Harm Reduction: How Australia Stopped HIV

In 1985 before the introduction of needle and syringe programmes (NSP) 90% of Australian injection drug users reported sharing injection equipment. By 1994 following introduction of NSPs this figure had fallen to 20%. In 2009 this figure was around 15% possibly reflecting the constant number of distributions from NSP programmes over the previous decade.

One of the most powerful modes of resistance to the spread of HIV/AIDS is Harm Reduction (HR) measures.

In Australia, HR exists as one of three pillars of Harm Minimisation (HM) – our official illicit drug control policy. The other two pillars are Supply Reduction and Demand Reduction. Reduction in supply receiving the lions share of funding directs energy at reducing international and domestic supply. Reduction in demand receiving less funding delivers programmes and initiatives designed to reduce the demand for drugs within communities.

Harm Reduction receiving the least funding from the HM pile targets the harm to individuals that eventuates from behaviour. HR has always drawn condemnation from conservative groups because of the association with drug use and sex. Initially men who have sex with men (MSM). Then later through maximal exploitation of drug using pop culture. Nonetheless, study after study comparing countries and districts within countries to have implemented HR or not done so, show a stunning success in favour of HR.

This post will look almost exclusively at IV drug use. HR for Injection Drug Users (IDU) includes provision of clean needles and sterile water, swabs, sharps containers for disposal and specialised filters capable of removing bacteria. Opioid Substitution Therapy (OST) including methadone and buprenorphine and safe injecting facilities are pivotal aspects of HR. Heroin on prescription is not available in Australia but has shown unprecedented success as a HR measure where it has been implemented.

Despite the evidence supporting HM as an effective policy and the reality that Supply Reduction [law enforcement] is the most highly funded pillar, Aussies are still subject to notions such as “Tough on drugs” and code words such as Drug Free Australia’s Harm Prevention. Intuitively it sounds fine. Why minimise harm if you can prevent it?

Yet on examination “harm prevention” is the abandonment of HM for the reintroduction of Just Say No approaches. Known to have had deleterious effects on self esteem, no effect on lowering drug use and providing the field upon which drug use flourished, Just Say No quite simply failed, and failed Epically. Today of course, skeptics are well aware of how beliefs and behaviours are reinforced through attacking them. Harm Prevention even more so is code for punitive, custodial and forced behaviour control.

It is at times perplexing as to why so much energy is spent on attacking HM entirely. Supply Reduction however is based in part upon the reality that people want, seek, use and enjoy illicit drugs. Education to accompany this is open and honest – not promotion of illicit drug use . Yet to the conservative mind the idea that their children, friends or the community at large is the demographic from which drug demand comes, is morally untenable.

With HR it is aspects of this pillar that equally cannot be accepted. To the conservative mind, just as condoms cause AIDS and promote sexual promiscuity so too do clean needles, safe injecting facilities and safe injecting education encourage drug use. Drug Free Australia write:

We need to re-focus our drug policy and practice on an approach that prioritises primary prevention, if we are to see any real change in the health and wellbeing of our current and future generations of young people. We need to acknowledge that Australia has one of the highest rates of drug use, because of a priority on Harm Minimisation rather than Harm Prevention, and we now need to take a leaf out of the books of the policy makers in the UK and United States. Both these countries have given greater emphasis to prevention initiatives, while still aiming to help people who are drug dependent, to recover.

The towering dishonesty inherent in this nonsense is typical of the tactics used by DFA in what has become over just a few years, one of the most immoral lobbying groups on the illicit drug landscape. Australia has high levels of cannabis use and abuse. This is handy in arguing that we have high drug use generally. A synopsis of the above is simply: Harm Minimisation has caused Australia to have one of the highest drug use levels in the world. We should be doing what America and the UK do.

The UK get a mention because they reclassified cannabis to a Class B (like speed/other amphetamines) from a Class C drug and punish users accordingly. Of 2.3 million USA prisoners in 2010, over 65% or 1.5 million meet DSM IV medical criteria for substance abuse or addiction. On top of this another 458,000 have a history that meets DSM IV criteria for addiction, were under the influence when they committed their crime, committed a crime to finance the purchase of drugs or were incarcerated for a drug law violation.

Between 1960 and 1990 official crime rates in Finland, the USA and Germany were similar. Incarceration in Finland dropped 60%, remained stable in Germany and quadrupled in the USA, driven primarily by drug convictions.

Today around around 80% of USA prisoners are incarcerated due to illicit drugs. 11% are receiving some type of “treatment”. The last thing Aussies need is a dose of the USA nightmare.

What of the impact of changing our strategy on HIV and consequently other types of blood borne virus transmission? The graph below is from a TED talk by Sereen El-Feki, vice-chair of the Global Commission on HIV and the law:

HIV infection in Injection Drug Users

Whilst Thailand and Russia have ignored Harm Reduction and Australia and Switzerland have embraced it the USA and Malaysia employed only some Harm Reduction techniques. Should Australia embrace USA tactics our prison population will explode, HIV infection in IV drug users will increase by about eight times the present rate and treatment – presently some of the best in the world with plunge to 11%. The cost to the public health purse would simply gut present programmes and destroy any hope of improvement for say, dental, mental health, public hospital care, nursing home care etc.

There is a 4 minute out-take from Sereen El-Feki’s TED talk in April this year below. Or download MP3 here.

The first case of AIDS was reported in Australia in 1983. At that time morbidity rates to rival World War II were expected. Following the innovative approach of HR, levels of infection in all demographics fell from 2,500 per year to 500 in the decade following inception of HR. This infection rate has remained stable.

At the time, initiation of clean needle supply contravened the states Drug Offensive which, already highly criticised, had regrettably escalated drug use and criminalisation via the failed “Just Say No” approach. The pilot programme ran from St. Vincents Drug and Alcohol Service on November 13 1986. It was run in the suburb of Darlinghurst. An evaluation recommended they should be adminstered by social workers, drug agencies, pharmacies, medical professionals and urged:

The urgent widespread introduction of needle exchange programmes in all states and territories

There needed to be an amendment to the Drug Misuse and Trafficking Act following which NSW pharmacies sold “anti-AIDS kits”. By mid 1989 there were 40 public outlets run across Sydney. By 1994 there were 250 outlets run by NGOs, government agencies and pharmacists distributing 3.5 million syringes annually. For the year 1993-1994 10.3 million syringes were distributed across Australia. The USA with 15 times the population of Australia distributed 8 million syringes in 1994-1995.

More comprehensive analyses refuted the concerns of increasing drug use. No increase in drug use was seen in any country that had instigated needle exchange and more so, attendance at rehabilitation and abstinence programmes had increased. Australia’s Commonwealth Department of Health (now Dept. of Health and Ageing) estimated that 25,000 cases of HIV were averted in the 12 years from 1988 – 2000 due to needle exchange alone.

The infection rate among Aussie IDU sat at around 3%. Users who were also MSM had an infection rate of 27%. In Russia where HR for drug users was denied, the figure for IDU was between 75 and 90%. One study in 1997 looked at 81 European cities with and without needle exchange programmes. Seroprevalence (measured from the presence of HIV within blood taken from used syringes) increased 5.9% annually in cities without clean needle distribution, and decreased 5.8% in cities with needle exchange.

In an astonishing comparison, Edinburgh with no NSP experienced a 65% HIV infection rate amongst IDU. Glasgow, less than an hours drive away and with NSP experienced a 4.5% increase in HIV infection amongst IDU. The one issue Australia faced was return of used syringes. Users were placing them in sharps bins. Yet to return any syringes to Exchanges meant risking being questioned by police. A used syringe is evidence of illicit drug use and this acted as a disincentive to return items for safe disposal.

Of note however is that fears and front page headlines of beach goers and joggers stepping on syringes and undergoing “agonising waits” for blood tests to be cleared of HIV infection are out of proportion. HIV dies very quickly once outside the body and syringes on beaches have been discarded into drains, washed out to sea and then beached. Nonetheless despite the absence of actual transmission it is an unpleasant experience which can be lessened by removing all offences for possession of a used syringe.

Clearly, Australia’s decision to take the necessary steps and bring together members of drug using demographics, gay rights advocates and prostitutes collectives and allow them to consult upon and shape this programme was one of it’s greatest public health initiatives ever.

Between 2000-2009 NSPs have averted 32,050 new cases of HIV and 96,666 Hepatitis C infections. Needles distributed increased from approximately 27 million to 31 million in that decade. For every one dollar invested, four dollars have been saved. 140,000 Disability Adjusted Life Years were gained over the same decade.

Still, conservative biblical fundamentalist group Drug Free Australia boldly inform us that Return On Investment is quite wrong and should show an expense. In earlier posts you can access from the tag on the right, I highlight how they cherry pick phrases and select data out of context. At other times they simply dismiss WHO findings based solely on the reviews of just one Swedish researcher, Dr Kerstin Käll.

