Letter to the Editor

In an ideal world, public health emergencies would be responded to by immediate resource allocation to those interventions that are known to be most effective. Since there are rarely silver bullets in public policy, when novel approaches are to be tested, rigorous evaluation would accompany any experimental efforts to ensure that funds are being spent on the most efficient and effective programs. In turn, ineffective programs would be halted and cost-effective strategies would be prioritized for augmentation. Unfortunately, experience has demonstrated that the policy response to the illicit drug use problem has often not benefited from this type of evidence-based approach. On the contrary, policy-makers have repeatedly directed vast sums of public funds to law enforcement efforts, with little systematic evaluation their impact. For instance, a 2001 Auditor General's report on Canada's drug strategy concluded: ‘of particular concern is the almost complete absence of basic management information on spending of resources, on expectations, and on results’[1]. This is problematic since existing evaluations of supply reduction activities have generally indicated that this approach is largely ineffective at reducing the supply of drugs to street level markets [2]. Perhaps the best evidence of this is a recent report by the World Customs Organization, which found that even post-September 11 security measures had a ‘negligible’ impact on the influx of illicit drugs into the USA, despite the substantial supply reduction efforts already in place in America [3]. However, a number of studies have clearly demonstrated that a marked reduction in heroin supply has been observed in Australia since 2000, and there has been much debate and investigation into the potential explanations [4,5]. In this issue of Addiction, Smithson and colleagues report on their efforts to demonstrate that an increase in Australian heroin seizures was observed after increased funding for Australian supply reduction efforts, and that this was subsequently associated with a reduction in street-level heroin purity [6]. The author's statistical analyses support the explanation that increased funding to Australian supply reduction efforts contributed to the causes of the heroin drought. This finding is consistent with a number of studies that have attributed the reduction in heroin supply to Australian supply reduction efforts [7,8]. However, there are a number of limitations inherent in the study by Smithson et al. that are inherent in all ecological study designs, and the investigators should be praised for clearly articulating these concerns in their article. To be fair, all studies examining the Australian heroin drought have had certain limitations, not the least of which is that the role of external global forces has not been adequately examined. Specifically, if strong shifts in global heroin supply patterns simply coincided in time with the increased funding to Australian supply reduction efforts, the association between increased supply reduction funding and the heroin drought would be clearly due to confounding rather than a causal mechanism. Nevertheless, with regard to evidence-based drug policy, even if one were to assume that the reduction in heroin supply in Australia is due to the enhanced funding to Australian supply reduction efforts, it is critical that the overall long-term social and public health impacts of this strategy be weighed against the potential impacts of alternative strategies [9]. One relevant concern stems from the evidence that Australia may have experienced a shift away from heroin towards increased cocaine and other stimulant injection in the wake of the heroin drought [4,10]. While heroin injection is responsible for the greatest number of fatal overdoses in many settings, stimulant injection, especially cocaine, may be responsible for significantly elevated blood-borne disease incidence rates [11]. Regardless of the causes of the Australian heroin drought, the nation now provides an excellent opportunity to observe the changes in a heroin market when supply is markedly reduced. As such, while the mystery of the Australian heroin drought continues to unravel, there will be increased onus on Australian policy-makers to apply evidence-based decision making when directing resources towards the new challenges these changes produce.

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