A serious risk of harm

About half of all New Zealand adults have used recreational drugs within their lifetime, and nearly a quarter have drinking patterns classed as hazardous. What is addiction, and how should we be treating it? 

We all have that friend. The one who doesn’t know when to stop, who can’t have “just a couple of drinks”, or owns a seemingly endless array of shoes. The colleague who can’t get going in the morning without two long blacks, or the flatmate who can’t relax at the end of the day without a joint.

The Ministry of Health’s 2007/08 alcohol and drug use survey reported that nearly half of all adults had used drugs (excluding alcohol, tobacco and BZP party pills) for recreational purposes at some point in their lifetime.

A 2011 report by the National Committee for Addiction Treatment (NCAT) found that alcohol and other drug abuse is the sixth highest contributor to the burden of disease in New Zealand. It found that serious alcohol and drug misuse and addictions affect 3.5 per cent of the total population or around 150,000 New Zealanders. For people aged from 16 to 25 years that figure rises to 9.6 per cent. 

Many people who need it won’t get treatment, or will wait too long to seek help. A 2011 report by the Mental Health Commission reports that about 50,000 people aged 16-24 had wanted help to reduce their level of alcohol or drug use. And younger people (aged 16-34) were significantly more likely to have wanted help and not got it. Maori and Pasifika people are also much more likely to miss out on help.

Last year, Stuff.co.nz reported that hundreds of people were being locked up for petty drug offences. Along with having the highest frequency of illicit drug possession or use apprehensions in 2012, the 21–30-year age group also had the highest apprehension rate (the number apprehended per 10,000 people), Statistics New Zealand reports.

So how should addiction be treated? With hospitals and doctors, or with court and prison?

Professor David Nutt, a British psychiatrist and neuropsychopharmacologist says addiction is caused by the confluence of three separate factors. The availability of a liked, desired commodity, like drugs, or porn, or gambling; the way in which the brain reacts to a substance – particularly with drugs; and the individual.

Professor Nutt says some individuals clearly have a propensity for addiction. “There’s no drug that makes everyone addicted. The most additive substance is cigarettes. About 40 per cent of people who ever smoke will become addicted. Heroin and crack 30 per cent, alcohol 10 per cent and cannabis 4 per cent. That tells us there’s something in the individual.”

So what is it that can make an individual more likely to develop an addiction?

“A typical profile of a serious addict would be…They’re the first one in their class who starts smoking cigarettes. They start smoking cigarettes when they’re nine or ten, they like to break the rules.”

Ben Birks Ang, 30, who runs programmes for the addiction treatment provider, Odyssey House, says some believe there are genes and an “addictive personality” involved, some believe it’s shaped by the way people have developed.

“For everybody there’s the potential to develop patterns that are unhelpful for us, whether it is substance use, or whether it’s another addictive process that we fall into.”

He says as part of growing up, people will sample different substances, to see how much they can handle – whether that’s a couple of glasses of booze, or a couple of joints. “Where I see most of the concern is where it develops into a pattern that takes up a lot of their time – so they’re not getting the socialising, or learning new skills, or they’re using it to be able to cope with different emotions.”

Professor Nutt says he doesn’t think anyone wants to become an addict, but there are people who find it easier to get into an addictive mode of behaviour. “A typical profile of a serious addict would be…They’re the first one in their class who starts smoking cigarettes. They start smoking cigarettes when they’re nine or 10, they like to break the rules.”

He says they start drinking at 11 or 12, cannabis at 13 or 14, then heroin at 16 or 17. “Then they become addicted to heroin, then they’re on the methadone programme, and after 10 years they may come off that, then they may go back to alcohol. They might stop drinking, but they carry on smoking and drinking lots of coffee.”

Dr Jeremy McMinn, an addiction specialist for the Capital and Coast District Heath Board, says even though people are smart enough to know that their substance use is a problem, they struggle to do anything about it. “They’re compulsively using, they feel that it’s bigger than they are, it’s got out of control.”