So to be very clear, Dr Kerstin Käll, working for the Swedish government who are dodging UN demands to establish more Needle Exchanges and accelerate HR or remain in breach of the international right to health, conducted no research but criticised methodology that was favourable of NSP success. Her own research argues regular testing for HIV is more of a prevention – yes prevention – than clean needle supply.

It’s easy to get confused because whilst Käll supports NSP programmes as reducing hepatitis C in prisons DFA refute any change in HCV attributable to NSP programmes… anywhere. They also lobby stridently against the establishment of needle exchange in Australian prisons. Of course, despite the evidence above they insist the impact of NSP on HIV is “inconclusive”.

Ultimately it’s irrefutable how successful Harm Reduction has been in controlling the spread of blood borne viruses. Paramount amongst these is HIV, Hepatitis C and Hepatitis B. The most significant and visionary measure to now apply would include steps to decriminalisation and regulation.

Today however, this is where Australia is falling behind.

Australia still shirking drug policy discourse

The prohibition of illicit drugs is killing and criminalising our children, and we are all letting it happen

Senator Bob Carr (Foreign Affairs Minister), Mick Palmer (former Federal Police Chief), Nicholas Cowdery (former Director: NSW Public Prosecutions), Geoff Gallop (ex W.A. Premier)

On April 3rd this year Aussies woke to news of “the most significant challenge to drug laws in decades”, as reported by Fairfax media below. Or download MP3 [41sec]:

Interesting then that Bronwyn Bishop looks set to sit on the Front Bench of Australia’s next Federal Government. In 2007 Bishop chaired a House of Representatives Senate Inquiry into the impact of illicit drug use on families. Dreamed up by John Winston Howard to give an airing to the extreme right wing anti-drug movement whilst simultaneously heaping shame upon the brilliant minds driving the policy of Harm Minimisation, it was an appalling example of a predetermined agenda.

For many years prior it was axiomatic to those involved with illicit drug policy and the impact of organised crime that prohibition was a failure. The War on Drugs is a war on people and it surprised no-one that Bishop entitled her all singing all dancing moral panic final report “The Winnable War”. It was rejected by every D&A policy, funding and health service of any standing. Indeed by many more with pretty much no standing.

Drug Free Australia (DFA) and a range of conservative anti-drug lobbyists held it in high regard. Ann Bressington, who squeezes anti-vaccination, anti-fluoride, anti-Harm Minimisation and Festival of Light fundamentalism into her day, was delighted. Then again, Ann verbally coached a witness through his submission to say he “escaped harm minimisation, not addiction”.

Bishop had given succor to one of their fundamentalist favourites, and on the same day attempted to batter one of their sworn enemies for his devotion to health policy, science and evidence. Perhaps I shall recount one exchange with the G.P. who used naltrexone, sedatives and the bible in bringing about the death of 25 of his heroin dependent patients in 20 months [summary]. Now an “expert” in naltrexone related fatality with Drug Free Australia (I kid you not) he said then:

I was interested to discover that the actual historical site of Sodom and Gomorrah has recently been found in Israel. On the bottom right of this slide are pictures of sulphur balls that have been found there. So consequences matter, and they can destroy a civilisation quickly, as we saw with yesterday’s tsunami and so on.

This slide shows a tree with snakes, which to my mind is a lot of the stories that you hear from harm minimisation. Methadone, syringe giveaways, injecting rooms, medical cannabis, heroin trials all those are catered for by the same people. But, on the other side of the tree, you have all the downsides, the side effects, which are not talked about in this culture.

It is of extreme concern to me that medical science which is known and understood overseas is not understood and not talked about and given no airplay whatsoever in this culture.
These are old slides I made several years ago, charting a lot of these behaviours: this is condoms and the AIDS risk, charting the parallel between condoms and AIDS deaths.

Ms GEORGE (Senate committee member): Sorry, I do not understand. What are you saying – condom protection and AIDS deaths are correlated?
Dr Reece: Yes, condom sales and AIDS deaths. I am saying that there is a statistical association between the two.

Under Keeping Up The War On Drugs Bishop wrote in her report:

A significant amount of damage to families and the community has been avoided by the government’s uncompromising approach to the trafficking and use of illicit drugs. Drug industry elites who have repeatedly claimed that the ‘war on drugs’ has failed are simply wrong. [...]

The Australian Federal Police (AFP) and its partners have been highly successful in limiting the damage of illicit drugs in Australia. The number and weight of detections for selected illicit drugs are generally higher than before 2000…

Increasing drug seizures reflect increasing drug traffic. Increasing traffic reflects increasing and increasingly varied demand. Such demand indicates more use and we already knew more use was due to ineffective tactics globally. The snide term “drug industry elites” still has life in certain circles. Essentially it demeaned those who dealt in evidence alone and advised accordingly.

Australia endured the rejection of science by politicians for the very tenuous reason of hopefully securing votes. At the States and Territories health ministers’ conference in Cairns in 1997, the issue of a heroin trial – the latest step in Harm Reduction to show exciting success in Europe – was raised. Ultimately Michael Wooldridge, four states and the ACT voted for trials to begin. The result was 6-3 in favour.

Whilst credit is due for his continued funding of needle exchange programmes, Howard had not just a conservative eye but a retributive one. The success of Harm Minimisation under the previous government left him keen to change the essence of a policy that had seen Australia emerge as world leaders. Thus we copped his Tough On Drugs approach – a dismal failure. He immediately cancelled the trial on advice from his Evangelical adviser and first Chair of the ANCD, Major Brian Watters.

Watters was already making enemies in the ANCD itself, for merging his Salvation Army role with what should have been best practice. A Drug Free Australia Board member, Watters’ disdain for science and academics was manifest. He had spoken on an episode of Four Corners with John Howard:

WATTERS: I mean, the Salvation Army’s been doing it for 120 years. No good these academics telling us it doesn’t work.

HOWARD: And I feel in very safe hands, with the police on the one side and the Salvation Army on the other.

WATTERS: It’s the law and the prophets.

HOWARD: It’s the law and the prophets. That’s right.

So it continued. The “law and the prophets” looking after in-need Aussies. One of the most used phrases in the bible, it’s most significant aspect is that Jesus came to “fulfill” The Law and The Prophets. Then we got the faith healers and the purists. The Evangelists and the righteous. Anti-harm minimisation groups arose – DFA itself funded by [then] Health Minister, Tony Abbott. Others re-emerged keen to sink the conservative boot in to such sinful wickedness as clean needles, condoms and honest, open health education.

In 2007 The World Federation Against Drugs firmed it’s resolve in Sweden in striking mockery of the NGO Forum at the 50th Commission on Narcotic Drugs. Human Rights, Harm Reduction and Health Responses we heard from [then] UNODC Executive Director, Antonio Maria Costa, would be crucial to future global policy initiatives. Apparently not if conservatives could help it. Populated, perhaps unsurprisingly, by a number of biblical fundamentalists, evangelists and young earth creationists one might appreciate the uncompromising stance and anti-rights position that WFAD entertain.

On May 21st Mark Metherell reported:

DRUG Free Australia may not be a household name but its leaders claim a role in repelling further moves towards what they see as the evil of drug decriminalisation.

It fears the ”tough on drugs” regime of the Howard government is unravelling, with the abandonment of the school drug education strategy and declining use of community advertising campaigns. [...]

‘Our view is that Australia’s illicit drug policy is too lenient, sending mixed messages to our youth,” [Jo Baxter] said.

Here’s a picture drawn by a child attending a DFA school education strategy (Hint: be drug free, go to heaven). Interestingly the Education Department in S.A. has a different view to Baxter on the matter. That article mentions a member of Youth for a Drug Free Australia, who is also head of The Recovered Drug Users League SA, Ryan Hidden.

He just happens to be the chap Ann Bressington coached to lie to the House of Representatives. But later Jo had him chatting to kiddies in school against Education Department instructions. A few weeks earlier he chose to dob in tobacconists the very day after Ann Bressington’s “bong ban” came into force.

Now… where did I read “mixed messages”?

Jo Baxter is Executive Officer of Drug Free Australia, Spokesperson for the S.A. “campus” of the evangelist driven Delgarno Institute is also vice-president of the World Federation Against Drugs. If you want an attack on human rights driven policy in Australia, Drug Free Australia is the group. If you want a “Heads Up People!” attack on the Global Commission on Drug Policy, whose main report also concludes prohibition has failed, the Delgaro Institute is the place.

