Thursday, 8 January 2009

Q & A: Dr. James Rowe

This is the second in a series of Q & A's for people who have some relationship or interest in illicit drugs.

: Dr. James Rowe
Role: Research Fellow with Centre for Applied Social Research / Lecturer at RMIT, School of Global Studies, Social Science & Planning
Date: January 2009

I must say that I was totally surprised at how open and personal Dr. Rowe was with his answers. Through his vast knowledge and honesty, we get a clear picture of someone who has real credibility and insight into the issue of illicit drugs. Dr. Rowe mentions that drug policies and some drug treatments are designed by people who don’t fully understand the problem at hand and after reading his answers, it becomes obvious that what we need is more people like him. If ever there was someone who deserved to be advising the government on drug policy, it’s this guy ... intelligent, articulate, educated, compassionate and with real life experience.

About Dr. James Rowe:
James Rowe divides his time between teaching in the School of Global Studies, Social Science & Planning and as a Research Fellow with Centre for Applied Social Research. He has worked at RMIT in a research capacity since 2000 before joining the school in a teaching role in 2005. He received his doctorate from Monash University in 2000 after conducting a critical analysis of Victorian drug policy in which he argued against the continued politicisation (and consequent criminalisation) of what is essentially a health and welfare issue.

Since joining RMIT James’ research has had a largely qualitative focus. He believes that the experiences that we have as diverse and different members of the community emphasise our similarities rather than our differences. However, circumstances often beyond personal control lead to many members of the community being marginalised and losing their ‘voice’ – particularly when discussing policies and practices that directly affect their lives.

James is also a member of Amnesty International.
RMIT University

You have recently published a report in conjunction with the Salvation Army, titled, A Raw Deal? Impact On The Health Of Consumers Relative To The Cost Of Pharmacotherapy. Can you tell us what the goals are?
The goals are to provide evidence to demonstrate that charging dispensing fees for opiate maintenance treatment (OMT) (whether involving methadone, buprenorphine or the buprenorphine / naloxone combination) is the single greatest obstacle to engagement with and / or retention in this treatment.

The evidence is that OMT is the gold standard for treatment of opiate, or speaking plainly heroin, dependency. In Australia, every medication prescribed and dispensed by a pharmacist attracts a dispensing fee – this is part of a pharmacist’s everyday income. In the case of practically every other medication, this dispensing fee is subsidised fully by the Commonwealth Government under the Pharmaceutical Benefits Scheme (PBS). The exception is opioid maintenance treatment in which clients must pay the dispensing fee. In this respect, there is a basic and fundamental human rights argument to be made for including the subsidisation of MOT dispensing fees. Every government is every jurisdiction in Australia recognises heroin dependency as a chronic health condition. Why, then does the Commonwealth Government discriminate against this group of individuals in terms of uniform health care?

Unlike most dispensing fees that are set on a scale with a slight increase on an annual basis, dispensing fees for opioid maintenance are set at the pharmacists’ discretion. They have remained at approximately $60 per week since the mid-1980s.

The problem is the majority of clients of OMT live on government income support (e.g. NewStart or a Disability Support Pension). The current NewStart rate for a single individual is $437 per fortnight. When one considers even boarding house accommodation in Melbourne costs up to $190 a week at present – leaving the recipient with $57 remaining for the fortnight to pay for food and other everyday expenses (e.g. travel to their pharmacy), then the $60 for dispensing fees is impossible to pay.

In conducting the research, I interviewed 120 clients on OMT in Victoria. All were in receipt of government income support as their main source of income. Many times I was told of how dispensing fees were prioritised over food and accommodation, leading to a negative impact upon health, nutrition and personal security. Some admitted to petty crime and, in some cases, sex work so as to afford their medication for what is, as noted, a universally recognised health condition. Eventually, many people have their treatment involuntarily discontinued such is their level of debt to their dispensing pharmacist. A new pharmacist will not dispense OMT to a client without a letter of reference from their previous prescriber. Consequently, the individual, now with a higher level of opioid dependency than when they commenced treatment (so as to meet the needs of their existing dependency and block cravings to ‘get on’) is left to meet the needs of their dependency with no recourse to legal opioids … with predictable results.