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Lani Hunt realised he was out of control when he saw that his habit was taking money out of his children’s mouths. He calls himself the cliché of a troubled kid, having lived on the street since age 13, ending up under a bridge in New Plymouth. Of Ngapuhi and Te Atiawa descent, Hunt says from the first time he took cannabis he kept chasing the same high.

“It was like I was going to die the first time I ever had it, but then it got to the stage that it was fun and [I was] experimenting even more, then it got to the point where I needed it, and was abusing it at the same time. Where a tinny wouldn't be enough, I wanted more and more and more.”

But Hunt says getting that high wasn’t easy. He’d switch between cannabis and alcohol, and between different varieties of pot. “You'd go to different forms of cannabis, whether it was sativa, or a higher one like orange roughy, or skunk, after that, to get a hit, to get that same hit,” he says. “You wanted that same hit, and some of them were extreme, so you'd go back to that, and then that wouldn't work, so you'd go to the next level, and sometimes that would be like, manufactured oil, and stuff like that.”

He says it was a long way to fall from that high, and the people who were losing out were his kids. “I was taking money out of my kids’ mouths, and not really realising the effect I was having on my family, because I was looking for a family myself.”

Hunt says he started using cannabis because he watched his uncles doing it from a young age. “And them having fun, and growing up with it all my life, and then seeing that hey, this is normal.” He says it was a social thing. “And then I got to an age in my life where my friends were doing it, and [thought] ‘I'll have a try,’ and then having that one hit, and then going wooaaahh.”

Ben Birks Ang says for some young New Zealanders, getting hold of cannabis is easier than getting alcohol.  While there’s health promotion – drink slower, don’t drink and drive, don’t drink while pregnant – advice for alcohol, there’s very little information around for cannabis. And with both alcohol and cannabis, people are getting mixed messages about the effects.

“We’ve got 13-year-olds that can attribute qualities to certain alcohols – if they’re drinking a certain kind of alcohol, they’re a certain kind of person,” Birks Ang says. “So they’re getting that brand association at a very early age, through both advertising that they see on the way to school and also in social media.”

Alcohol’s overwhelming presence in life in New Zealand belies how harmful a drug it is. Birks Ang talks of the social expectation that what we do to socialise is to get drunk. And Murray Trenberth, who heads the youth alcohol and drug service WellTrust, says alcohol is the world’s biggest drug problem.

“We work with teenagers, and probably two-thirds of our referrals are actually for cannabis. But alcohol is still the biggest problem,” he told Radio New Zealand’s Outspoken programme.

Professor Nutt refers to a study, conducted in the UK, which found alcohol was by far the most harmful drug. He says when the harm to the user and the harm to others are weighed up, alcohol is more harmful than heroin, crack, and methamphetamine. In the study, the harms to others include violence, car accidents, and deforestation. When those harms were given different rankings in a similar study done right across Europe, the result was the same. Professor Nutt says he’s certain the results would be the same in New Zealand.

 A report compiled by the economic research group BERL for the Ministry of Health and ACC in 2009 found that harmful drug use in 2005/6 caused an estimated $6.5 million of social costs. (Equivalent at the time to the GDP of the agriculture industry). Of that, harmful alcohol use cost about $4.5 billion.

The report cites research that found about a third of the cost of harmful drug use results from injury. There are also costs in terms of crime and policing, road crashes, drug production, and lost production.

The Mental Health Commission’s 2011 report says in 2006/7, 18 per cent of New Zealand’s population had a potentially hazardous drinking pattern. That means there’s about half a million people who had a high risk of damage to their physical or mental health from their drinking. That percentage rises to 43 per cent when it’s people aged 18-24, and for men aged 18-24, it’s 54 per cent.

Dr McMinn says alcohol is in essence a Class B drug (meaning it has a very high risk of harm), but it is so pervasive and traditional that no one sees it like that. “Whilst the legal approach is often to look at narrowing the focus on the user…the major approach is society’s permissive, over-promotion, over-acceptance of excessive alcohol consumption.”