But if you want to read an attack on the host of eminent Australians who produced the report raised in Parliament last April 3rd, Jo Baxter will even pop on her WFAD V.P. hat. So what do we get? Labelling the report compiled by 24 former senior state and federal politicians, experts in drug policy and public health, young people, a leading businessman, legal and former law enforcement officers, as “lacking substance” Jo begins:

The so-called ‘high level’ report on illicit drugs, suggesting that decriminalisation across the board, will solve Australia’s drug problems, lacks sound scientific basis and credibility and, as such should be discounted. The following a (sic) just some of the reasons:

First, it is not the ‘War on Drugs’ that has failed, but rather, it’s the failure of Australia’s Illicit Drugs Policy to satisfactorily address primary prevention.

For over 25 years Australians have endured a policy of Harm Minimisation, which has left a ‘train wreck’ in families and communities across the nation. [...]

They have failed to recognised that, between 2000 and 2006, Australia had a Tough on Drugs Strategyand our illicit drug use rates dropped significantly. The trend is now turning around. [...]

Which is it I wonder? A Harm Minimisation train wreck or a Tough on Drugs victory? Harm Minimisation arrested the spread of HIV, Hepatitis B and harmful drug using practices. The surge in heroin use is well documented as due to immigration of a S.E. Asian demographic able to import large quantities and sell at reduced rates. If prohibition was working initially this would not have happened.

Instead criminal cartels blossomed and later shifted to manufacturing their own product indoors. If prohibition worked that would never have happened. It seems to me like Tough On Drugs actually oversaw the rise of many new classes of drugs and an actual shift in the drug using habits of our community more in line with criminal profit.

As always Harm Minimisation and Reduction have functioned to manage the fallout from prohibition’s failure.

Effectively Jo’s article is a repeat of what the Drug Free Australia mantra has been, no matter what the title, debate, paper or conference. A synopsis of what Bronwyn Bishop concocted in 2007. A reflection on their bogus research on Supervised Injecting Facilities, Needle Syringe Programmes, Medicinal Cannabinoid research and so on.

The global Drug Free movement is to illicit drug policy in the community, what creationism is to evolution in the science curriculum.

Given the demonstrable failures of prohibition, we are still reticent to discuss this issue vociferously. Clearly it is a topic that can be easily misinterpreted, accidentally misrepresented or used to cast mischievous accusations toward those who mount firm evidence backed arguments. Much of the confusion stems from the fear that drug use under relaxed laws will equate to greater use. Often this is expressed as if one believes use will be compulsory.

Yet needle provision did not lead to increased use. The return on investment is four dollars for every one dollar invested. As needles are returned potential virus reserves are removed from the community. Users reciprocate with services learning to manage health and exploit opportunity to cease using. New users are resourced and educated to develop the means to never risk cross infection. The entire community benefits and vital dollars are not spent dealing with preventable problems.

Still, the false belief that use is encouraged this way persists in the face of overwhelming evidence to the contrary. Similarly the notion of deregulation is seen as a “free for all”, quite bizarrely likened to alcohol. Perhaps understandably challenges to drug prohibition evoke images of the end of alcohol prohibition. With this comparison comes the assumption all drugs will be readily available and an integral part of culture. Businesses will provide and houses will be stocked. The roads will be full of talkative, super-horny, hallucinating, dozing, dancing, slurring and very hungry drivers heading for pizza.

No. The only relationship to alcohol prohibition will be the removal of the millions of Al Capone types and the violence, intimidation, corruption, ruined families and poisoned customers that inevitably evolve. The failure of prohibition can be seen in a top down, if not linear fashion. Yet the way in which it is finally dismantled is in my mind not completely predictable and remains a complex bottom up venture to be managed with flexibility.

Evidence across the world shows use drops or remains stable with relaxed laws. The Portuguese example has presented in over a decade, remarkable success. The advantages of removing extensive punitive measures and simple stigma become manifest in a few short years. Legal resources freed from the waste of hassling petty users are brought to bear on serious crime. Users, freed from the fear of severe prosecution and shame become proactive in seeking help.

Potential users become a smaller market as drugs become controlled by authorities and subject to medical oversight – not criminal endeavour. More so, the opportunity to get ones life back on track is a reality that provides huge motivation to avoid drug use and experimentation. Presently in Australia, by the time users need substantial help they may be alienated from society, ashamed, angry and overwhelmed by the prospect of “perhaps” getting a decent life back under way.

Options used to mange illicit drug use are well explained in the Australia 21 Report:

  • Decriminalisation means specified proscribed behaviour is removed from the criminal law and is dealt with under the civil law.
  • De-penalisation means reducing the severity of penalties.
  • Legalisation means that the specified forms of behaviour are no longer offenses dealt with by the law.
  • Regulation means establishing a strictly controlled legal market for drugs as is the case with pharmaceutical drugs, tobacco products and alcoholic beverages.

Deconstructing prohibition is not a licence to take drugs. It is a means to remove lucrative profits from criminals and steer in-need and at-risk Aussies toward a healthier and more hopeful future. Those able to see a way out of the present mess all hold a somewhat unique view. No one person holds the solution, but certainly as experts and visionaries, groups such as the Australia 21 Board are urgently needed to begin the process of improving Australian lives and saving tax payer dollars.

400 Aussies die from drug related causes annually and countless others suffer a range of related harm that varies from mild to severe interpersonal conflict, financial tragedy or horrific violence. Lives are cropped of potential and under the present system valuable, talented and vital community members slowly withdraw from society even years after they have ceased to use any drugs.

Stopping us from turning this mess around is the movement I opened this article with. Whether it’s same sex marriage, being an atheist or removing the stigma from elicit drugs a vocal and well organised minority conclude that they can do any and everything to impose their own moral values on the rest of the society. In effect however, knowing that they cannot successfully do this the outcome is merely to impede progress to equality and thus limit the freedom of others.

Hence we cannot really have this discussion without at some point acknowledging it isn’t resisted just on philosophical grounds. The continuance of the war on people and the fruitless prohibition of illicit drugs, regardless of means used, is the single aim of those who today are seen attacking Harm Minimisation and Harm Reduction.

Therein lies the problem. Whilst arguments are akin to anti-vaccination rhetoric: repetitive, evidence free, conspiratorial, personal and peppered with linking all related ills to the present policy, in this case conservatives do have political sway. Thus full and open discourse regarding the retrieval of control from organised crime must include the reality that the anti-drug movement is guilty in it’s own way of inflicting suffering, corruption and death on our nation.

More so, they know this well. The bulk of attacks on Harm Reduction revolve around creating the pseudoscience and pathological theories to argue HIV has not been controlled by reducing the personal exchange of blood and body fluids. Despite the exquisite correlation between Harm Reduction absence and HIV presence across the globe it is still argued that HR “enables” drug use, thus causes all negatives that go with it.

Discourse is poor because the reality is that no government would dream of even broaching the subject for fear of alienating the conservative vote. Dr. Reece states above that condom use parallels AIDS deaths and God’s wrath will follow Harm Reduction measures as a “consequence”. Rhetoric fed to parliamentarians about Injecting Facilities is nowhere near as absurd, looks genuine to the untrained eye and can influence decisions. We should expect the same polish in defence of prohibition.

Changes in equal rights now look set to take years. The public is well versed in who the bigots are in matters of marriage, abortion and euthanasia. For the public to be prepared to take on a gradual change in their world view as it pertains to drug use and abuse, those truly dedicated to abolishing prohibition need to expose the bigots and the saboteurs also. And yes, it may be that simply opening channels of discussion will be enough to do this.

The evidence is irrefutable. Prohibition has failed and it is killing Australians. We don’t just need discussion on the necessity for change. We need discussion on why there is as yet no change and instead a persistent silence. Every report on this issue and every report on Harm Minimisation success is attacked by anti-drug lobbyists such as Drug Free Australia.

When we do expand the discussion we must be prepared to lay the blame at their door.

Drug Free Australia’s attack on Insite really an attack on individual scientists

A close look at Drug Free Australia’s recent attack on research supporting Vancouver’s Safe Injecting Facility, Insite, suggests a long planned attack on individual authors, not evidence.

Recently I wrote a piece on Drug Free Australia’s selective and misleading use of peer reviewed publications, government reports and pseudoscience to mislead readers with the claim of academic fraud and professional misconduct in the Lancet.

Their target was Insite, Vancouver’s Supervised Injecting Facility. Yet more specifically three authors of the Lancet piece, Evan Wood, Julio S G Montaner and Thomas Kerr have earned the retributive ire of Drug Free Australia’s parent body, Drug Free America Foundation. DFAF’s “division”, the Institute on Global Drug Policy fund the Journal of Global Drug Policy and Practice, which is not a journal but a vehicle for lobbying against progressive drug policy primarily that which targets HIV control. The JGDPP was initially funded by the US Department of Justice, presently under investigation for corruption.

