Professor Margaret Hamilton has more than 40 years’ experience in the drug and alcohol field. Her background is in social work and public health, and her broad range of research has included epidemiology and policy. Among many influential roles, she has been an Executive Member of the Australian National Council on Drugs, the Founding Director of Turning Point Alcohol and Drug Centre and the President of the Cancer Council Victoria. She is a Board Member of VicHealth, the Patron of DANA (Drug and Alcohol Nurses of Australasia) and a Life Governor of the Australian Drug Foundation. She is ‘retired’ but remains ‘active’ in this arena.
What do the current statistics tell us about drugs and alcohol use in Australia?
Drug and alcohol use can cause severe difficulties for some people; while others use them without problems, regardless of whether they are using legal products like alcohol or nicotine cigarettes, or products such as cannabis, heroin and a range of other hallucinogens and stimulants, the most recent being crystal meth-amphetamine, also known as ICE. Being in possession of these can involve trouble with the law and use of them can sometimes involve negative health and social consequences.
Is the situation in Australia quite bad in terms of overuse?
We are high consumers of alcohol on a per capita basis and comparatively low consumers of tobacco/nicotine cigarettes due in large part to the very active and persistent efforts to reduce tobacco smoking. Australia does rank as a country with relatively high illicit drug use. Overall, we are high consumers of psychoactive substances.
Which demographic is most at-risk, or composes a large number of those statistics?
We think of young people as most at risk and the usual roles they would fulfil, the expectation as they develop and conduct themselves into the world as adults. We worry about the disruption to their usual developmental milestones and stages. However, middle and older age groups are of concern too, especially if we look at alcohol use where, for example, older adults are continuing to drink regularly at risky levels. Older people who are on various medications are especially at risk from the mix of drugs – prescription and otherwise – that they are using. Our capacity to metabolise alcohol gradually reduces as we age. Our tolerance reduces and if we continue to drink at the same levels as drinking in our 40’s and 50’s, the risks increase. Another group of drugs that are especially problematic for older people are opiates (for pain, etc.) where, if not used sensibly can lead to an overdose.
Young people are more at risk with episodic binge drinking or acute episodes of intoxication – ‘getting wasted’. All of us face risk when intoxicated since alcohol and most psychoactive drugs affect our capacity in many ways; perception is altering and influencing things like our sight and response times, thinking is impaired and reducing our capacity to make judgements, and our behaviour is impacted such that we are less coordinated and less likely to behave in the way we usually do. This is why we have laws about driving when we have been drinking or using drugs. Intoxicated pedestrians also pose a risk to themselves and to others. People who are drinking are at a higher risk of getting an injury associated with aggression, family violence, street fights and accidents of all sorts.
It is precisely because these psychoactive substances change the way we feel, think and behave that they have value, why we like them and why a colleague (Jonathan Caulkins) at a recent NYU seminar spoke of these as ‘temptation goods’. We like to be relieved of anxiety, feel more relaxed or be more convivial, and some enjoy altered perception. These drugs provide many of us with pleasure. It’s not always easy to decide on a small amount that may have a positive effect but decide that more of that same thing might be harmful. These products impact our neurophysiology, targeting areas of the brain that are pleasurable rewarding, and there are also cultural and social rewards associated with their use.
Our Australian culture is very pro-alcohol. People know well that they shouldn’t use too much; but decisions about this are made in an accepting and expecting social milieu and, with strong advertising and promotion of alcohol and prolific bars, lounges and such outlets, even our physical context encourages drinking.
Are there any solutions to these problems?
Yes there are. The public tend to think the programs and interventions directed at preventing or reducing the harm associated with the use of these substance are not effective in changing our behaviour. They call on school drug education. This is necessary; but not sufficient. It can have only limited impact on what people choose and how they behave in the long-term on its own.
Using tobacco as an example; social marketing campaigns can have a place to provide a rationale for policy and to explain potential harmful effects of use, the ways of quitting and access to help, and to promote knowledge about the years of life that you might save by quitting now. We have banned advertising, passive promotion and sponsorship. However information and help to quit alone would not have produced the low rate of smoking we now see here. The synergy of other interventions together with these is critical. A potent instrument available to governments has been the ability to manipulate price through taxation provisions. The recent increase in tax on tobacco is likely to further reduce smoking rates downward. Further research is evident about secondary smoking of people who share the workplace, home, car travel, etc., providing a further rationale for why we shouldn’t be smoking, and why we shouldn’t smoke around others. This gave me the right to say, please don’t smoke around me!
