HEROIN, IT'S WHITE HOT

It is shaping up to be a tragic, quintessentially Australian dilemma, a
sad, perplexing trend that seems to negate one of the world's more
successful public health strategies, as PAOLA TOTARO writes.

Thanks to a pioneering commitment to harm minimisation schemes like needle
exchange, we lead the world in stemming the burgeoning incidence of
blood-borne viruses like HIV and hepatitis C - yet Australia is awash with
heroin users.

More and more people are using illicit drugs, first-time heroin users are
becoming younger, are using syringes far earlier and injecting much more
often. The price of heroin has continued to plummet in NSW and Victoria,
with the median price hitting a low of $240 a gram in Sydney this year,
nearly half the cost just two years ago.

The 1999 Illicit Drug Reporting System (IDRS), which monitors the price,
purity, availability and use of the four main illicit drug types - heroin,
amphetamine, cocaine and cannabis - finds this dark trend continues in
Australia, seemingly unchecked.

Unlike the Netherlands, Switzerland and some cities in Germany, we don't
appear to be putting a dent in drug use. In Switzerland, overdose deaths
have been halved, from 419 in 1992 to 209 last year, while our fatality
rates continue to rise, from 347 in 1988 to more than 600 in 1997. Here,
users are injecting younger, while in the Netherlands the average age of
injectors is in the late 30s.

Is it possible, ask some researchers, that relentless pop culture - from
films like Trainspotting and Pulp Fiction, to fashions like the appallingly
named "heroin chic" - have helped to finally demystify one of the most
addictive and destructive of drugs? Or that in our herculean efforts to
stem disease, we have helped strip away possibly the most powerful cultural
inhibitor of all - the stigma and fear of heroin and syringes?

The University of NSW's Dr Shane Darke - a senior investigator on the IDRS
project, which is to be released today - believes the fear that surrounded
syringe use in the 1970s is not as powerful today, and that may be having
an impact on younger drug users. He thinks new messages may be needed,
targeted particularly at young males.

He believes that public health strategies - like the promotion of needle
exchange - may have inadvertently conveyed the message "that it might be OK
to inject if you don't share a needle".

"Well, it's a serious activity ... I think that message, somehow, has to be
straightened up," Darke says. "It's important to prevent blood-borne
viruses, but we have to get across once again that [it] is in no way
condoning or saying it's ever safe [to inject]."

He and many colleagues argue that public education campaigns need "a bit of
a kick in the guts", to work against the changes in public perception of
heroin. "This image of heroin, that it is becoming seen as less dangerous,
that is false ... [young people] also think that you can't get into trouble
snorting or smoking.

"We have documented cases of people dying of overdose from smoking. The
message is, 'If you are using, it's never safe.'"

Darke's colleague, the National Drug and Alcohol Research Centre's
information manager, Paul Dillon, recalls a talk to Year 12 boys at a
Sydney school: "I asked them what they knew about heroin and heroin use.
They answered, all of them, names like Courtney Love, like [Aerosmith's
lead singer] Steve Tyler, like Keith Richards ... all people who survived
heroin, who have become successful in spite of it.

"I suppose in the '70s, heroin was about icons who died - like Hendrix,
Janis Joplin - they didn't talk about heroin use, it wasn't public until
they died. These kids all know someone that got through ... it's very
difficult to scare them about how awful it is, that it can kill you."

One of the great difficulties in the drug debate is that too often those
who advocate an approach based on abstinence - "just say no" - exploit any
questioning or discussion about the potential adverse side effects of
harm-minimisation approaches like needle exchanges. The issues raised in
the debate become an excuse to call for a winding back or abandonment of
such initiatives, effectively threatening hard-won community support.

Researchers, medical specialists, and drug and alcohol workers at the
coalface agree that the more tools in the doctor's kit, the better the
chance of reducing the problem and helping users.

Alex Wodak, the director of drug and alcohol services at St Vincent's
Hospital, is a passionate advocate of harm-minimisation strategies and
established the first needle exchange in Kings Cross in 1986. He rejects
any suggestion harm-minimisation strategies could have contributed to
upward trends in drug use.

We are, he argues, a piece in a worldwide opiate jigsaw. Global heroin
production is estimated to treble every decade and Australia has the
biggest airport and biggest container terminal in the Southern Hemisphere.

Put simply, we are the closest, richest nation to Burma, the world's
biggest heroin-producing region.

He says six reviews of international evidence by US government agencies
have each concluded that increased needle availability did not increase
illicit drug use. "In China, the registered number of drug users increased
from 70,000 in 1990 to 596,000 in 1998, and there is no needle exchange in
China ... the longevity of the hypothesis is clearly not related to
evidence," he says.

"It's not hard to see a lot of evidence that young Australians are in a lot
of trouble [and these troubles] are not unconnected to heroin use." Wodak
argues that high unemployment rates, shrinking education and training
opportunities, high youth suicide rates and rising rates of binge drinking
contribute to heroin use.

"Those factors, each on their own, let alone in aggregate, are 10 or 20
times more important than any influence from pop culture about needles or
syringes ..."

Wodak cites expenditure on drugs - law enforcement and treatment - as the
best indicator of why we are failing in the war against drugs. Switzerland,
which has managed significant inroads in reducing overdose deaths and
curbing blood-borne viruses, spends about 500 million Swiss francs ($486
million) on law enforcement and the same amount on health and welfare
intervention.

The most recent figures from the UN International Drug Control Program
state that 84 per cent of Australia's response to illicit drugs was
channelled into law enforcement, and only 6 per cent into treatment and 10
per cent for prevention and for research.

"So, you can see that nationally we are spending our money very differently
to the Swiss," Wodak says. "They spend 50:50 health and law enforcement.
When our drug overdose figures doubled, between 1991 and 1997, theirs
halved between 1992 and 1998.

"How did they do it? Well, while they spent $500 million ... and the Swiss
franc is about the same as the Australian dollar and they have a similar
population to NSW, we spent roughly $70 million."

Wodak insists that despite "what you hear from the zero-tolerance people",
Switzerland provides a wide range of options for drug users, including
funding for abstinence programs and harm-minimisation schemes.

Unless the treatment system is dramatically expanded, he says - both its
capacity and the range, quality and attractiveness of services - the
illicit drug market will keep growing.

"It's like a pyramid-selling operation. Every additional user recruited to
the illicit drug market ... tries to recruit others to pay for his or her
own drug consumption. Each new customer becomes a new wholesaler or retailer."

Asked if he is disheartened by drug-use figures, Wodak says, "You have to
approach it like you do treatment - be patient, expect relapses. We had a
relapse with the [abandonment] of the heroin trial in 1997, but we know
that will come good again. We have had setbacks in injecting rooms in NSW
and Victoria, but we know ultimately it will happen. Commonsense will
prevail; it almost always does. It's just a shame sometimes it takes so long."