according to the hierarchy of harm (health, economic, social and legal) with sufficient flexibility to respond to emerging harms.
The inclusion of headline performance measures facilitating strategy evaluation is commended.
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