If we look then at alcohol, we need to get rid of advertising and promotional images about the joy and pleasure of drinking, especially at the time and in the locations where children and young people are exposed to them. We also need to address the availability and omnipresence of alcohol (in both location and price) in our community. If we could do these things it would likely to be more effective in reducing the harm associated with alcohol use.
Research is ongoing on reduction in per capita consumption amongst young people and how this can be achieved. We are fortunate to have the Centre for Alcohol Policy Research (CAPR), one of the world’s best and most prestigious groups led by world leader Professor Robin Room, here, initially at the University of Melbourne (now at LaTrobe University) and a group of top researchers who are looking at the social determinants of alcohol use, the potential ways of influencing alcohol consumption, or more importantly – ways of reducing alcohol related harm.
This effort to reduce harm must be the approach to so-called illicit drugs. Regardless of the legal status of use of these drugs, we desperately need to reduce the opportunities for people to be harmed by them. There are high rates of drug use among prisoners, and that group does not have access to the most obvious harm reduction tools such as clean injecting equipment. We all need to be protected from the harms associated with any drug use that may occur. Similarly there are not enough treatment places for people who want to do something about their drug use, so it remains difficult for people to get treatment when they’re ready for it and when they want it. There are families struggling to help family members and most drug treatment services are not sufficiently funded to help them. Much could be done to reduce the potential of death, illness and other harm, and also make it safer for drug users, and for those around them as well as reducing the overall cost to us all.
What recent roles have you been involved in?
I was appointed as a representative of the Oceania Region to the international Civil Society Task Force (CSTF) in association with this year’s United Nations General Assembly Special Session on Substance Abuse (UNGASS). Our role was to work towards engaging civil society in the discussion around international drug policy and we consulted people and groups around Australia about this. Themes for UNGASS were on demand reduction, supply reduction, Cross-Cutting Issues (such as use of drugs by women, children; vulnerable populations, etc.) and new challenges such as the new psychoactive substances (NPS) that have been of significant concern internationally.
There has been a proliferation of NPS, and governments around the world have been challenged about whether to leave them as they are (not regulated) or to regulate them. In some South American countries, governments are looking to de-regulate traditional products. There are clear and less clear costs of either position, some more obvious to us than others. For example, farmers from developing nations (where many of the plant based raw materials originate) depend on these products for their livelihood. With crop eradication as one means of reducing supply, this can be quite harmful to these farmers and their communities.
Access to essential medicines was another Cross-Cutting Issue since many psychoactive drugs have a significant role in pharmaceutical medicines, like opiates that relieve people of pain. The Australian government took a significant lead in the discussion about this and also in ultimately unsuccessful efforts to ban the death penalty for drug use related crime. Though there was a strong push from civil society groups and many countries for this, the practice of consensus decision making of the UN meant that the countries wanting to retain the death penalty ensured that this did not eventuate.
Can you comment on the legalised cannabis debate and medicinal cannabis?
The recent attention in Victoria and in other states to the potential of medicinal cannabis and how to make it available needs to be seen and understood as quite different to the push for access to cannabis products for social and recreational purposes.
The Victorian and Australian governments are working toward strongly regulated and tightly controlled production and manufacture, including the specific formulation, prescribing and availability or sale of medicinal cannabis. It will be a separate market to the market that operates to supply cannabis for social use. I personally think that we should also examine ways in which this currently illegal market could be regulated and cannabis made available in manner that could save significant resources and harm, recognising that this is a separate matter in most respects.
And your Report to Minister of Defence in 2011?
Our Defence Force reflects our general community pro-alcohol culture, with additional motivation for using this drug: a culture of pro-drinking at heavy levels, sometimes for stress relief and in an historic culture of heavy use. We looked into the contexts where drinking occurred, the cultural acceptance of alcohol consumption and the provision of alcohol in the Defence Force, and adopted the overall framework of Australia’s alcohol (and other drug) policy. We looked at the supply related issues – whether economically, physically/geographically available (it’s cost and promotion). In most circumstances it’s certainly available. Demand related issues: both cultural expectations and the nature of work together with the age at which most enter the Defence Force were examined and we also examined costs and harm associated with alcohol. I continue to sit on a mental health advisory group for the Defence Force in following through on some of the recommendations made by the enquiry that I chaired.