One of the co-authors of the paper was Robert DuPont. Present DFAF board member, past White House Drug czar and former first director of NIDA, DuPont’s history is “impressive” but shamefully controversial. A champion of drug war tactics, the long debunked random drug testing of kids in schools and suppression of individual rights suggest he’d be better suited to the role of a cat-stroking super villain in a Bond movie.

The scale of human rights abuses and the litany of egregious conduct orchestrated by the ultra-conservatives drawn toward DFAF and the morally bankrupt satellite groups they inspire, is impressive indeed. DFAF was founded by Betty Sembler. Betty and husband Mel, both lacking any qualifications founded Straight Incorporated in 1976. Over 15 years this “coercive” rehabilitation programme, based upon the infamous and crime riddled Church of Synanon‘s approach, racked up hundreds of accounts of abuse of clients and their families. Synanon called it a day in 1989, by which time tax evasion, civil suits and attempted murder cases had eventually outshone their claims of Divine Detoxification.

Neither Drug Free America Foundation nor it’s pretend “Institute” on Global Drug Policy is a scientific organisation. The purpose of the IGDP is spelled out on the DFAF website:

The Institute is charged with creating and strengthening international laws that hold drug users and dealers criminally accountable for their actions. It will vigorously promote treaties and agreements that provide clear penalties to individuals who buy, sell or use harmful drugs. […] The institute supports efforts to oppose policies based on the concept of harm reduction.

Over recent years some rather spectacular junk science was produced by Dr. Colin Mangham, (then) president of the Drug Prevention Network of Canada. Whilst harm reduction initiatives save countless lives per year Mangham’s DPNC claims it “leads to terror, degradation and the eventual death of the addict”. Consequently Mangham writes accordingly and publishes in the discredited Journal of Global Drug Policy and Practice. In volume 1, issue 2; Summer 2007, Mangham wrote a critique of Insite’s “parent philosophy”.

In a stunning display of self sabotage he churned through 20 peer reviewed articles from journals including The New England Journal of Medicine, the Lancet and The British Medical Journal. All articles had published positively on Insite’s potential. Primarily Mangham used largely belief, irrelevance, moral outrage and assumption to mount his criticisms. The Royal Canadian Mounted Police (at that time opposed to Insite) had commissioned the review and later dismissed it themselves because it “did not meet conventional academic standards”.

It’s impossible to miss Mangham’s primary evaluation targets on his self-annointed meandering journey to Super Scientific Autonomy. Evan Wood, Julio S G Montaner and Thomas Kerr.

Conservative health minister, Tony Clement, desperate for even a hint of science to uphold the government’s case against Insite seized upon it as validation. In Canada’s National Review of Medicine, September 2007, Clement is quoted as saying to the Canadian Medical Association:

There has been more research done, and some of it has been questioning of the research that has already taken place and questioning of the methodology of those associated with Insite.

The article continued:

But extensive research has shown Insite is successful at reducing crime and overdoses, getting addicts into treatment and saving money.

Asked what research Mr Clement still needs to see in order to make his decision, Erik Waddell, a spokesman for Mr Clement, answers, “To see if Insite is getting people to programs to help them get off drugs.” However, the NEJM study, published June 9, 2006, concluded that Insite increased admissions into detoxification programs and addiction treatment.

The piece, written by Colin Mangham, PhD, argues that the studies carried out by researchers from the BC Centre for Excellence in HIV/AIDS and elsewhere have been flawed and misleading. Questions about the article’s trustworthiness have arisen. Dr Mangham is the president of the Drug Prevention Network of Canada, an organization run by former Conservative MP Randy White, and has previously written commentaries criticizing the philosophy of harm reduction….

Writing in Open Medicine on September 7th, 2007 Thomas Wood noted the unscientific nature and discredited status of Journal of Global Drug Policy and Practice. He further highlighted that the non scientific conservative lobby group Drug Free America Foundation and it’s ill disguised front shop (the so-called Institute on Global Drug Policy) were behind this ambitiously named “new research”. Wood calmly observed:

We stand by the published findings from the evaluation and believe that the limitations of the research are well described in these published reports. We agree with Colin Mangham, however, that there are many instances where media reports go beyond what is described in scientific studies. A colourful example of this is the large amount of media attention given to Mr. Mangham’s recent essay in the Journal of Global Drug Policy and Practice which was funded by the Royal Canadian Mounted Police.

As scientists, we are strongly in favour of scientific debate and academic critique, but we believe what is contained in Mr. Mangham’s essay falls well short of this. The paper is fraught with a host of outright factual inaccuracies and unsubstantiated claims, which we would be happy to list should the readers of Open Medicine wish. We strongly encourage the readers of Open Medicine to read Mr. Mangham’s essay alongside the various reports examining Insite’s impacts and to judge for themselves the state of the science in this area.

Yet Dr. Colin Mangham was beyond saving. None would come to his aid. From mountain top to valley floor, from deep blue sea to desert sand, from darkened ghetto to opulent penthouse from… okay, you get the idea – his demise was complete.

By September 30th, 2007 Wood, Montaner, Kerr and Mark Tyndall had submitted to The Global Journal on Drug Policy, an article questioning the conservative Canadian government’s treatment of the scientific process and evidence. The abstract includes [bold mine]:

Although the recommendations of scientific review bodies have traditionally been free of political interference in Canada, there have recently been growing concerns raised about Canada’s new federal government’s treatment of scientific processes and evidence. This concern is relevant to the scientific evaluation of Canada’s first medically supervised safer injecting facility… [...]

This commentary describes what may be a serious breach of international scientific standards relating to the Canadian government’s handling of the SIF’s scientific evaluation, and the circumstances which eventually led to a moratorium on SIF trials in other Canadian cities.

The genesis of such striking criticism was the government’s observance of a single cancer in illicit drug policy. One that had metastasised into Colin Mangham’s Drug Prevention Network of Canada, DFAF’s unscientific Institute of Global Drug Policy and the dumping ground for all conspiracy pieces by those opposed to progressive HIV control and human rights observance, the Journal of Global Drug Policy and Practice. The Australian arm of DFAF is Drug Free Australia.

Added to this was a petition signed by over 130 physicians and scientists. Released the day after Clement’s speech noted above, it condemned the government’s “potentially deadly” misrepresentation of evidence for harm reduction programs. This misrepresentation encompassed “the overwhelmingly positive evidence” of Vancouver’s Insite safe-injection site.

In September 2008 The Lancet Infectious Diseases, published Illicit Drug Addiction, Infectious Disease Spread and the need for an evidence based response, by Wood, Montaner and Kerr. It included:

To our knowledge, this is the first time a lobby group such as the Drug Free America Foundation has created for itself a venue for the dissemination of opinion essays, which to the untrained eye could easily be mistaken for a scientific journal

There is no doubt that in just a couple of years, Montaner, Wood and Kerr continually exposed and dismantled a politically driven, pseudoscientific ideology and it’s masters simply by addressing the evidence at hand. One could be forgiven for thinking these chaps might be upsetting a certain group of fundamentalists.

By this time a suit had been filed with the BC Supreme Court arguing closure of Insite would violate the Charter right of Insite patrons regarding “security of the person.” As late as May 2011 the federal government was still claiming indecision of whether to keep Insite open or not. As this was in contrast to Clement’s previous statements everybody had heard enough from the government. On May 12th the Supreme Court reserved it’s decision on whether the government could close Insite or not. On September 29th, 2011 the Canadian Supreme Court ruled unanimously to uphold Insite’s exemption from the Controlled Drugs and Substances Act, allowing indefinite operation.

A win for human rights, humane disposition and indeed for evidence based public health.

Almost certainly planning revenge for months prior was a team under Drug Free Australia’s Secretary, Gary Christian. Consisting of three Aussies of biblical repute: Joe Santamaria, Stuart Reece and Gregory Pike. Also included was present DFAF board member yet past White House Drug czar and former first director of NIDA, Robert DuPont. Finally, none other than one disgraced PhD holder, Colin Mangham.

The Lancet reportReduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study published in April 2011 was compelling evidence on reduced overdoses in a vicinity around Insite, and accepted by the Supreme Court. The problem for DFAF was that three of the five authors were Kerr, Montaner and Wood. The same three who had demolished so much of the amateur ideologists and DFAF’s non scientific lobby groups.

On September 13th hoping to besmirch the reputations of these men, the team struck. They released a collection of misleading claims cobbled together in a free range “analysis” enveloped in thunderously accusatory tone. It was designed to rebuke harm reduction in general and injecting facilities specifically. In this light it inexplicably republished many of Mangham’s already debunked criticisms as if new, misrepresented existing reputable studies by comparing unrelated data sets and publishing outright falsehoods.

