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(2022)ThesisThe adoption of the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances 1988 (“the 1988 Convention”) has been widely viewed as the final step in establishing global drug prohibition. This thesis provides an examination of Australia’s decision to support and sign the Convention which has not been analysied before. It also provides a detailed history of the development of the Convention as Australia was a key participant in UN drug meetings at the time. This thesis is based on the first research to access archival files, primarily from Foreign Affairs but also from the AFP and Department of Health. Nearly 180 folders, totalling approximately 35,000 pages, were copied from the Australian archives. These files provide detailed reports of almost all meetings and drafts that progressed the 1988 Convention. Interviews with key participants were also conducted. It provides an interdisciplinary legal history of Australia’s involvement in the 1988 Convention using the lens of the international relations theory of neorealism and the political theory of historical institutionalism. Through process tracing, it uses the theories to examine whether neorealist geopolitical forces and institutional forces caused Australia to support and sign the Convention. The analysis finds that geopolitical considerations trumped early concerns that a third convention was not necessary. The analysis also demonstrates that institutional forces within the UN benefitted financially from drug prohibition and played an unusually strong role in encouraging the development of the 1988 Convention. It also finds that institutional forces within the Australian government, such as the AFP and Foreign Affairs, supported the new Convention to increase their own jurisdiction and powers. Lastly, it looks at whether alternative policies such as regulation or decriminalization were considered by key policymakers. It finds that key individuals did support decriminalization but were overpowered by institutional and geopolitical forces. The significance of the dissertation includes: large amounts of new data to explain the development of the 1988 Convention; it increases knowledge around the institutional forces of criminalization and global criminalization; it significantly increases our knowledge of the role of the United Nations in waging the War on Drugs; and it increases knowledge around how mid-level nations interact with global institutions.
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(2023)ThesisChronic non-cancer pain (CNCP) is highly prevalent and highly burdensome. Evidence supports a biopsychosocial, multidisciplinary approach to CNCP management, however, there is limited research assessing use and accessibility of health services and treatments in Australia. In addition, opioids are commonly used for CNCP, despite limited evidence of effectiveness and associations with harms including fatal and non-fatal overdose. These harms have prompted the introduction of policies and other measures restricting opioid use, and the impacts of these on Australians living with CNCP are not well known. This mixed-methods thesis included five studies using i) longitudinal cohort study data (Pain and Opioids IN Treatment study) with linkage to administrative health service use data (Australian Medicare Benefits Schedule claims) and ii) semi-structured qualitative interviews, to examine health service and medicine use, and understand lived experiences and perspectives of people living with CNCP. The specific objectives of this thesis were to (i) describe use of Medicare-subsidised services among people prescribed opioids for CNCP and examine factors associated with use; (ii) characterise long-term patterns of health service and medicine use by people prescribed opioids for CNCP and examine factors associated with use; (iii) evaluate the accessibility of treatments and services for CNCP management, from the perspectives of people living with CNCP; (iv) explore the challenges experienced by people prescribed opioids for CNCP in obtaining ongoing opioid prescriptions; and (v) explore the lived experiences and perspectives of Australians prescribed opioids in the context of increasing restrictions and measures targeting these medicines. Overall, people prescribed opioids for CNCP were observed to have high use of primary, allied health, and specialist services in comparison to the general population, as well as non-opioid analgesics and adjunctive medicines for pain. In qualitative interviews, participants expressed a willingness to engage with multidisciplinary treatments where available. However, in all studies, multiple accessibility issues were identified for both health services and medicines, including affordability and access in regional and remote areas. Despite the provision of universal health care in Australia, specialist health service use was associated with private health insurance. People with CNCP described being referred to health care providers and services which did not meet their needs, and people prescribed opioids for CNCP described feeling stigmatised for their opioid use and unfairly blamed for increases in rates of opioid-related harms. Overall, the experience of attempting to manage CNCP in Australia was characterised by frustration and, among people prescribed opioids, by stigma, blame, and fear of the future. The findings of this thesis demonstrate the utility of considering health care and medicine use and accessibility from multiple angles, including consumer perspectives, and suggest a number of potential areas to improve how CNCP is treated. Broadly, there is a need for improved management of CNCP in both primary and secondary health care settings. There is also a need to ensure that the intended and unintended impacts of opioid policies on people with CNCP are considered, and to balance the need to reduce opioid-related harms with the need to manage pain and the risk of introducing stigmatisation and other harms.