The pharmacists also suffer under the existing system. Many run programs at a loss due to their empathetic nature and an understanding of the individual client’s inability to pay. Eventually, however, once a debt gets so large, they may eventually refuse to dispense if they are not to continuously lose money. This leads to arguments with desperate clients who now face a choice of ugly, painful opioid withdrawal from methadone (a withdrawal that is significantly worse in intensity and length) or return to illicit sources of opiates.

The goals of the project were to demonstrate the harms of the existing arrangements and to recommend that, firstly, pharmacists be properly remunerated in terms of the fees they receive for dispensing opioid [pharmacotherapies – but that these dispensing fees be fully subsidised by the Commonwealth for financially vulnerable individuals (i.e. those on any form of government income support).

How is it coming along?
The advocacy stage of the project is long and ongoing. To date there have been a couple of meetings with Ministerial advisors here in Victoria. We also have an influential body of stakeholders who are prepared to support the report and publicly argue for the acceptance of its recommendations.

What are your views on other OMT¹s in use or on trial in Canada and Europe like slow release morphine, injectable hydromorphone, dihydrocodeine and prescription heroin?
My knowledge is largely restricted to the use of prescription heroin via the Swiss trial - which was approved on a permanent basis by a national referendum at the end of November 2008. Germany didn’t even decide to conduct a trial, such was the evidence of the success of previous prescription trials that have shown a reduction in crime, greater stability in ones personal life, less or no illicit drug use, financial security … the list goes on … my view is that heroin shown be regulated in Australia and not prohibited in the first instance … given it is the prohibition of heroin and the enforcement of this prohibition via the criminal law

In 2003, you posted an article titled We Need To Find Out More About Drug Users Who Do Not Fit The Stereotypes. This is one of the goals of The Australian Heroin Diaries. Are you aware of any similar websites or groups that active in trying to dispel the ‘junkie’ myth?
No, I’m not – In was mightily impressed when I stumbled across the site quite accidentally when looking for information and potential online links for students who take a course I teach – the Sociology of Drug Use. The course has the same aim as the site, deconstructing the stereotypes upon which our current criminal law enforcement approach to illicit drugs is based. Why should the visible minority – the homeless, the street sex worker, the mentally ill users – suffer the full weight of this law enforcement ‘crusade’ while the greater majority of illicit drug users go through life unfettered by the authorities (hell, many of them are the authorities). To scapegoat these individuals and their drug use for society’s ills … when society’s ills may well play a central role in their drug use – is utterly hypocritical and presents, in my mind, an obligation on the part of those who are able to hide their own use behind this popularly accepted construction of drug users to challenge these constructions by being a little more willing to be honest about their own behaviours. The fact is the law is based on the perception that drug use causes immorality, criminal behaviour and a breakdown of social norms – hence the need for tough legal boundaries to separate drugs from potential and existing users – even if that means prison bars. The visible minority provide evidence for such false assumptions. These people might comprise 5% of all illicit drug users (or do people really believe this small population sustains the multi-million dollar importation of drugs into Australia annually?)

By showing that the assumptions about illicit drugs are unfounded, we can begin to challenge the very foundation of laws that are built on a century of racism, ignorance, moral panic and moral crusading on an international scale.

Do you feel it’s someone right to take illicit drugs?
I believe that no one should be obliged to obey a law that is creating more harm than that which it seeks to prevent. I don’t believe anyone should be compelled to obey a law that classifies different drugs – alcohol, heroin, aspirin, tobacco, cocaine, sedatives, MDMA, anti-depressants, tranquillisers, marijuana (etc.) – as legal or illegal on the basis of erroneous assumptions has any place in our response to the potential harms of all these drugs.