If we dig up Clement referring to Mangham, from the National Review of Medicine September 2007, we can almost hear the echo:

There has been more research done, and some of it has been questioning of the research that has already taken place and questioning of the methodology of those associated with Insite

Fortunately history did not repeat. This re-choreographed material has been addressed more than once and found to be entirely baseless on each occasion. Despite the pollution of the material by Colin Mangham’s unprofessional accounts it becomes stranger when we note the “analysis” was conducted for Mangham’s Drug Prevention Network of Canada and REAL Women of Canada (the only supporting interveners for the government during the Supreme Court hearing).

Predictably published in the DFAF funded opinion rag Journal of Global Drug Policy and Practice, it’s accompanying media release included:

Three Australian doctors are part of an international team which has exposed major, inexcusable errors in a highly influential 2011 Lancet study on Vancouver’s Insite injecting facility, errors which nullify the study’s claim that it has demonstrably reduced overdoses in its immediate surrounding area.  The international team’s analysis has been sent by the Drug Prevention Network of Canada to the Ethics Committee of the agency which funded the Lancet study with questions regarding research fraud and professional misconduct.

The article was influential in the Canadian Supreme Court hearings of May 12 this year, where the court reserved its decision on whether the Canadian Government is rightfully able to close the facility.  The Canadian government has been trying to close Insite since 2006, but has been hampered by court action by harm reduction activists.

A full two more paragraphs are spent attacking the individual researchers for acting dishonestly, much of which relies on the already debunked material from Mangham 2007. Using bitterly crude figures to inflate “overdose” deaths – including suicides and homicides – they maintain the authors “knew” they were acting dishonestly. They challenge the findings by increasing the sample area by a factor of 10, and hold this against the original sample area.

Christian’s team selectively quote the Lancet authors earlier work on displacement of users from the area due to an increase in policing. This would be a splendid point were it not that “this policing initiative ended within weeks of Insite’s opening and was not ongoing throughout the study period”. This claim was also a resurrection of Mangham’s still unpublished and disgraced 2007 academic corpse. The vicious “media release” finished:

Drug Free Australia’s Research Coordinator, Gary Christian, said, “…. Inexplicable errors and memory lapses is the price the Canadian government has paid for entrusting injecting facility lobbyists with its scientific evaluation. Activists are never likely to provide objective science and there are dozens of other Insite studies that must now be under a cloud as a result.”

A complaint was lodged with the University of British Columbia by Mr. Christian. This and the JGDPP piece were independently reviewed and found to be “without merit”.

Yet so many questions arise as to why this apparently devastating material was not presented in court. When I first asked Mr. Christian on December 2nd he took a superior tone claiming that they could not because they did not have it available until September 2011. “It would have been a good point but for you not checking your facts”, he replied. Let’s review these facts I supposedly failed to check.

On June 8th, 2011, the (new) President for Colin Mangham’s Drug Prevention Network of Canada, Gwendolyn Landolt insisted that data supporting Insite is flawed. In an extraordinary claim (for June) she asserted in a letter to Canada’s National Post that OD’s had actually increased around Insite in most years since it had opened and thus, Thomas Kerr was in error for accusing DPNC as presenting misinformation (as he had earlier done):

Mr. Kerr tried to discredit a report from the B.C. government — which stated that since the site opened, the area has seen an increase in drug-induced deaths every year — by claiming that it included deaths unrelated to drug use

I say! That claim seems to be lifted straight from Christian’s September debacle. The one they didn’t have… until, er… September. And what do we read on page 2 of Christian’s piece about “a report from the B.C. government”, also mentioned above?

The claims of this article are very curious from the outset, simply because a review of the statistics by the British Columbia Coroner’s Service, found at clearly indicates the contrary – since Insite commenced operations on 21 September 2003 illicit drug deaths have very clearly and unmistakably increased, not decreased.

Okay, the same claim. So they had access to this data 2 1/2 years before the Supreme Court sitting in May 2011. Every other accusation – the impact of policing, the supply of drugs, criticisms from Mangham go back to 2007. Other papers and studies used are also well before 2011. That the president of the Drug Prevention Network of Canada is shooting off unpublished material in response to a May 30th statement by Kerr suggests they were keeping their powder dry.

I put this to Mr. Christian on the same day he dismissed my poor fact checking (December 2nd). He replied on December 10th as follows:

I have received an e-mail back from Gwen Landolt of Real Women of Canada explaining that Colin Mangham’s work was not admissable to the Supreme Court because it was not available for lower court hearing. The truth, Paul, is that there were court-imposed limitations on evidence which have nothing to do with your fanciful fabrications here.

Okay. So the material was available (despite his earlier claims it wasn’t), but could not be submitted due to “court-imposed limitations on evidence”. My “inability to check facts” had disappeared in a puff of reality, but was now replaced with my “fanciful fabrications”. Oh dear!

Of course before the Court in May, the government was armed with the figures mentioned, but had stated it had “no evidence” to submit. So, a day later on December 11th, 2011 I replied in part to Mr. Christian:

The time to strike was in the Supreme Court. Exactly why information from 2007 (Mangham) and 2008 (BC report on OD’s) was not admissible for lower court hearing in 2011 is a question best answered by your colleagues, Mangham and Landolt. If there is a genuine technical reason I would be grateful if you could provide it.

Otherwise it must remain possible, indeed probable, that it was excluded due to a.) the paucity of evidence presented by Mangham in attempting to debunk 20 peer reviewed studies from esteemed journals, and b.) that the BC report on OD’s was irrelevant as a variable effecting the efficacy of Insite and thus the SC sitting itself.

If so, this renders Landolt’s comments to the media and your own use of both sources impotent.

Failing this, you must explain… exactly why it was unavailable given 4 and 3 years respectively to craft an effective rebuttal of Insite’s success with these figures.

What were those “court imposed limitations” and why were they not mentioned in your article or your media release which explicitly referred to the [Supreme Court] decision as influenced by the Lancet article and “harm reduction activists”?

As one may expect those points have never been addressed. No-one is any more the wiser as to why this apparently cutting edge demolition of the court accepted Lancet article, was not itself either in total or in substance, presented to the Supreme Court. Are we to believe an ambiguous and unmentioned “court imposed limitation” prevented the exposing of “research fraud and professional misconduct” by five authors in one of the world’s most prestigious journals, the Lancet? That these supposed academic crimes were overlooked by the Supreme Court of Canada, as they examined the material in question itself?

Or shall we accept the demonstrable trend and tone exercised throughout the ideological attempts to sabotage Insite, is now manifestly clear as an attempt to smear researchers and their work? As the media release claimed, “dozens of other Insite studies that must now be under a cloud as a result”.

The anti-drug brigade may be cruel but they are not stupid. I point this out to Mr. Christian very clearly above, and still await a cogent reply. An academic mirage supposedly good enough to undermine the work of five authors. But not offered in objection to their work. What then was it’s purpose?

It was clear any such opinion from known offenders would have no bearing against over 30 papers in 15 peer reviewed journals. The singular attack upon Kerr, Wood and Montaner is striking. Christian has never answered my queries, preferring to accuse me of “imaginations and suppositions” without facts. Exactly why this argument was not published anywhere until after the Supreme Court hearing has never been made clear.

Why it was not raised by DPNC or REAL Women of Canada (both for whom the final “analysis” was supposedly written) in court is unknown. “No evidence”, was the official position.

Yet Gary Christian gives the game away himself. On November 30th, 2011 I had written in response to his refusal to accept his ploy was found to be “without merit”:

You write as if Montaner and Kerr are under scrutiny. You had your chance. It and the complaint have been found to be without foundation.

He replied on December 19th suggesting conflicts of interest assumed on his part override the independent analysis of his attack. He offered two mundane sources and extraordinarily suggests intentional favouritism on the part of the University of British Columbia and independent reviewer, Dr. Mark Wainberg toward the Lancet authors:

Of course our complaint to the University of British Columbia was not progressed because Dr Mark Wainberg absolved Dr Montaner, Dr Kerr and Dr Wood of any errors in their Lancet article, claiming that it was exemplary science.

However, if you look at the relationship between Wainberg and Montaner, I think that you will find that the relationship breaches the most liberal guidelines in the corporate or political world as to who is qualified to conduct an independent inquiry. [...]

Now tell me that the University of Britush Columbia’s ‘Independent Advice’ was absolutely according to the common understanding of independence.

More accusations of corruption. More suggestion of conspiracies. More of the same junk.

What were these devastating pieces of insight? At a meeting of the International AIDS society, 2009 Julio Montaner congratulates, “my friend and colleague, the esteemed Dr Mark Wainberg” on getting the conference to Durban in his capacity as IAS president. The other is a humdrum op-ed piece written with Stephen Lewis on urging the Canadian government to ensure HIV/AIDS therapies remain central topics.

