SUMMARY: Australian youth harm minimisation drug policies increased substance use and harm and were inferior to American abstinence polices. When Australia adopted abstinence polices, substance use and harm reduced

Professor John Toumbourou, Deakin University.

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In what might go down as the most expensive experiment in missing the point, Australia’s decades-long dance with harm reduction policies has produced results that would be laughable if they weren’t so tragic. New data reveals a sobering reality: whenever harm reduction takes centre stage, drug-related deaths perform their own tragic encore.

Historical Context: Australia’s Drug Policy Journey

The trajectory of Australia’s drug policy reads like a cautionary tale in unintended consequences. Between 1985 and 1999, as Australia embraced harm reduction approaches, it achieved an unfortunate distinction: the highest drug use rates among OECD countries. The numbers tell a stark story – opiate deaths rose from 347 in 1988 to 1,116 in 1999, a trajectory that should have set off alarm bells throughout the public health community.

However, a brief period of hope emerged between 1998 and 2006, when Australia implemented the Federal Prevention approach. During this period, deaths from all drug types decreased significantly. This success was short-lived. From 2007 onward, with the return to harm reduction priorities, death rates began climbing again across all drug categories.

The harm reduction movement’s reliance on questionable scientific methodology deserves scrutiny. Consider the 2011 Lancet study on Vancouver’s injecting room, which claimed a 9% reduction in overdose deaths. Official British Columbia coroner’s figures tell a different story:

• 2001: 90 overdose deaths
• 2002: 49 deaths
• 2003: 51 deaths
• 2004: 67 deaths (37% increase after facility opened)
• 2005: 55 deaths (still 12% higher than pre-facility)

The study’s methodology artificially created positive results by comparing different time periods in a way that obscured the actual impact of the facility.

Current Harm Reduction Proposals: A Critical Examination

Pill Testing: The Dangerous Illusion of Safety

Proponents of pill testing present it as a scientific solution to drug-related deaths. However, a comprehensive analysis of 392 Ecstasy-related deaths in Australia between 2000 and 2018 reveals the fundamental limitations of this approach:

• 14% of deaths resulted from allergic-type reactions that no pill testing regime could predict
• Nearly half (48%) of deaths involved polysubstance use, particularly combinations with alcohol and cocaine
• 29% of deaths occurred due to accidents while intoxicated

These statistics highlight a crucial flaw in the pill testing paradigm: it creates a false sense of security while being unable to prevent the primary causes of Ecstasy-related deaths. The very presence of pill testing facilities may inadvertently legitimise drug use, suggesting to potential users that there exists a “safe” way to consume illegal substances.

Injecting Rooms: The Statistics That Don’t Add Up

Perhaps nowhere is the failure of harm reduction more evident than in the statistics surrounding injecting facilities. The Sydney injecting room reported overdose rates 63 times higher than the pre-registration rates of its clients – a number that defies logical explanation. Melbourne’s Medically Supervised Injecting Room (MSIR) reported even more troubling numbers, with overdose rates 102 times higher than street rates.

These statistics raise serious questions:

1. How do these facilities actually prevent harm when they appear to be associated with increased risk-taking behaviour?
2. Are these facilities inadvertently creating “safe spaces” for dangerous behaviour rather than reducing it?
3. Does the presence of medical supervision encourage users to take greater risks?

The 2020 government-funded evaluation of Melbourne’s MSIR revealed another troubling trend: deaths actually increased in the facility’s area, mirroring increases across Melbourne. This suggests that rather than preventing deaths, these facilities may be prolonging dangerous drug use patterns, ultimately leading to greater loss of life.

The International Experience: Cautionary Tales

Portugal’s Decriminalisation: A Closer Look at the Data

Portugal’s 2001 drug decriminalisation policy is often cited as a model for drug policy reform. However, a detailed examination of the outcomes reveals concerning trends:

• Overall drug use has increased by 59% since implementation
• Minor drug use has seen increases of up to 80%
• Overdose deaths have risen by 85% since 2002
• Portugal now ranks among the top three EU countries for illegal drug use in wastewater testing

These statistics stand in stark contrast to the narrative of success often presented by harm reduction advocates. The Portuguese experience suggests that removing criminal penalties, while maintaining technical illegality, creates a confusing middle ground that may actually increase drug use and associated harms.