I guess that’s a roundabout way of addressing that question. That said, these are my personal beliefs. I have never stopped and said, before consuming an illicit drug, this is not my right … in fact contemplating this has never even entered my consciousness. I would not seek to impose my personal beliefs on others … but I believe we should all have equal rights and I believe that I have a right to make an informed choice about what I put into my body … so I believe others should also have that informed right … tragically, prohibitive policies have spread misinformation so many people suffer injury as a consequence of uninformed decisions they may make.

Do you use drugs (including alcohol) recreationally?
I did for a long time … and still do occasionally (when thinking in terms of opiates). To some degree there is an element of self-medicating in respect of my alcohol consumption.

Do you think a recreational drug user has obstacles to living a normal productive life in comparison to someone who completely abstains?
It’s an interesting question – as long as their use remains recreational, then the only obstacles are the laws that make their drug use a criminal offence. I was arrested and charged with possession and use of heroin in late 1998 – a time when my use could still be classified as recreational. The Magistrate gave me a good behaviour bond – if she had chosen to give me a criminal record that would have limited many of my opportunities for the future – in terms of employment, opportunities to travel and many other areas. The criminal prohibition of certain culturally proscribed drugs is a massive obstacle. Provided their drug use remains undetected (and recreational as opposed to self-medicating) then there need be no obstacles.

However, if their drug use causes them to lie to loved ones, to even to deceive loved ones who disapprove of the user’s behaviour – this can lead to issues of shame and guilt – and these can prove to be obstacles to one’s general wellbeing. I’d hasten to add that these would only be issues (and thus obstacles) for some – but they have proven to be obstacles for me.

The "War on Drugs" and prohibition has been a huge failure. Do you support legalising drugs in anyway?
I support legalisation of marijuana for personal consumption and I fully support the regulated supply of heroin with stringent conditions. I’m still struggling with how such drugs as crystal methamphetamine might be controlled – certainly prohibition is of limited effect – whenever a lab is destroyed or a so-called ‘trafficking ring’ allegedly smashed, there will always be those willing to pick up the slack such is the dynamics of the black market that prohibition has created.

Prohibiting something that has been in demand since humanity could first express their experiences in the etchings of cave walls (i.e. mind-altering psychoactive drugs) is not going to work by simply legislating to forbid it. No matter how strong the enforcement of a law, a basic need of humanity will ensure the continued demand for such substances. Hence, when there is demand, there will be supply (why don’t neo-cons understand the most basic law of economics when it comes to drugs?!?!?). By handing control to the black market, the authorities effectively remove pricing and quality controls … inflated costs and poor quality drugs. The tougher the penalties threatened for supply, the greater the risk to the supplier, the greater the compensation demanded via prices of drugs, the more desperate the dependent become to meet the financial demands of their dependency … it just makes no sense – a horrible, dangerous, nay, deadly, policy.

You had an opiate addiction. Was it before or after you got your PHD?
I used mostly recreationally throughout the three years I was writing my PhD.I found that my use started to get a little out of hand towards the final months of the process – at it’s height it was three, sometimes four times a week, so never really a ‘full-on’ dependency (I don’t like the word addiction because it implies an incurable illness). Following the completion of my thesis, my partner and myself went to Japan to work for a year as a deliberate plan to do a geographical where accessing heroin would be extremely difficult. I did not use for the next 5 or so years.

Sadly, my marriage broke up in 2006 … what had once being a (largely) recreational drug became a form of self-medicating and this is when drug use becomes dangerous – when it is used to cope with pain or trauma as opposed to taking drugs to enjoy the altered sensations. Things got increasingly problematic until I started on a Suboxone program in mid-June 2007. Since then I have dabbled, but it is largely a waste of money given the Suboxone has greatly reduced the impact any heroin will have … and I have never missed a day of Suboxone dosing since beginning the program …