To this day Gary Christian remains unapologetic and impervious to volumes of criticism and questions generated by his single opinion piece. There has been no apology, no explanation nor any correction of demonstrable falsehoods.

Attacks on Evan Wood, Julio S G Montaner and Thomas Kerr however, continue apace.

The “drug free” ideology is as free from compassion and evidence as it ever was.

Drug Free Australia manipulate, misrepresent data to discredit Insite

In April 2011 the Lancet published an article written by authors from the British Columbia Centre for Excellence in HIV/AIDS, the UBC Faculty of Medicine, the UBC School of Population and Public Health and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.

The title was Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study, by Brandon D L Marshall, M-J Milloy, Evan Wood, Julio S G Montaner, Thomas Kerr was followed by a media release from The University of British Columbia which included:

Researchers compared nearly 300 case reports from the British Columbia Coroners Service documenting all illicit drug overdose deaths in Vancouver between January 1, 2001 and December 31, 2005.

Compared to the 35 per cent reduction in overdose deaths in the immediate vicinity of Insite following its opening in September 2003, overdose deaths in the rest of Vancouver declined only nine per cent over the same period. No overdose deaths have been recorded at Insite since the facility’s opening. The researchers also noted that there was no evidence of significant changes in drug supply or purity during the study period.

“This study provides the first unequivocal scientific evidence of the benefits of supervised injection facilities, and clearly demonstrates that facilities such as Insite are saving lives and playing a vital role in reducing the harms associated with illicit drug use,” says co-author Dr. Julio Montaner, director of the BC-CfE and Chair of AIDS Research at the UBC Faculty of Medicine.

The Abstract can be read here. Insite which opened in September 2003 has also been the subject of more than 30 studies in 15 peer reviewed journals. These have cited a number of benefits including increased access to rehabilitation services, detoxification, reduced syringe litter, reduced public injecting and most importantly reduced needle sharing which serves to reduce blood borne virus spread.

Background

In 2006 the new Conservative government which did not support the initiative threatened to let the site’s legal exemption lapse before the project was complete. On September 1st 2006, Health Minister Tony Clement cited a need for more research as he deferred his decision to extend the site’s legal exemption. On the same day the Government cut all funding for future research. In August 2007 two addicts and the Portland Hotel Society filed suit in the B.C. Supreme Court arguing violation of rights – “security to the person”. What followed was from a legal and human rights perspective remarkable including the May 2008 strike down of sections of the Canadian criminal code on drug trafficking and possession as a breach of the Canadian Charter of Rights and Freedoms.

The struggle between progression and conservatism continued with the federal government appealing this legal advance in human rights. The B.C. Court of Appeal dismissed this in a 2-1 ruling. The government announced a further appeal to the Supreme Court of Canada. There were nine interveners in the Supreme Court Case. Only one supported the stance of the conservative government to close Insite. That group was the socially conservative, anti-women’s rights lobby group REAL Women of Canada.

National vice president of REAL Women…, Gwen Landolt, argued against the Canadian Medical Association and other supporters. She claimed that Insite would allow users to get “worse and worse until they die” and that such facilities “are assisting in the suicide of drug addicts.” The government had to admit it had no credible research to show Insite was not working. There were no valid data to show Insite was not reducing drug related harm. In essence the government and REAL Women of Canada were mounting non evidence based claims.

The Supreme Court of Canada ruled unanimously on September 29th, 2011 to uphold Insite’s exemption from the Controlled Drugs and Substances Act. This allowed the site to stay open indefinitely. The ruling was highly critical of Health Minister Tony Clement’s application of the CDSA to Insite stating it was grossly disproportionate and undermined “the very purposes of the CDSA, which include public health and safety”.

Drug Free Australia’s Bogus Critique

Drug Free Australia (DFA) is a conservative right wing prohibitionist lobby group of loosely affiliated extremists masquerading as a quasi-official body critical of Australia’s illicit drug policy. Regarding Injecting Facilities they have a discredited history (indeed presence) in maintaining the highly flawed opinion piece Case For Closure attacking Sydney’s Medically Supervised Injecting Centre. The Drug Misuse and Trafficking Amendment (MSIC Bill) was passed in October 2010 with considerable support from then Premier Kristina Keneally, The Australia Medical Association and the Royal Australasian College of Physicians. All three along with countless other individuals, MPs and organisations rejected the efforts of Drug Free Australia under the auspices of Secretary Mr. Gary Christian to sabotage over a decade of trial success.

On September 17th 2011, perhaps in a final effort to sway the Supreme Court of Canada (at that time yet to hand down it’s decision) DFA presented a media release claiming to have “exposed major, inexcusable errors” alleging “research fraud and professional misconduct” in the Lancet paper by Marshall et al. They cited an article headed Analysis of the 2010 Lancet study on deaths from overdose in the vicinity of Vancouver’s Insite Supervised Injection Facility published in the Journal of Global Drug Policy and Practice (JGDPP).

The authors were familiar names. Dr. Greg Pike co-author of the Case for Closure, and already profiled here. Dr. Stuart Reece and Dr. Joe Santamaria, also both co-authors of the Case for Closure of the Sydney MSIC. Prohibitionist Robert DuPont, former “White House Drug War Czar” under Richard Nixon and present board member of Drug Free America Foundation and finally Dr Colin Mangham, Director of Research, Drug Prevention Network of Canada. Their coordinator was anti-Harm Reduction campaigner Gary Christian.

In a comprehensive response the Lancet authors note their methodology and data was subjected to extensive scientific peer review and that this independent process “confirmed the appropriateness of the data and methods that we employed”. They further note Mr. Christian’s source has not been subject to peer review nor published in any scientific journal.

Nevertheless this formed the basis of a complaint by “research coordinator”, DFA Secretary Mr. Gary Christian to the University of British Columbia. The media release included:

The international team’s analysis has been sent by the Drug Prevention Network of Canada to the Ethics Committee of the agency which funded the Lancet study with questions regarding research fraud and professional misconduct.

Mark Wainberg, professor of medicine and director of the McGill University AIDS Centre was called upon to independently review the matter. Wainberg reviewed DFA’s analysis, the Lancet paper and the author’s response. He concluded in part:

In my view, the allegations that have been made by ‘Drug Free Australia’ are without merit and are not based on scientific fact. In contrast, it is my view that the work that has been carried out by the team of Thomas Kerr et al is scientifically well-founded and has contributed to reducing the extent of mortality and morbidity in association with the existence of the safer injection facility. . . . The University of British of British Columbia should be proud of the contributions of its faculty members to the important goal of diminishing deaths due to intravenous drug abuse.

The JGDPP analysis and complaint were found to be entirely without merit and the complaint was dismissed.

Drug Free Dishonesty

Along with the Lancet author’s response and the independent review there are a number of elements which render this amateurish attack particularly offensive. As noted above the “analysis” is not peer reviewed nor published in any recognised scientific journal. It was published in the JGDPP which is a collection of non peer reviewed articles and opinion pieces. Described as a “glorified blog” by The Media Awareness Project, the JGDPP is run by DFA’s parent body Drug Free America Foundation (on whose board sits DuPont). It was initially funded by the US Department of Justice which is presently under investigation for corruption. It has an international reputation for hosting articles seeking to sabotage human rights oriented policy initiatives successful in controlling the spread of blood borne viruses. Many authors hold extreme and archaic religious and/or anti-science views.

Essentially the JGDPP piece argues that the 35% reduction in overdose deaths in a delineated area following the opening of Insite and documented in the Lancet by Marshall et al. is flawed. Tactics by which this is done obfuscate context and manipulate the import of data in such a way as to misrepresent it to the reader. By using flawed population analysis and failing to state the nature of deaths across a much larger area it seeks to claim overdose deaths increased. The JGDPP team also suggest the Lancet authors should have dismissed an entire year as irrelevant because doing so decreases the overall decline in mortality. Thus it was, in their minds, only included by Marshall et al. to skew results.

The Lancet authors note the JGDPP report:

[U]ses crude Vital Statistics data, which included all accidental poisonings to define its estimate of overdose deaths, and it did not exclude deaths unlikely to be affected by a supervised injecting facility (e.g., suicides, adverse effects of drugs in therapeutic use). We note that the REAL Women/DPNC (JGDPP) critique seeks to call into question the Lancet paper’s findings using these crude data, and then goes on to argue that the Lancet paper’s findings cannot be relied upon because they use similarly unrefined death counts. We would argue that you cannot have it both ways.

The JGDPP article also fails to admit it used crude death counts and not population-adjusted mortality rates. This fails to account the relevance of death rates in a changing population. The Lancet study used annual population estimates from Statistics Canada to conclude on overdose mortality. Most shocking however was the increase by the JGDPP authors in area consulted by around a factor of 10. The Lancet studied mortality in 41 city blocks. The JGDPP article refers to mortality in a 400 block area. This further obscures the fact that the greatest reduction in overdose is within 4 blocks of Insite and significantly decreases outside that area.

