Drug policy in Australia has been debated for decades but doesnt seem to be getting close to resolution.However some progress is being made. Examples include the Victorian government’s decision in 2017 to establish a Medically Supervised Injecting Centre in Melbourne and the ACT government’s in principle decision in 2017 to allow a trial of pill testing. Social policy reform is always slow. The drug policy debatehas some particular characteristics that make it especially difficult.

The debateabout drug policy in Australialooks like a swan moving swiftly but serenely across a lake. However, under the surface the swans feet are paddling furiously. The intellectual debate about drug law reform is now largely over with only a few still claiming that drug law enforcement is an effective and safe way to control illicit drugs. Many experienced and senior Australian political leaders and police Commissions now acknowledge the futility of trying to control the drug market with punitive measures.The serious political phase of this debate has begun with the Greens now supporting the regulation and taxation of recreational cannabis. This is an important new development.

There are many reasons why the drug policy debate is difficult. The objectives of drug policy are rarely discussed. Politicians often emphasise decreasing drug consumption as if this was the only goal of drug policy. But for many community members, a safer community is the top priority with fewer deaths and less disease, crime, corruption and violence.

The consumption ofalcohol and tobaccois very closely correlated with the immenseharm these (legal) drugs cause. For example, deaths from cirrhosis are closely correlated at both the individual and community level with the quantity of pure alcohol consumed over a period of time. Similarly for tobacco, the risk of lung cancer is highly correlated with the number of cigarettes smoked over the years. But therelationship between consumption of illicit drugs and harm is much less certain. Most of the harms associated with illicit drug use are more the result of the black market distribution system than the pharmacology of the drug. When pharmaceutical heroin is provided medically to people severely dependent on street heroin they will often improve even though no previous treatment had helped. Harm reduction, that is, policies designed specifically to reduce harm rather than just reduce drug consumption, and the difficulties of accurately estimating consumption of illegal drugs make it even harder to try to correlate quantities of illicit drug consumption with harm.

The illegality of drugs means that much of the data governments and researchers collect or estimate are inevitably very crude approximations. The inaccuracy of these data makes it much harder to draw firm conclusions about the effectiveness of policy.

It is also hard to ever be sure whether the concerns that the community is so worried about are in reality due to the effects of the drugs themselves or are rather the effect of drug policy. Robbing banks is not a likely side effect that could be confidently predicted from what is known about the pharmacology of heroin. Yet when demand for heroin is strong despite heroin prohibition and legal heroin is therefore unavailable, the black market supplies street heroin at very high prices. Some of the people who have become dependent on street heroin may then go to great lengths including robbing a bank in order to be able to pay the inflated price of street heroin. It is more accurate to attribute these bank robberies among some heroin users to an unintended adverse effect of drug prohibition rather than to blame them on heroin.

Drug policy often has unanticipated counterproductive effects. Many drug policy decisions are based on intuitive guesses about the likely effect of future policy changes. But in practise, these guesses are often quite wrong. During the 20thcentury, Asian countries were encouraged by western countries and the growing international drug control system to ban opium smoking. One by one, these countries did as they were advised. Elderly men were the main group then smoking opium. Mostopium smokerscame to little harm but some frittered away precious family savings, did not eat properly or failed to carry out their family or community responsibilities. Within a decade of the disappearance of opium smoking in these Asian countries, young, sexually active men appeared who had taken up heroin injecting. This prepared the ideal conditions for a dangerous HIV epidemic in an area that was home to almost half the population of the planet. An American researcher in 1976 referred tothere unintended negative effects of banning opium smoking as the pro heroin effects of anti-opium laws in Asia.

When communities rely heavily on drug law enforcement to control illicit drugs, the iron law of prohibition often takes over as traffickers trying to evade detection search for more powerful and more concentrated drugs in their lucrative trade. Heroin occupies about 10% of the volume of opium and lacks opiums pungent odour. The iron law of prohibition was also evident when alcohol was prohibited in the USA in 1920. Soon afterwards, beer disappeared, only to be replaced by more lucrative wine and spirits. After prohibition was repealed in 1933, beer soon became available again. We are now once again observing the iron law of prohibition in a number of western countries with the contamination of street opioid with extremely powerful and concentrated drugs such as fentanyl and carfentanil. The emergence of ice and synthetic cannabis (Spice) in the Australian drug market are other examples of the iron law of prohibition.

In messy debates like drug policy, it is important to be careful to discuss questions in some sort of order. First order questionsshould be discussed before questions of detail. For example some critics of cannabis regulation are concerned about the connection between cannabis and schizophrenia. However assuming that cannabis sometimes causesschizophrenia, and this is still debated, it is hard to understand why the risk of cannabis would be less when the black market has a monopoly for cannabisdistribution rather than when most of the demand is supplied by aregulated source.

In the 16thC, Niccolo Machiavelli could have been referring to drug law reform when he wrote in The Prince It ought to be rememberedthat there is nothingmore difficult to take in hand, more perilousto conduct, or more uncertainin its success, than to take the leadin the introduction of a new orderof things.Because the innovator has for enemiesall those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new.This coolness arises partly from fearof the opponents, who have the lawson their side, and partly from the incredulity of men, who do not readily believein new things until they have had a longexperienceof them.

Dr Alex Wodak is anAustralia21Director. From 1982 to 2012 he wasDirector of the Alcohol and Drug Service at St Vincents Hospital, Sydney and he is now the President of theAustralian Drug Law Reform Foundation.

There was an encouraging editorial on drug policy in the Canberra Times and the SMH on 23 April 2018 “An enlightened approach to drug policy”.