Can you tell us about your addiction?
I’d just say I wouldn’t wish it on anybody. It destroyed a lot of self-respect and remains the source of great shame and guilt for what it did to me family, both that which I had started with my wife and the family I grew up in. I’ve overdosed four times to the extent that paramedics attendance and a shot of naloxone has been required to revive me … The last time – 2 days before beginning the program – my mother, whose house I was now staying in – had to give me mouth-to-mouth until the paramedics arrived. My credit cards were maxed out (I never committed a crime to finance my use) and I felt nothing but self-hatred, loathing and shame. I often still do … my drug use has deprived my beautiful daughter of a full-time father. I have a lovely relationship with her … and my relationship with my ex is amicable, but I miss her and she misses having a family of the kind that every other child in crèche has. Going through that dark period, if I didn’t have a daughter whose need for me forced me to place myself second (after months of selfishly placing myself first) I doubt I’d be here to type this today

Although with the exception of the OD mentioned above, I didn’t use during the marriage, I was however, self-medicating with alcohol … I wasn’t happy … and the freedom of the watchful eye and family obligations allowed heroin – my drug of choice – to take over from alcohol.

Do you think a drug addict has obstacles to living a normal productive life in comparison to someone who completely abstains?
Again, I have to point out my dislike of the word ‘addict’. It carries so many negative, generalised connotations and infers that incurable condition – once an addict, always a ... (fuck off!) In any case, as to obstacles in front of the drug dependent individual although it depends on the degree of dependency. A large dependency will outstrip all but the most lucrative of incomes raising the need to find sufficient resources through less than legitimate means. As soon as a substance is the most integral aspect of a person’s existence, it robs them of the capacity to live a life than does not incorporate constant and regular access to that substance. I hate to generalise … I can see that there are dependent drug users who, provided their drug use remains undetected, leave utterly ‘normal’ lives (if such a thing exists).

Some people say that ex addicts especially those on heavy medication like methadone don’t have a place discussing addiction treatment. Are they correct?
I’d say they’re robbing themselves of some of the most informed opinions and expertise that is available. One of the primary reasons for the failure of existing drug policies (including the failure of many models of treatment) is that drug users are completely excluded from the process of policy making. Consequently, policies are made on the basis on perceptions as opposed to lived reality and lived experience. Who is better placed to offer advice of policy and its effectiveness if not those directly affected (or, alternately, despite its intentions) unaffected by it.

You have very strong views about drug policy that would make most conservative politicians cringe. Have you have encountered any obstacles from politicians or the religious right?
No – but that is hardly surprising. The evidence for change in terms of moving away from moral positions on drug use and the criminal prohibition of drugs is irrefutable. The religious right, in particular, cannot mount an argument against the evidence. There are plenty of references in the Bible that cannot be interpreted to be referring to anything other than the celebratory use of alcohol and the wonderful properties of now illicit drugs (Jacob Sullum’s book Saying Yes has some excellent stuff in terms of the hypocrisy of religious opposition to drugs)

You were involved with a book called Harm Minimisation vs. Zero Tolerance: The Politics of Illicit Drug Policy in Australia. Can you tell us about it?
It was a simply presented textbook in two large sections – the first looked at case studies of drug policy making which invariably revealed the irrationality and media manipulation of perceptions that condemn potentially useful and much needed policy proposals. The second looked at drugs from a number of different angles in terms of how it might be addressed differently – with views from academics, liberal clergy and experts in the field.

The US is infamous for it’s drug policy and opposition to Harm Reduction.
Though the US has about 10 times the number of HIV/AIDS sufferers amongst injecting drug users compared to Australia, only recently has federal funding been allowed for needle exchange programs. Do you think this trend will continue in the US?

One can only hope that the President-elect Obama brings change to this realm as well as to many others in the US. To have continued the ban on federal funding that you mention – as HIV rates were spiralling out of control – suggests the fundamentalism of moralists who think it better that people die than to make drug use safer (and thus seeming ‘send the wrong message’ that drug use was, somehow, endorsed or accepted). It reminds me of former head of the ANCD Salvation Army Major Brian Watters when referring to addiction stated that there were worse things than death. What an utter disgrace - to suggest an individual with a drug dependency would be better off dead … and this zero tolerance zealot was appointed by a thankfully departed PM to chair the ANCD, a body established simply because the aforementioned PM couldn’t stomach the advice of the (until then) pre-eminent policy body in respect of drugs – the Ministerial Council on Drug Strategy – due to its endorsement of the heroin trial proposed in the ACT back in the mid-1990s.