The area in green is that studied by the Lancet authors showing a 35% reduction in overdose mortality. The area in red is that used by the JGDPP authors to misrepresent the Lancet finding.

The JGDPP article was written as an analysis for REAL Women of Canada and the Drug Prevention Network of Canada (DPNC). It is demonstrably a collation of highly selective, misleading, out of context and academically discredited material. The “analysis” relies time and again on a 2007 “critique of [the Insite] parent philosophy” written by co-author Dr. Colin Mangham of the DPNC. The DPNC holds a highly partisan irrational anti Harm Reduction position claiming it “leads to terror, degradation and the eventual death of the addict”, refers to supporters of HR as “enablers” and presents a grossly distorted misrepresentation of HR on it’s website.

They are dedicated to:

…advance abstinence-based drug and alcohol treatment and recovery programs, to promoting a healthy lifestyle free of drugs and to opposing legalization of drugs in Canada.

Their Mission Statement freely includes, Lobbying in the media, at the community level and in government for the support of our stated principles. At no point does the DPNC propose to hold to an evidence based approach or accommodate advances in scientific consensus. Not surprisingly the previous 2007 article by Mangham is critical of research which supports harm reduction and Insite. Even less surprisingly it too is published in Journal of Global Drug Policy and Practice.

Along with accusations of fraud, professional misconduct and research errors directed at the Lancet authors, the media release From Gary Christian also expanded on the supposed impact of the work of Marshall et al:

The article was influential in the Canadian Supreme Court hearings of May 12 this year, where the court reserved its decision on whether the Canadian Government is rightfully able to close the facility. The Canadian government has been trying to close Insite since 2006, but has been hampered by court action by harm reduction activists.

This is extraordinary. The JGDPP analysis that has so emboldened Mr. Christian was written for REAL Women of Canada and the DPNC. REAL Women of Canada were interveners in the Supreme Court in favour of the Canadian Government. The JGDPP analysis relied significantly upon material critical of Insite produced by the DPNC in 2007. The same DPNC with a mission statement to lobby community and government. Surely the time for accusations and presentation of evidence was in the Supreme Court itself. Yet the reasons why the government could produce none of this flawed “evidence” are manifestly clear.

The JGDPP piece cites the 2007 critique of Mangham in formulating the claim that changes in policing, “could account for any possible shift in overdose deaths from the vicinity of Insite”, arguing this was intentionally ignored by Marshall et al. Mangham is also cited as refuting Insite as having any impact on public crime or public disorder. Yet the Royal Canadian Mounted Police who had commissioned Mangham’s 2007 report claimed it, “did not meet conventional academic standards”.

Although every injection within Insite is sterile and safe from contraction of blood borne viruses, Christian’s JGDPP analysis further cites Mangham 2007 in arguing:

Added to this [the impact of policing] are the spurious claims by Insite researchers that the facility has impacted HIV and HCV transmission, despite the claim being possible only if ALL injections by those HIV or HCV positive are hosted by Insite, which has rarely been the case.

Unsurprisingly Mangham’s 2007 report was ignored by Canada’s Expert Advisory Committee on Injecting Site in formulating their own report. This doesn’t stop the JGDPP piece from citing data from Canada’s Expert Advisory Committee on Injecting Site that Insite statistically saves only one life per year. It’s argued that “this would not be detectable at the population level. This estimate is backed by the European Monitoring Centre’s methodology and avoids the error of naively assuming overdose rates in the facility match overdose rates in the community.”

At first blush this sounds compelling but is in fact a rogue construct manipulating entirely different methodologies, which yield entirely unrelated data sets, to imply naivety on behalf on Marshall et al. Regardless of what is “detectable at the population level”, neither study is relevant to the other. Citing the European Monitoring Centre’s methodology is simple weasel wording applied to distract the reader from the straw man of “one life per year”.

In truth the “one life per year” comes from person to person intervention in a clinical facility. It actually underscores the safety of the Insite environment in averting dynamics which may predicate a potentially fatal overdose. Community overdose rates considered by Marshall et al. cover 41 blocks surrounding Insite. The Lancet authors seek to quantify the impact of Insite’s presence on these rates.

Canada’s Expert Advisory Committee on Injecting Site is in no way at all dismissive of the “one life per year”. They write plainly [bold mine]:

INSITE staff have successfully intervened in over 336 overdose events since 2006 and no overdose deaths have occurred at the service. Mathematical modelling (see caution about validity below) suggests that INSITE saves about one life a year as a result of intervening in overdose events.

Marshall et al. write in their abstract [bold mine]:

We examined population-based overdose mortality rates for the period before (Jan 1, 2001, to Sept 20, 2003) and after (Sept 21, 2003, to Dec 31, 2005) the opening of the Vancouver SIF. The location of death was determined from provincial coroner records. We compared overdose fatality rates within an a priori specified 500 m radius of the SIF and for the rest of the city.

Furthermore it is interesting that the EMCDDA 2004 report notes such rooms can be expected to reduce high-risk behaviour beyond the consumption room setting itself and reduce exposure to and transmission of drug-related infectious diseases [p.25]. On public order and crime the same report lists two main objectives of 1.) to reduce public drug use and associated nuisance and 2.) to avoid increases in crime in and around the rooms [p. 61].

It should be noted each of these four points is in dissonance to the position of the JGDPP authors and every point they cite from Mangham 2007. More so, as noted during the Supreme Court Case the Canadian Government and the government’s only supporting intervener REAL Women of Canada, chose not to produce Dr. Mangham’s 2007 report. They effectively admitted they had no evidence to support their case to close Insite. As such it is remarkable Mr. Christian relied so heavily on Mangham to argue there were, “questions regarding research fraud and professional misconduct.”

Mr. Christian’s problem is not that the Canadian Government, “has been hampered by court action by harm reduction activists” since 2006. It is the simple reality that despite having had five years in which to produce convincing evidence in a court of law to close Insite, the Canadian Government has been unable to do so all the way to the Supreme Court of Canada. Apart from criticising Clement for undermining the purpose of the Controlled Drugs and Substances Act the ruling also acknowledged the dysfunctional nature of the prohibitionist mindset, stating:

…the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs on Insite’s premises.

Other shonky tactics employed by Christian’s team include intentionally misrepresenting the findings and recommendations of other research. In attacking cost effectiveness of sterile injecting the JGDPP report states:

The 2009 Andresen and Boyd cost-benefit study calculated savings to government from 35 supposed HIV/AIDS transmissions averted by Insite annually, despite the most authoritative international review to date not finding any demonstrated effectiveness of clean needle provision reducing HIV transmission via needle exchanges.

This is a misrepresentation of the cited IOM review. Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence, states:

The report provides evidence-based recommendations regarding drug dependence treatment, sterile needle and syringe access, and outreach and education. The report urges high-risk countries to take immediate steps to make effective HIV prevention strategies widely available.

Page 2 of the report brief includes [bold mine]:

Avenues for making clean injecting equipment more widely available—and thus reducing drug-related HIV risk—include needle and syringe exchange; the legal and economical sale of needles and syringes through pharmacies, voucher schemes, physician prescription programs, and vending machines; supervised injecting facilities; and disinfection programs….. Multi-component HIV prevention programs that include sterile needle and syringe access are effective in reducing drug related HIV risks such as the sharing of needles and syringes.

Gary Christian also claimed in his media release as part of the allusion that policing, not Insite had caused a reduction in mortality:

These researchers cannot truthfully claim they knew of no policing changes in the immediate area around Insite when some of their number produced an indignant study condemning the changed policing.

Yet in their response the authors indicate that the police initiative referred to ended “within weeks” of Insite opening. It was not ongoing during the study – which is what Christian’s team had falsely suggested. More so if the crackdown was the cause of a reduction in mortality after Insite opened then it was the cause of an increase in overdose deaths in the area prior to Insite opening. Even more crushing for Gary Christian, is that this means the decline in drug related overdose clearly demonstrated in the Lancet occurred because the policing initiative ended.

Perhaps most scurrilous as mentioned above is the suggestion by Gary Christian’s JGDPP team that the Lancet authors included 2001 in their methodology in order to skew results in favour of overdose reductions. The JGDPP report suggests a review from 2002 onwards would show an increase. Yet the Lancet authors had written an earlier report in 2009 showing stable use from 2001 to 2005:

As shown in a figure from that report (below), although the proportion of IDU reporting daily heroin use declined from 1998 to 2001, the proportion of IDU reporting daily heroin injecting remained stable from 2001 to 2005 (i.e., the period considered in our Lancet study).