What is your overall approach to drugs and drug policy?
With alcohol, tobacco and illicit drugs, including those that we have not yet seen but are likely to emerge, we need to sustain efforts to monitor what’s available and how is it being used and as far as possible anticipate possible problems and harm and intervene earlier at a total population level as well as providing responses to those already exhibiting difficulties. Ongoing research to further inform what measures might work, what might not; trailing, testing, evaluating and repeating these efforts and then investing in the things that work.
Our drug policies should be humane and pragmatic, so human rights and social justice must be the first principle. The second one is that they have to work in order to ensure that the things that work are adopted. You can’t have a revolutionary change; it is going to take a long time to adapt. This requires patience and persistence.
Tell us about your academic pathway.
I grew up on a farm wanting to do Veterinary Science (VS) and came to Melbourne University where I met and spoke with the Professor of Veterinary Science at the time. I received a follow up letter, that said , “we would welcome you as an applicant for entry, however it’s important to understand that women veterinary scientists work in the suburbs with small dog practices such as poodles and birds and your interests suggest that you were more interested in what we call large animal practice. This is done by men.” And the very sad thing was ‘alright I don’t want to be a vet then’ instead of saying ‘right well that’s what they think’ because all I was interested in were cattle, sheep, horses, etc! At about that time I was selected as a Rotary Exchange Student and went to The Philippines for a year. This had quite a profound impact on me; I had never seen such poverty and, more importantly, the big gap between the incredibly wealthy and the very poor. I found that quite confronting as a 17 year old. I felt the need to do something about that in the world; it was unacceptable. So on return, I applied to do social work and was very focused on acquiring the qualifications to be able to help people who were unequally treated.
I worked at St Vincent’s Hospital for about 7 years, that at that time had an alcoholism clinic. Then I got a Rotary International Fellowship at the University of Michigan to do postgraduate work. There, using my work experience, I got more involved in some of the drug related courses and became more informed and more interested. I also spent time teaching as well as working with people who had drug trouble. My first research efforts involved studying those who came to the accident and emergency department and whether they were really accidents or emergencies. This contributed to the early thinking about community based health centres.
After doing other research in the USA, I returned and worked on alcohol in Mount Isa, Queensland as I responded to an article because there was no one available or wanting to do it. There I saw our own version of extreme poverty and disadvantage in the town camps as well as drawing attention to the heavy drinking among the workers and their families.
I continued with a sessional clinical role in alcohol and drug dependence and maintained my networks in the non-government treatment world.
This was about at the time when the Australian Government developed what became known as the national drug strategy under Bob Hawke (1985) and I was appointed to the first evaluation task force to evaluate the national drug strategy and from that to various other national and state advisory groups. As part of that National Drug Strategy there were funds to employ alcohol and drug coordinators in the medical schools and I was successful in applying for this position in the Department of Community Medicine (now school of Population and Global Health) here at Melbourne University.
It is interesting being here at Graduate House because during the time when I was in the medical faculty, I developed a Drug and Alcohol Research Team (DART) and we had an education and research group (DREGS!) that would meet here at Graduate House.
What would you say that you are most proud of?
The people I’ve had the opportunity to work with and to see them go on to achieve their goals in leading major research groups or doing very significant research and contributing in a wise and well-grounded evidence manner to policy debates and discussions in Australia and elsewhere.
What are the greatest lessons you have learned?
I think my lesson here is to tap the energy and enthusiasm of youth and to support persistence, while being patient. Young people have the capacity to push and I think that’s really important and valuable. I would encourage, support them and be ready to pick them up when they get so frustrated and even angry when something is not achieved and to point out to them the components of what they’ve done and if they weren’t successful, guide them on what they can do next time to get one step further.
As a concerned population, what can we do?
We can be well informed about the things that work and those that don’t. We can avoid joining the populist calls for responses to problems that are evidentially not successful and instead work on what might be successful and support calls for that. We are often too quick to call for simple ‘why don’t they do X’. Be careful; often the ‘X’ responses are ill-informed and may be unlikely to succeed. Some of these knee jerk measures might achieve re-election but won’t solve the drug problems in our community. We all have a responsibility to try and be well informed about what might actually work and call for that; and if we are not informed, we say we don’t know and seek answers.