The Colorado Cannabis Experiment: Unintended Consequences

Colorado’s journey with cannabis liberalisation provides another warning about the potential consequences of harm reduction approaches. Following medical cannabis law loosening in 2009 and full legalisation in 2013, the state experienced:

• A 410% increase in cannabis-related suicides by 2016
• A 360% increase in cannabis-related hospitalisations
• A 230% increase in cannabis-related traffic deaths
• A doubling of adult cannabis use

These numbers suggest that policies intended to reduce harm may instead normalise drug use and increase overall societal costs.

Evidence-Based Success Stories: What Actually Works

While the failure of harm reduction approaches is clear, several jurisdictions have demonstrated remarkable success with prevention-focused policies:

• Sweden achieved an 80% reduction in secondary student illicit drug use between 1971 and 1990 through a consistent focus on prevention and clear anti-drug messaging.
• Iceland’s prevention-focused approach resulted in a 60-90% reduction in secondary student illicit drug use from 1998 to present.
• Australia achieved a 40% reduction in both student and adult drug use during the “Tough on Drugs” period (1998-2007).
• The US much-maligned but effective “Just Say No” campaign achieved a 70% reduction in secondary student use between 1981 and 1991, demonstrating the power of clear, consistent messaging.

Time for Change: The Path Forward

As Australia approaches another Drug Summit, policymakers face a critical choice. The evidence clearly shows that harm reduction policies, despite their compassionate intentions, have failed to deliver on their promises. Instead, they have often contributed to increased drug use, higher death rates, and greater societal costs.

The success stories from Sweden, Iceland, and Australia’s own “Tough on Drugs” era provide a clear roadmap for effective drug policy:

1. Prioritise prevention over harm reduction
2. Implement clear, consistent anti-drug messaging
3. Maintain strong legal deterrents while providing appropriate treatment options
4. Focus on reducing overall drug use rather than merely managing its consequences

The time has come to acknowledge that enabling drug use while calling it “harm reduction” has failed. The data shows that Prevention, Demand Reduction, and Recovery aren’t just buzzwords – they’re proven lifesavers. The cost of maintaining failed harm reduction policies is measured not just in dollars, but in lives lost and potential squandered. It’s time for a return to these evidence-based strategies that have demonstrated real success in reducing drug use and its associated harms. (WRD News November 6th 2024^thWRD News November 6th 2024)

Also see

• How Harm Reduction Works in Australia
• And Podcast “Drug Policy: ‘Injecting’ Healing, Hope or Harm?”

Background: Resurgent psychedelic research has largely supported the safety and efficacy of psychedelic therapy for the treatment of various psychiatric disorders. As psychedelic use and therapy increase in prevalence, so does the importance of understanding associated risks. Cases of prolonged negative psychological responses to psychedelic therapy seem to be rare; however, studies are limited by biases and small sample sizes. The current analytical approach was motivated by the question of whether rare but significant adverse effects have been under-sampled in psychedelic research studies.

Results: We find that 16% of the cohort falls into the “negative responder” subset. Parsing the sample by self-reported history of psychiatric diagnoses, results revealed a disproportionate prevalence of negative responses among those reporting a prior personality disorder diagnosis (31%). One multivariate regression model indicated a greater than four-fold elevated risk of adverse psychological responses to psychedelics in the personality disorder subsample (b = 1.425, p < 0.05).

Conclusion: We infer that the presence of a personality disorder may represent an elevated risk for psychedelic use and hypothesize that the importance of psychological support and good therapeutic alliance may be increased in this population.

(Source: https://journals.sagepub.com/doi/epub/10.1177/02698811241232548 )

Question:  What is the risk of developing schizophrenia spectrum disorder following an emergency department (ED) visit caused by substance use with and without psychosis?

Findings:  In this cohort study of 9.8 million people, individuals with an ED visit for substance-induced psychosis or substance use without psychosis were at increased risk of developing schizophrenia spectrum disorder within 3 years relative to the general population.

Meaning:  These findings suggest that people who present to the ED for substance use, with or without psychosis, are at increased risk of developing schizophrenia spectrum disorder.