Speaking to the New Zealand Drug Foundation’s conference last month, the head of the Christchurch Youth Drug Court, Judge Jane McMeeken said there’s something wrong with a system where she can put someone in prison any day of the week, but getting them into treatment is a challenge.

“There’s a whole lot more custodial beds for young people than there are beds in treatment facilities,” she says. “You have to understand the nature of addiction. It’s important for our drug court that the young people we work with have been diagnosed by clinicians as having a dependency. They’re not just young people who are having a couple of drinks and are making bad decisions.”

And she says the drug court is successful in many respects. “It assists these young people to have a better shot at life. It assists them to get back into education ... many of them are from families where their parents or parental figures have dependencies of their own, so they’re in this really vicious cycle, and drug court is one way to break that.”

But the Youth Drug Court is one small court in one city. The criminal justice organisation Just Speak says in 2011, 80 per cent of all young people who appeared before the court had substance abuse issues. And it says, young Maori are more likely to be prosecuted.

Just Speak’s Sacha Norrie, 24, says it’s impossible to look at particular drug issues in isolation. “We can see that in the discretionary processes of our justice system, we can see at every step along the way, we are more enthusiastic about inviting young Maori men into our system,” she says. “And it's no longer acceptable for us not to engage with those questions and starting to ask for some explanations.”

"If they are addicted, then they are ill, and you wouldn’t put someone with diabetes in prison because they ate sugar."
 

Norrie says the acceptance that young people make mistakes – and a willingness therefore to keep them out of the system – is one of the major successes of the youth justice system. But that’s challenging when the young person comes from a background of poverty, family violence or being disengaged from the education system.

“Starting to deal with those issues becomes a bigger process than dealing with an ideal offender who comes from an ideal family and community and cultural context, in which case, they are supported to rehabilitate to a position which we feel is an appropriate level of rehabilitation or "habilitaton". Because a lot of these young people don't come from a situation where they are ever habilitated to begin with. So how do we engage with some of those more contextual and environmental issues?”

Birks Ang says there needs to be a broadening of what people see as drug and alcohol treatment. “When people think of drug and alcohol treatment they think of the very hard core residential, and they see that as the end of the road.” He says treatment needs to get to people before they’ve built up so much harm around their substance use that they end up in court or in hospital. And that’s a shift for both the community and the treatment sector.

Birks Ang says particularly if someone is in a pattern of daily use, they don’t see the warning signs, and treatment can be as simple as giving them time to reflect. “It could be the associated friend problems in a social group – that seem unrelated, but they actually track back to the night everyone was drinking and someone did or said something stupid.”

Dr McMinn says treatment is cheap, but it is inaccessible. “We’ve got people on waiting lists for opioid treatments, for example, which is one of the most effective and cheap treatments available,” he says. “It costs around $5000 dollars a year, all up, to treat someone with opioid substitution. It costs around $100,000 to imprison someone ... why keep people on a wait list where they’re potentially going to be causing $2000 worth of crime a week, when you could sort it all out for five grand?”

Professor Nutt says programmes like needle exchange and methadone are effective. “In the sense that for every dollar you invest, you save three dollars in terms of crime and public health. They make life better for society and drug users.”

He says those are simple, straightforward harm reduction approaches to dealing with drugs, but criminalising addiction is the wrong approach. “The reason we tax vodka more than we tax beer is because it’s more dangerous to drink a pint of vodka than a pint of beer. So basically, we know that you can regulate consumption by price.”

He says there needs to be a more rational debate about drugs – without the media splashing headlines of drug use, and stigmatising users. "Putting someone in jail for a drug offense – a user – is absurd," Professor Nutt says. “If they are addicted, then they are ill, and you wouldn’t put someone with diabetes in prison because they ate sugar. But you put someone that’s got an illness in prison because they’re using. It’s not only absurd, it’s immoral."