In 1999, John McCain proposed a plan to remove most methadone programs for abstinence based treatment. Do you feel Barack Obama follows the same ideology as McCain or will he support a more evidence based drug policy if he wins office?
I hope for the latter … imagine the catastrophe if the recognised gold standard of existing treatments was removed. One can only hope that evidence is used in drug policy making in the US and Australia – at least to the degree that a number of Europeans have allowed it to inform drug policy.

There has recently been some criticism of Harm Minimisation in Australia. Do you think the Rudd government will expand Harm Minimisation or continue with John Howard’s route towards Zero Tolerance?
Rudd’s been remarkably silent – with the exception of the (obligatory) pre-emptive policy to get tough in the face of the now seemingly disappeared ‘ice epidemic’ that existed in the pages and broadcast of the mainstream media, the focus has been solely on tobacco and – via the binge drinking panic – alcohol. He seems a man for whom evidence is important …I hope so … there is the potential for much positive change on the international scene with the changes in the US and Australia. ANCD Chair, John Herron, who replaced Watters, has called for the UN to accept the need for some countries to depart from the rigid criminal prohibition of drugs … it seems there is some cause for hope.

Bronwyn Bishop chaired an enquiry into illicit drugs and produced a report called The Winnable War on Drugs. What did you think of it?
It was an atrocious ideologically based document that was dismissed as the hate-mongering moralising that it was. Even Herron stated that harm minimisation was very successful and would not be considering the radical recommendations of this bile filled tome of prejudice. ‘Addicted mothers’ wanting their children back for the child care payments (as opposed to loving them – something a drug user is apparently incapable of). Forced adoption of children under five years of age whose parent(s) are drug dependent.

It was one woman’s personal mission … the very same Committee had conducted an almost identical Inquiry into the Impact of Drugs on Australian Communities just a few short years earlier and the government had only recently tabled a response. As the dissenting Labor members rightly noted, the recommendations made in the first report addressing the harm done to families by illicit drugs (and very real they are) had not even been addressed, there was no justification for such a waste of money to allow one woman a chance to inflict her bile on the population (and castigate and insult recognised experts in public hearings when they did not agree with her).

Under John Howard, some individuals like Brian Watters were given important roles for advising on drug policy. Who do you think are the people in Australia that the government should be consulting with and why?
Drug User Organisations, drug users in general and those at the front-line working with problematic users. Why? Um, because they’re the true experts. Drug users alone know why they’re using drugs despite laws prohibiting them too … they may be able to inform a policy that actually does much to minimise the continued damage wrought by prohibitive policies.

Who do you think are the people in Australia that the government should definitely not be consulting with and why?
Purported experts whose expertise is based upon moral assumptions and ideology.

The Australian National Council on Drugs (ANCD) has no official decision making role for our drug policy and is an advisory group only. Considering they have had members like Jo Baxter, Brian Watters and Ann Bressington, Are they relevant for serious drug policy debate?
Given Watter’s replacement with Herron – and the [presence of people such as Margaret Hamilton, there is still the possibility of good advice. However, Howard’s removal of consumer advocate Jude Byrne, Families & Friends’ for Drug Law Reforms’ Tony Trimingham and other like minded folks, it was obviously a body the (blessedly) former PM’s desire was for a body that would provide him with info that matched his ideological preferences – the supposed independence of the body was something of a sham. However, with a change of government, and appointments of better qualified individuals not pulling some ideological or moral wagon, this could become a genuinely useful advisory body to work alongside the MCDS.

