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Providing the evidence base to reduce harmful AOD use in
Aboriginal and Torres Strait Islander communities
Since 1985 Australia’s documented drug strategy has aimed to address the harmful use of licit drugs (tobacco, alcohol and pharmaceutical drugs), illicit drugs (heroin, cannabis, cocaine and amphetamine-type stimulants) and other psychoactive substances (e.g. inhalants), using a harm minimisation approach.
The principle of ‘harm minimisation’ provides the overarching framework for drug policy in Australia [1, 2]. There are multiple ways to minimise the harms to individuals and communities from drug use – reflecting this, the framework of harm minimisation encompasses the three pillars of demand reduction, harm reduction, and supply reduction . Harm minimisation seeks a balance between these elements, and is regarded as an evidence-based and pragmatic approach . This approach has facilitated collaboration across health, law enforcement and education, as well as partnerships between governments and with non-government agencies and community stakeholders.
Demand reduction aims to prevent or delay the uptake of drugs, or stop or reduce drug use once it has commenced. Demand reduction may be thought of along a spectrum, ranging from prevention and education to treatment interventions for people who use drugs. Within the current National drug strategy, demand reduction objectives include strategies which aim to:
prevent the uptake and/or delay the onset of use of alcohol, tobacco and other drugs;
reduce the use of alcohol, tobacco and other drugs in the community;
support people to recover from dependence and reintegrate with the community; and
support efforts to promote social inclusion and resilient individuals, families and communities .
The social determinants of health perspective provides a framework for thinking about demand reduction in drug policy . A person’s health is not solely determined by their individual choices and behaviours, but is closely linked to social status. The social determinants of health include the social, economic and cultural conditions which shape living, and influence health outcomes . As gender, ethnicity, social inclusion/exclusion, and socio-economic status have been shown to be significant determinants of inequality in health outcomes, these factors should be important considerations in health interventions (including those aimed at drug use). Education is a protective factor. The development of culturally inclusive curriculum and teaching practices contributes to improved educational outcomes, which in turn feeds back into improved health and wellbeing for individuals and communities. This is important as a lower level of educational attainment is linked to greater unemployment, poverty and homelessness, which are key social determinants. Employment and stable housing are protective factors in overcoming alcohol and other-drug related issues .
Education is also essential for health literacy. Population health education messages need to be inclusive of the needs of people from culturally and linguistically diverse backgrounds. This does not merely entail translation from English, but also requires an understanding of culturally specific determinants of alcohol and other drug use.
Overall, the social determinants of health perspective attempts to address the causes of alcohol and drug use, rather than the symptoms, by reducing risk and building resilient communities through social inclusion and the promotion of protective factors.
A range of programs and interventions fall within demand reduction. For example, programs aimed at preventing or delaying the uptake of drugs by young people are undertaken in community settings such as schools and sport and recreation organisations. An example of this is the Sporting chance program, which aims to increase educational outcomes for Indigenous students through a sport and recreation program . Other prevention programs focus on Indigenous culture, such as the Culture is life and Back to culture programs [7, 8]. Community based approaches to demand reduction recognise that health-related behaviours (such as drug use) are connected to issues present within the home, work and community settings where we spend time, and are not solely influenced by individual factors .
Treatment programs which aim to change an individual’s drug use  including detoxification, counselling, residential rehabilitation and pharmacotherapy interventions, are also encompassed within the aims of demand reduction. In Australia, treatment may be delivered in residential, out-patient or community settings, and through specialist alcohol and other drug treatment services, or generalist services such as local GPs or other health agencies such as Aboriginal Medical Services. People who use drugs may come into contact with the criminal justice system, and treatment is also delivered in these settings through programs which divert people detected for drug use and possession offences away from the criminal justice system and into education and treatment .
Harm reduction seeks to minimise the harmful consequences of drug use to the individual, families and the community at large, without necessarily reducing drug consumption [1, 11]. Within the current National drug strategy, harm reduction is aimed at reducing the adverse health, social and economic consequences of the use of alcohol, tobacco and other drugs, with a particular focus on reducing harms to community safety and amenity, as well as reducing harms to families and individuals .
In Australia, the main harm reduction activities for illicit drugs include needle syringe programs to reduce the transmission of blood borne viruses, supervised injecting facilities, overdose education and naloxone distribution programs, as well as treatment programs which help people to control or cut down their use . For alcohol, harm reduction programs focus on drinking patterns and practices so as to minimise the risk of harm and injury through responsible service of alcohol, drink driving interventions, community-level interventions to promote safer night time economies, as well as sobering up shelters and chill-out spaces .
Supply reduction aims to remove or reduce the supply of drugs within the community . Supply reduction strategies include enforcing the prohibition of illicit drugs, as well as regulating and enforcing access to legal drugs such as alcohol, tobacco and pharmaceuticals . Within the current National drug strategy, supply reduction includes strategies and actions which prevent, stop, disrupt or otherwise reduce the production and supply of illegal drugs (both current and emerging); and control, manage and/or regulate the availability of alcohol, tobacco and other legal drugs .
Australia’s drug laws controlling the sale and supply of legal and illegal drugs should be understood in the context of international treaty obligations which require federal, state and territory governments to enact laws which address particular drug offences as well as monitor and regulate the supply of pharmaceutical drugs . Drug law enforcement through police, border control and customs aims to control drug supply and reduce drug-related crime . Drug law enforcement activities include source country control, interdiction, clandestine laboratory detections, disrupting domestic distribution networks, local policing and third party policing .
Enforcement activities also focus on regulating and controlling access to licit drugs such as tobacco and alcohol . Here, supply reduction involves restrictions on sales to minors, restrictions on licenced venues including lock-outs, restrictions relating to when alcohol can be bought and sold, and restrictions on public alcohol consumption  . Pricing and taxation of alcohol and tobacco are also important tools for the Federal Government to regulate the availability of licit drugs in the community.