Abstract

Importance:  Episodes of substance-induced psychosis are associated with increased risk of developing a schizophrenia spectrum disorder. However, there are limited data on the transition risk for substance use without psychosis.

Objectives:  To quantify the risk of transition to schizophrenia spectrum disorder following an incident emergency department (ED) visit for (1) substance-induced psychosis and (2) substance use without psychosis and to explore factors associated with transition.

Results:  The study included 9 844 497 individuals, aged 14 to 65 years (mean [SD] age, 40.2 [14.7] years; 50.2% female) without a history of psychosis. There were 407 737 individuals with an incident ED visit for substance use, of which 13 784 (3.4%) ED visits were for substance-induced psychosis. Individuals with substance-induced psychosis were at a 163-fold (age- and sex-adjusted hazard ratio [aHR], 163.2; 95% CI, 156.1-170.5) increased risk of transitioning, relative to the general population (3-year risk, 18.5% vs 0.1%). Individuals with an ED visit for substance use without psychosis had a lower relative risk of transitioning (aHR, 9.8; 95% CI, 9.5-10.2; 3-year risk, 1.4%), but incurred more than 3 times the absolute number of transitions (9969 vs 3029). Cannabis use had the highest transition risk among visits with psychosis (aHR, 241.6; 95% CI, 225.5-258.9) and the third-highest risk among visits without psychosis (aHR, 14.3; 95% CI, 13.5-15.2). Younger age and male sex were associated with a higher risk of transition, and the risk of male sex was greater in younger compared with older individuals, particularly for cannabis use.

Conclusions and Relevance:  The findings of this cohort study suggest that ED visits for substance use were associated with an increased risk of developing a schizophrenia spectrum disorder. Although substance-induced psychoses had a greater relative transition risk, substance use without psychosis was far more prevalent and resulted in a greater absolute number of transitions. Several factors were associated with higher transition risk, with implications for counseling and early intervention

(Source:  JAMA Psychiatry | JAMA Network 2023)

Months after Australia found itself at the global forefront of work to treat mental illness using psychedelic substances found in illicit drugs like ecstasy and magic mushrooms, those working in the field say confusion is rife. 

A surprise decision by the country's drug regulator to approve the use of the substances, which caught even those working in the field unawares, came into effect on July 1.

Months after Australia found itself at the global forefront of work to treat mental illness using psychedelic substances found in illicit drugs like ecstasy and magic mushrooms, those working in the field say confusion is rife. 

A surprise decision by the country's drug regulator to approve the use of the substances, which caught even those working in the field unawares, came into effect on July 1.

Since then, public interest in the use of MDMA and psilocybin to treat conditions like PTSD and treatment-resistant depression has grown while mental health practitioners try to navigate the unexpected change — with some flagging "serious reservations".

As issues around how treatment should be administered, who should be able to access the tightly-controlled substances and how much treatment should cost remain unclear, a body of medical and health practitioners has called for an urgent industry meeting to help iron out the problems.

Some say 'premature' decision has led to 'virtually unworkable' system

Anthony Bloch chairs the Australian Multidisciplinary Association for Psychedelic Practitioners (AMAPP), a 160-member organisation formed in the wake of the decision by the Therapeutic Goods Administration (TGA).

He said the group understood the TGA decision was "both unexpected and perhaps premature" given "the lack of adequate research up until now into psychedelic medicines".

But Dr Bloch said in light of the decision having been made, the group is calling for an urgent meeting to be held with the TGA, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and state health departments to help improve how things are working.

"The current regulatory system is virtually unworkable, overly cautious and cumbersome and needs to evolve with the help and input from those practitioners who have appropriate knowledge and experience working in the psychedelic field," he said.

The TGA said it was "always open to meet with stakeholders in order to help overcome points of confusion that may exist" and had met with stakeholders regarding the use of psilocybin and MDMA.

"The TGA welcomes an expression of interest to meet with any organisation should they wish to seek further discussion on these issues," they said.

RANZCP president Elizabeth Moore said guidance developed by the body regarding psychedelic-assisted therapy involved consultation with experts, "with patient safety as the primary concern and number one priority".

"Use of psychedelic-assisted therapy may carry its own unique risks that necessitate careful clinical judgement."

Dr Moore said the RANZCP was committed to safe practice and would meet with stakeholders as appropriate.

