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Australia, well known to outsiders for its ancient indigenous culture and uniquely evolved flora and fauna, is also a society with a significant drug problem. Like many industrialized countries, Australia has experienced a massive surge in injection drug use over the past thirty years. Unlike many nations, however, Australia has managed to head off almost completely an epidemic of HIV infection among its drug users.
As much as anyone, the credit for this remarkable achievement belongs to Dr. Alex Wodak. As Director of St. Vincent's Hospital Alcohol and Drug Service in Sydney, Dr. Wodak has spent two decades bringing humane care to drug users and reason and compassion (and, inevitably, controversy!) to the drug debate. His introduction of legally unsanctioned syringe exchange to Australia in 1986 began what may have been the most successful HIV prevention program the world has seen. On a visit to the United States in 2001, Dr. Wodak took the time to give colleagues in New York an overview of the situation "down under."
The widespread use of illicit drugs is a fairly recent phenomenon in Australia. In the 1890s several Australian states passed laws prohibiting the smoking of opium, exactly as California had done around the same time. The people who were smoking opium at that time É both in Australia and in America - were overwhelmingly Chinese immigrants working in the gold fields or as laborers, and racism, pure and simple, was the basis for these laws on both sides of the globe.
In the 1920s - even before the United States - Australia introduced prohibition of cannabis use. As for heroin, however, it continued to be legal, and doctors used it as an effective painkiller. Those (relatively few) patients who became addicted to heroin in the course of medical treatment were provided assistance to detoxify and to maintain abstinence, but where that wasn't possible, the doctor and the health department would come to an agreement whereby authorization was given to prescribe heroin indefinitely. Other than iatrogenic addicts, however, Australia did not experience the illegal use of heroin or a "street scene" until years later. Heroin treatment for pain continued until 1953, when the World Health Organization pressured Australia into prohibiting it.
In the late 1960s, U.S. servicemen visiting Australia for "rest and recreation" during the Vietnam War sometimes brought heroin with them. From those beginnings the heroin problem grew exponentially. It is estimated that by 1997 there were 100,000 people injecting drugs on a regular basis, and an additional 175,000 using intermittently. By far the most common drug taken intravenously was heroin; to go from virtually zero in the late 1960s to 275,000 injectors within 30 years implies a growth rate of approximately 7% per annum - which would result in a doubling every ten years. In fact, the rate of growth appears to have been, even more rapid over the past five years than in the preceding quarter-century.
In late 1984 it became public knowledge that the Prime Minister's daughter was using heroin. This was the beginning of a national psychodrama of epic proportions, resulting in a campaign against drug abuse. In April of 1985 the Prime Minister called a meeting that resulted in the official adoption of a national policy of harm minimization. This policy has been reviewed and re-endorsed every three or four years. Curiously, concern over HIV infection among injecting drug users really played no significant role in the adoption of the harm minimization strategy.
It wasn't until September of 1985 that Australia became concerned about HIV infection among injecting drug users. This concern stemmed from the visit of Dr. Jim Curran, of the CDC in Atlanta, who pronounced strong warnings about the danger of neglecting this very high-risk vector of the disease. He argued convincingly that it was essential to create a policy, and to get it right the first time.
I'd already been working on this issue for some years. By chance I had met someone in London in the late 70s who fell ill with an immunological condition and eventually died in the early 1980s - probably without ever becoming a statistic of AIDS. After I moved back to Australia the first cases in the country were diagnosed at my hospital in Sydney. Since the area in which I worked had a high density gay community, high density drug use, and high density commercial sex work, it was obvious that if the epidemic were going to start anywhere in Australia, it was going to start in my backyard.
Sometime in 1984 I started holding meetings and to discuss what steps might be taken to address the problem. I'd heard about the needle exchange program in Amsterdam, and it seemed that we needed to implement something similar. I began pressing for needle exchange in 1984 and 1985, and wrote numerous proposals to government authorities - all of which were rejected for one reason or another. I soon realized that unless I was prepared to establish a needle exchange service without official approval, none would ever be established.
In November of 1986 I called my staff together and expressed the view that if we didn't start a needle exchange no one else would. And so we did just thatt: we began a needle exchange and the very first day people started showing up. We had access to the neighborhood of King's Cross — the major drug dealing area — and the visits quickly increased. Hospital staff and administrators provided personal funds to support the effort, and when we ran low on money the users were asked to contribute, and they did.
I was called to a meeting by the health department, told that our exchange program was illegal, and threatened with "serious trouble" from the police. But we kept on, and the program gained national publicity. Soon the state health department announced it would start an official program of its own, and in December of 1986, the first "official" Australia syringe program was launched.
The following year syringe programs were started at many venues throughout the country. In less than 2 years every state and territory in the country had started its own syringe exchange service, and these now cover the entire continent. The services are very well organized, and provide almost 20 million syringes a year. With a population of only 19 million, this is about the same number of syringes as distributed in the U.S., with a population of 280 million.
The bottom line is that HIV is under control among injecting drug users in Australia. Four to five percent of the cases in the country are associated with injecting drug use, and about half of that number are men who have sex with men.
Methadone was introduced in Australia on a pilot basis in 1969, with the first official "program" started in 1970. The pioneer was Dr. Stella Dalton; she had met Dr. Marie Nyswander, a co-developer (just 4-5 years earlier) of methadone maintenance treatment, and was a firm advocate for methadone, having earlier tried therapeutic communities and finding that they did not have a high success rate. Dr. Dalton's program grew very rapidly, but lacked detailed organization and soon she, and methadone prescribing, drew criticism from officials and colleagues. Significant efforts were made subsequently to restore methadone's image, but gaining acceptance has been difficult - in part because the very success of methadone is a direct threat to the prevailing policy of prohibition which reigned in Australia for so many years. Whatever the reason(s), methadone has struggled in terms of its reputation in the community, but has nevertheless had consistent, widespread support from policy makers and officials.
Methadone has grown, on average, by 10-15% per annum and there are now some 27,000 people on methadone nationwide. As of the 1st of June 2001 in New South Wales (population 6 million) there were 15,054 people receiving methadone, compared to 13,863 one year earlier. Clearly, methadone treatment is still expanding!
Like most countries, opiate addiction in Australia is a difficult issue for both politicians and for health departments. Health policies reflect not just scientific knowledge but community attitudes. Since1953 Australia has had a strong commitment to a prohibition framework for drug policy, but it is now becoming inescapably clear that that the policy is failing, even with (perhaps in part because of) expanded penalties and increased drug squads. More and more it is being recognized that our current course is a road to futility - that the journey is arduous and expensive, and leads nowhere. While there is no consensus on alternatives, there is widespread acceptance of the premise that there must be a better way than a continued primary law enforcement focus.
The more therapeutic options available to clinician and patient, the better. Australia is now in the throes of introducing what is called "expanded pharmacotherapy." Down the road there's a likelihood that sustained release oral morphine will be introduced and trials are going on now in Melbourne. If they are successful, and early results look promising, it appears that shortly there will be available methadone, buprenorphine and MS-Contin.
In the state of Victoria, which has 20% of the nation's population, there has from the outset been a reliance on general practitioners, with very few clinics. About ten years ago it was recognized that both treatment options were needed -a place where people who were particularly high risk or who had many problems could be cared for more comprehensively than is possible in a general practice.
In New South Wales, on the other hand, there initially was a clinic-based system onto which, since 1985, a general practice component has been grafted. It's been difficult to find general practitioners, and keep them interested in this field of medicine, especially since there have been major financial impediments (i.e., inadequate reimbursement). Financial incentives recently have increased, and more general practitioners are willing to take part in methadone prescription.