Managing legal and medical complexities in caring for people with drug and alcohol problems: a call for change

How can we respond more effectively?

The current “ice (crystal methamphetamine) epidemic” has thrown into relief long-standing dilemmas for front-line practitioners dealing with the burden of care associated with drug and alcohol misuse in the face of legal complexity and insufficient support from the health system and other government agencies. Despite increasing investment in border protection and law enforcement, the Australian Crime Commission has been reporting growth in the importation, manufacture and supply of crystalline methamphetamine of increasing purity, leading to the establishment of the National Ice Taskforce.1 Concurrently, medical and public health bodies (including the Australian Medical Association, Public Health Association of Australia, and South Australian Network of Drug and Alcohol Services) are reporting under-resourcing of measures to reduce drug demand and to provide early intervention, treatment and rehabilitation in the community.2 The issues for clinicians are not new, and the views of the medical profession need to be strongly heard, so as to achieve rational, health-based policies in response to the ice epidemic and other drug problems, and to manage the problems associated with drug and alcohol misuse, particularly mental health issues.

Historically, in the first half of the 20th century, the predominant concern in Australia was with alcohol and alcoholism; then, the 1960s and 1970s saw an increase in public awareness of illicit drug problems. In 1985, then Prime Minister Hawke called a drug summit which instigated what is now known as the National Drug Strategy. The strategy addressed misuse of legal and illegal drugs, and upheld the principle of harm minimisation, subsequently seen in Australia’s response to the HIV/AIDS and hepatitis C “epidemics”.

However, legal and clinical responses have had different goals: while the legal system has aimed to restrict access to drugs and alcohol to prevent misuse and deter criminal behaviours, clinicians have aimed to prevent and manage the effects of drug misuse and associated secondary physical and mental health issues (including suicide risk and blood-borne virus transmission). As a result, law and medicine have often been in conflict in the sphere of drug policy.

The bottom line is that in the domain of clinical practice, associated legal complexities — especially when those affected are, or could be, “criminalised” — can complicate the implementation of effective management. In such circumstances, medical practitioners must try to negotiate complex interfaces between treatment, legislation, criminal justice and social disadvantage. It is among the socially marginalised — such as the homeless, prisoners and people with mental health disorders — that these interfaces are most notable.

In 1998, a comprehensive mental health survey of homeless people in Sydney night shelters found that while 36% had a drug misuse disorder, 75% had one or more mental health disorders and one in two had a physical health problem.3 Mortality was three to four times higher than that for the general population.4 In 2012, while 70% of surveyed Australian prisoners had used illicit drugs in the past year and 54% were drinking alcohol heavily before offending, 46% had received a mental health diagnosis in the previous 12 months and 21% were taking a prescribed psychotropic medication.5 Indigenous and female inmates were most likely to be affected by such health problems.5 The prison population also had high rates of blood-borne virus exposure.6

In 2013, the National Mental Health Commission reported that almost 340 000 Australians were both experiencing mental illness and misusing drugs, and up to 70% of patients who presented for a mental health or substance use problem were experiencing both concurrently. It highlighted that “People living with this mix of difficulties are discriminated against and are often judged and marginalised from services and the community”.7

Law enforcement agencies, including the courts, are common points for identifying users of crystal methamphetamine and other illicit drugs and for referring these people to treatment. This includes pre-arrest and arrest stages, and court- and sentence-based orders (all states have court-supervised treatment programs for users of illicit drugs). The focus is on illicit drugs, not alcohol. Only two states have treatment units for short-term involuntary “care and control” of severely substance-dependent people whose survival is at risk. Mental Health Acts deliberately exclude the effects of drugs and alcohol from the definitions of mental illness. A person manifesting features of a mental illness that are attributable to substance misuse can be held only for a temporary period as a “disordered” patient. Once discharged from care, primary health care workers may be faced with treating such patients in an environment that has scarce on-the-ground drug and alcohol services.

Three issues in current drug and alcohol policies stand out for resolution: substance misuse problems must be recognised as inherently “people” problems, not solely problems of pharmacology; legislation centred on drug law enforcement must be shifted to a public health framework based on reducing harm from misuse of all drugs; and management of drug and alcohol misuse needs to become a mainstream task for all health services. Accordingly, the nascent Primary Health Networks should be resourced to respond to region-specific drug and alcohol problems, and to work in partnership with specialist drug and alcohol services. To enable this, the speciality of addiction medicine should be recognised by the federal government. Finally, with increasing recognition of the co-occurrence of mental health and substance misuse problems, the historical separation between mental health and drugs and alcohol needs to be re-thought, and new approaches devised.