There is confusion about how treatment gets administered

For people who manage to access the treatment, the process is not a simple case of being handed a script.

Psychedelic-assisted treatment requires intensive preparation and supervision and trusting relationships with the mental health practitioners involved.

Experts say about 20 hours is the minimum requirement for a course of treatment.

Under the changes, only authorised prescribers — psychiatrists approved by the TGA — are able to access and administer MDMA and psilocybin.

Dr Bloch said he understood that less than 10 psychiatrists across Australia had been authorised as prescribers.

"While we understand the caution, limiting prescribers to that level of involvement in psychedelics does not add to safety, in our opinion," he said.

"All it does is completely restrict access."

He also said the level of involvement expected from the authorised prescribers was out of sync with the way mental health treatment worked on the ground.

According to the TGA, the authorised prescribers "must be directly involved in the immediate care of every patient undergoing treatment". That includes patient screening and consent, accessing the drugs for treatment and assessing the treatment.

Dr Bloch said the role supporting mental health practitioners could play in treatment was unclear, as were the settings for psychedelic-assisted therapy.

"Some state governments are now saying the clinics have to be inpatient facilities, while other state governments are saying they can just be day clinics," he said.

The research behind MDMA and psilocybin differs

Psychiatrist Nigel Strauss, who has been involved in psychedelic therapy for more than a decade, said the body of research behind the use of MDMA to treat PTSD is quite well established compared with the use of psilocybin to treat depression.

And he said the drugs worked differently.

"Psilocybin is a true psychedelic and I think there's a need for more research on who is suitable for this treatment, to discover outcomes and so forth," Dr Strauss said.

"Even though the TGA have announced that we can use it in treatment-resistant depression, I think there is some concern that there's still more to be learned about how we select people for this treatment, and how the treatment is carried out."

A Swinburne University study involving about 160 participants trialling the use of psilocybin for depression is about to begin.

Dr Strauss said such studies — the approval of which is separate to the TGA decision — were crucial to informing the use of the drug in one-on-one therapeutic settings.

"The results of that will tell us a lot about the effectiveness of the drug, but also to help to train a number of therapists," he said.

Public interest has geared up

Since the TGA's decision, public interest in psychedelic-assisted therapy (PAT) treatments has spiked.

One of the few psychiatrists authorised to prescribe the drugs, who wanted to remain anonymous, said they had a waiting list of 400 people interested in accessing the treatment.

"They won't all be eligible or ideal candidates — however, they are people who have tried every available mental health treatment and are interested in psychedelic-assisted therapy," they wrote.

Another practitioner said they received about 10 enquiries a week, with that figure jumping to about 30 "immediately after any news/Netflix special, etc".

Amid the increased interest is also a lack of understanding about the strict criteria that means many will not be eligible.

One practitioner reported that their client had told them that when they saw a psychiatrist the next month for their ADHD "they were going to ask … for a script of psilocybin so they could start microdosing".

The cost is still prohibitive for individuals

Given the intensive nature of psychedelic-assisted therapy, and the lack of subsidies in place for access to the drugs, the cost can run into thousands of dollars, making it too expensive for most people to access.

Dr Strauss said as well as the long-term goal of attracting a "meaningful" Medicare rebate, there were opportunities for other funding sources to help individuals access care as the use of the drugs becomes more established.

"Ideally, we want to see the Department of Veterans' Affairs, other first responder organisations starting to fund their members' PTSD treatments," he said

"We want to see private health insurers jumping in and realising that funding a person's treatment-resistant depression for a lifetime is more expensive than a psychedelic assisted therapy which may put them in remission for years, or longer, from a single treatment."

(Source: The use of psychedelic drugs to treat mental illness is allowed in Australia, but confusion remains (msn.com)

Further Reading

• Psychedelics: The New Panacea – Just Like Cannabis, it will Fix Everything, Won’t it?
• Psychedelics: The Hype, The Hope, The Harm? – Is the therapeutic potential of hallucinogens risky and overhyped?
• History repeating: A Roadmap to Address Common Problems in Psychedelic Science
• Problematic Psychedelics – Prescribing Harm? Researchers Warn of Major Threats to the Validity of Psychedelic Research
• We don’t want to run before we walk