South Australia recently banned drug paraphernalia and rejected a call to test MDMA for Post Traumatic Stress Disorder. Why is the S.A. government abandoning it’s position as one of the most progressive states on drug policy?
Political expediency … whenever a potentially valuable policy initiative has been mentioned and debated in parliaments around Australia – almost always as a consequence of recommendations from yet another expert inquiry calling for reform … the backlash of a misinformed public leads very quickly to a backing down – as seen in Victoria with the case of MSICs and tolerance zones for street sex workers in Victoria under the Bracks government.

There is now more evidence than ever before that drug addiction is a physical condition and some people are more susceptible to becoming drug addicts. Are you aware of any politicians who are prepared to admit this and risk being labelled ‘Soft on Drugs’?
Yes – in private. Only those without the chance of truly gaining a position from which to exercise actual change of drug law reform – e.g. The Greens – are able to address drug policy in an objective and informed manner. That said, the Australian Parliamentary Group for Drug Law Reform with members from both sides of politics actively advocates for the liberalisation of prohibition and the implementation of more progressive drug policy designed to reduce the terrible harms of our current, entrenched approach to illicit drugs in Australia.

Q and A: Kerry Wolf - Certified Methadone Advocate (USA)
Q and A: Gino Vumbaca - Executive Director of the Australian National Council on Drugs
Q and A: Sandra Kanck - Former South Australian MLC. South Australia spokesperson for Families and Friends for Drug Law Reform (FFDLR)
Q and A: Tony Trimingham - Chief Executive Officer, Family Drug Support


Paul said...

What an honest and insightful read.

Are there many medications that are not subsidised, other than OMT? I am curious as to how targeted this exclusion is.

Tonia said...

Nice one Terry! ;)

P.S.Paul- To my very limited knowledge, I believe that Methadone is one of the few (if not the only) PBS medication in Australia for which the dispensing fee is not covered. And, the dispensing fee is rather large.

Terry Wright said...

Thanks Paul and Tonia.

Hopefully James will drop by and clear your question up, Paul. I think Tonia is right though because James mentions it in his answers.

You are right, Paul. Jame's responses were brilliant. I have a few really interesting people considering a Q & A for me but it will be hard to beat the first 2 from James and Kerry Wolf.

Check out Kerry's Q & A for another fantastic set of answers.

James Rowe said...

Hey Terry ... thoroughly enjoyed your response to Mr Wharton's poor attempts at ridicule. It was also interesting to read sme more of your own history. It certainly puts many things into perspective.

Methadone, along with buprenorphine (sold in Aust by Reckitt Benckiser as Subutex), both alone and as a 4:1 mix with Naloxone (Suboxone) fall within Section 100 of the National Health Act 1953. This section lists 'specialised medications'that are dispensed according to different arrangements. However, the medications used for opioid substitution are realy in an area of their own when one examines the other medications for which 'special arrangements' exist/ The initial placement of these meds in sec 100 was understandable as public clinics were to dispense them at no cost. However, as we've moved to a community pharmacy model there has been no reform to move these meds into section 85 of the Act, along with practically all other medications on the PBS. Paying dispensing fees is no issue -community pharmacits rely on dispensing fees to make up part of their everyday income. The reform to place these meds into Sec 85 is long overdue and, as noted, is the single greatest obstacle to beginning or being retained in substitution treatment (the most successful treatment by a long shot as demonstrated by the evidence - as opposed to opinions about whether drugs should be given in place of drugs - if it stabilises ones life and allows them to address their chaotic circumstances and so on, it's a hell of a better drug than heroin ...) My life is a hell of a lot better with Suboxone instead of heroin in any event ... but as an emp,oyed individual, I can afford it.

Oh, I also just wanted to note that at one stage I refer to an overdose when living with my wife - this makes no sense given I removed information about that episode upon considering the relative merits of including it. I don't think it added anything that my last episode didn't cover and my ex certainly paid enough without people reading about that horrific night. Apologies for the typos too Terry - as I noted to you, a bit of a speedy, bang up job ... would've liked to take more time, but there's a book in those questions.

Cheers, James

Anonymous said...

Paul is there any news with the Feds subsidising methadone dispensing? its getting tough to keep up payments.