Figure showing that daily heroin use from 2001 to 2005 remained stable

Whilst this is a look at the most prominent manipulations and misrepresentations authored by Gary Christian’s team a quick reading of the Lancet author’s response – below – reveals a more comprehensive overview. Accusations of careless assessment are put to rest and a read of the original paper shows the lengths gone to in the Discussion to acknowledge other factors that may contribute to a reduction in drug induced mortality. There are also many other absurdities presented in the JGDPP article (such as “recommended reading” and citing a speech by “Christian voice in politics”, Gordon Moyes) that must condemn Christian and his team even further.

Of course like an antivaccination lobbyist Christian has not budged an inch, still insisting he is completely correct and that peer review and science itself is flawed. Now, in the shadow of their complete demolition we can review the hypocrisy and misplaced confidence of Mr. Christian in his ability to scam the public and academics alike.

 Activists are never likely to provide objective science and there are dozens of other Insite studies that must now be under a cloud as a result.

Drug Free Australia has never produced any science and peer reviewed research. This shows their inhumane prohibitionist world view as without merit, and data supporting Insite as entirely safe.


Bad politics vs good drug policy and prison health

Australia’s National Drug Strategy consists of the three pillars of Harm Minimisation

To hear major parties speak of Australia’s national drug strategy one may be forgiven for assuming it is a competition of muscle. To be sure, we’ve come a long way since the great stupor of the Howard years, as then federal Health Minister, Tony Abbott taunted Opposition leader, Kim Beasley for being “soft on drugs”. Translation? Taking the evidence based advice of global drug strategists.

Terrified of losing votes, Beasley all too readily took the bait. In this way successive debates and policy changes had a ratcheting effect on absurd non evidence based and wasteful attempts to be seen to be “tough” on drugs. Manfully tearing up cannabis plants and thrashing them against rocky outcrops or cursing at bags of cocaine aside, it follows quite logically that “tough on drugs” is nothing less than tough on people.

Should Abbott become PM we will quickly find that there is more to Aussie politics than just carbon taxes, boat arrivals and the odd NBN slur. It wasn’t just Howard’s homophobia, weapons of mass destruction lies and black and white 1950’s relativism we’d woken up from. Howard’s skill as a politician is rivalled very well by his inability to understand the 21st century. Indeed, perhaps the last third of the one before.

I’m not suggesting drug policy should become a national focus to the exclusion of any other policy. It never will. Yet, the list of human rights abuses ushered in by stealth and without reason under Howard is a long one. It was Tony Abbott himself who funded the extreme right evangelical lobbyists, Drug Free Australia with the explicit aim of destroying Neal Blewett’s 20 year old successful policy of Harm Minimisation. Howard’s sabotage of our role as world leaders in Harm Reduction is legendary.

Even in 1997 going against the advice of then health minister Michael Wooldridge, and taking that of (later) DFA board member, evangelist and disgraced Salvation Army Major, Brian Watters (initial Chair of the ANCD) to dump the heroin on prescription trial. From The Politics Of Heroin – ABC 4 Corners:

KATE CARNELL: The approach that we put, or I put, to that meeting, was that this was a small trial, only 20 people or so in the first instance. That the trial would be a medical trial with appropriate science backup.

ANDREW FOWLER: The vote came as a huge surprise. The Federal Health Minister, four States and the ACT voted for the trials to go ahead.

A 6-3 result. The decision marked a radical shift in policy.

KATE CARNELL: This is not just a heroin trial. It’s an integrated, national approach that brings in the majority of States in this country. I think it shows a huge amount of maturity and it really is a mammoth step forward.

ANDREW FOWLER: The Federal Health Minister, Michael Wooldridge, telephoned the Prime Minister to tell him the news. But a few minutes later, as he made his way back into the meeting, observers say he looked shaken.

Nothing to this day has beaten Bronwyn Bishop’s 2007 Parliamentary Committee Inquiry. A despicable abuse of our parliament and the role of standing committees, the final report was rejected by every D&A body in Australia. All except our installed enemies of humane policy, lobbyists Drug Free Australia. As Chair and at John Howard’s urging she intoned to field experts that, “the PM says he doesn’t want that” (Harm Minimisation), sounding much like an Inquisitor instructed to reject reference to heliocentrism. That this was her governments policy was entirely lost on her. It was a predetermined farce to attack progressive successes, and demonstrably so.

Her attacks upon Alex Wodak‘s internationally respected skill and evidence in favour of biblical stories from fundamentalist zealot Dr. Stuart Reece, left jaws agape. A bastard baptising, bible wielding, Jesus summoning fruit cake who’d knocked off 25 of his patients in 20 months with reckless naltrexone treatment. The investigation into which he described as “a conspiracy”. “They’re only drug addicts anyway”, he informed a grieving parent who later wrote to me.

As reported in Crikey by Ray Moynihan in Naltrexone II: no trials, just the power of prayer:

In lengthy evidence to a current parliamentary committee inquiry into illicit drugs, being run by Bronwyn Bishop, Reece suggested one of the biggest problems at the moment was a disease called “drugs, s-x and rock and roll.” As part of his evidence, Stuart Reece cited Sodom and Gomorrah, the Biblical cities destroyed by God for their immorality.

Reece’s testimony then suggested Australia’s civilisation was under threat of being destroyed by the scourge of injecting rooms, give-away syringes, and methadone. These of course are the well-established strategies of “harm minimisation”, the approach that underpins the way Australia deals with the dangers of illicit drug use. In contrast to his attacks on harm minimisation, Stuart Reece spoke reverentially of the work of Dr George O’Neil, and the immense value of the still unproven naltrexone implant.

Asked during an interview whether he currently prescribed naltrexone implants to heroin addicts, Dr Reece answered cryptically, “Yes and No”.

Suffice it to say, Reece as a member of Drug Free Australia still marches front and centre with the most dangerous and most irrational opponents to Harm Minimisation. Our National Drug Strategy. What they call “the noramlisation of illicit drug taking”.

However, the Public Health Association report below on the proposed Needle, Syringe Program (NSP) trial at the Alexander Maconoche Centre is clear:

The Australian government web page on the National Drug Strategy (NDS) identifies that

“the National Drug Strategy, a cooperative venture between Australian, state and territory governments and the non-government sector, is aimed at improving health, social and economic outcomes for Australians by preventing the uptake of harmful drug use and reducing the harmful effects of licit and illicit drugs in our society”. (Australian Government Department of Health and Ageing-DoHA, 2011)

The NDS is based on three inter-related strategic approaches to dealing with drugs in our community – the NDS refers to them as the “three pillars” of the overall approach of harm minimisation.
Harm minimisation, therefore, is our agreed national approach to drug policy which encompasses the three pillars of:

Demand Reduction

Demand reduction to prevent the uptake and/or delay the onset of use of alcohol, tobacco and other drugs; reduce the misuse of alcohol and the use of tobacco and other drugs in the community; and support people to recover from dependence and reintegrate with the community. To achieve this requires effort to:

  • prevent uptake and delay onset of drug use
  • reduce use of drugs in the community
  • support people to recover from dependence and reconnect with the community
  • support efforts to promote social inclusion and resilient individuals, families and
    communities

Supply Reduction

Supply reduction to prevent, stop, disrupt or otherwise reduce the production and supply of illegal drugs; and control, manage and/or regulate the availability of legal drugs. To achieve this requires effort to:

  • reduce the supply of illegal drugs (both current and emerging)
  • control and manage the supply of alcohol, tobacco and other legal drugs

Harm Reduction

Harm reduction to reduce the adverse health, social and economic consequences of the use of alcohol, tobacco and other drugs. To achieve this requires effort to:

  • reduce harms to community safety and amenity
  • reduce harms to families
  • reduce harms to individuals

Our NDS does not simply limit its scope to the broad community but states categorically:
“The approaches in the three pillars will be applied with sensitivity to age and stage of life, disadvantaged populations, and settings of use and intervention”. (DoHA 2011)

Over the years we’ve had the rants of Alan Jones and John Laws. The rubbish of Piers Akermann and Andrew Bolt. The fear mongering of the anti-science mob. Still many fail to appreciate not just good policy but the responsibility under human rights which (as I’ll get to in time) is exactly what Alexander Maconochie is about. Right down to using the name of the great penal reformer himself.

This Lateline segment from October 2009 gives excellent insight. On October 2nd 2009 they reported, “The Australian drugs conference in Melbourne has today called for a trial of needle and syringe programs in Australian prisons. One in three Australian inmates has hepatitis C, and it is thought that a needle and syringe program could reduce the incidence of blood-borne viruses in jail.

Resistance born of political will, not evidence, continues today. It will be a great shame if ignorance prevails.

Lateline


Public Health Association Report on NSP Trial at the Alexander Maconochie Centre

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