What does effective drug policy mean?

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What does effectivedrug policy mean?

• Ralf Jürgens
• Canadian HIV/AIDS Legal Network

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Todays Presentation

• Drug-related harm in Canada and in the world
• From prohibition to harm reduction
• A multi-faceted response the four-pillar
  approach
• Harm-reduction an ethical imperative
• Harm-reduction a legal imperative
• Examples of pragmatic drug policy
• Effective drug policy the way forward

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Facing up to an epidemic
Drug users are citizens they include our sons,
daughters, brothers and sisters and,
increasingly, our parents. They deserve humane
responses let us not wage war on them. Margaret
Hamilton, 1999
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Background

• Over 125,000 Canadian inject illicit drugs
• In 1993 Canadian researchers warned that an
  explosive HIV epidemic was about to occur
• Governments failed to respond with appropriate
  measures
• HIV hepatitis C outbreaks, and overdose deaths
  reached epidemic proportions in several
  municipalities
• In 1997, an annual HIV incidence rate of 18 was
  observed among injection drug users in Vancouver
• Injection drug users now account for 26 and 63
  of new HIV and hepatitis C cases respectively

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Background

• Human and Fiscal Suffering
• Endocarditis 25,000 per case
• Overdoses 500,000 in ambulance costs in the
  Downtown Eastside of Vancouver alone (annually)
• HIV Lifetime per case 150,000 HCV infection
  expected to be much higher
• Additional Costs Emergency room visits, acute
  hospital bed use, physician costs, laboratory
  costs
• ALL PREVENTABLE!!!

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Background
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From prohibition to harm reduction

• criminal laws to control illicit drugs and their
  use have been in place since the early 1900s
• the current statute was enacted in 1996
• it prohibits import or export of illegal drugs,
  as well as possession and trafficking

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From prohibition to harm reduction

• recognition that prohibitionist policies are
  ineffectual in stopping drug use and have several
  negative consequences
• they encourage users to inject quickly, out of
  fear of police apprehension
• compel users to inject with unclean equipment or
  to inject in unsafe and unhygienic circumstances
• produce an underground market for drugs,
  associated with crime and corruption
• create a culture of marginalized and stigmatized
  people who are difficult to reach
• undermine community caring, by fostering public
  attitudes that are vehemently ant-drug and
  anti-drug users

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From prohibition to harm reduction

• The Canadian federal governments stated
  position for two decades has been that
• the criminal law should be employed to deal
  only with that conduct for which other means of
  social control are inadequate or inappropriate,
  and which interfere with individual rights and
  freedoms only to the extent necessary for the
  attainment of its purpose.
• (Government of Canada. The Criminal Law in
  Canadian Society, Aug 1982)
• Such a position lends support to proposals for a
  drug policy based on harm reduction principles.

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From prohibition to harm reduction

• evidence that Canadian policy has shifted
  towards harm reduction philosophy
• Canadas Drug Strategy adopted in 1998 states
  that its goal is to reduce the harm associated
  with drugs to individuals, families, and
  communities
• Strategy further states that because substance
  abuse is primarily a health issue rather than an
  enforcement issue, harm reduction is considered
  to be a realistic, pragmatic, and humane approach
• Special Senate Committee on Illegal Drugs
  established in 2000 to develop a national harm
  reduction policy
• In 2001, Canadas ministers of health
  acknowledged a report that set out a harm
  reduction approach and framework for action.

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From prohibition to harm reduction

• further evidence that Canadian policy has
  shifted towards harm reduction philosophy
• In 2001, then Minister of Health Allan Rock
  recognized that changes are needed to existing
  legal and policy frameworks - both national and
  international - in order to effectively address
  IDU as a health issue
• In the interim, before these changes are made,
  the Minister advocated for harm reduction
  measures within the existing legal framework.

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The four-pillar approach

• Prevention focuses on education regarding
  substances
• Treatment includes numerous interventions and
  support programs, including detoxification,
  counselling, social programs, and medical care
• Enforcement consists of efforts to curb the
  supply of drugs
• Harm reduction involves interventions that focus
  on decreasing the negative consequences of drug
  use for communities and individuals

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Harm reduction an ethical imperative

• the criminal approach to drug use has
• failed to achieve the goals for which it is
  designed and promoted
• excluded those who inject drugs from the
  community
• misused limited resources
• stimulated the rise to power of socially
  destructive and violent empires
• adopting an ethic of harm reduction acknowledges
  that prohibitionist approaches to drug use have
  not worked
• it is deemed unethical to demand from someone
  something of which they are physically or
  mentally incapable

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Harm reduction a legal imperative

• international law demands that harm reduction
  initiatives be undertaken, as part of the
  obligation to provide the highest standard of
  health possible
• international drug conventions do not prevent
  such initiatives
• several articles in the treaties can be
  interpreted as permitting or even supporting harm
  reduction efforts
• the vagueness of the conventions permits parties
  to look at state practice to help determine how
  to interpret the provisions
• state practice is inconsistent, lending support
  to the argument that responses to harms
  associated with IDU should be left to the
  discretion of states

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Examples of pragmatic policy

• needle exchange programs
• generally regarded as the single most important
  factor in preventing HIV epidemics among IDUs
• hundreds of sites exist in Canada today
• Canadian studies have created confusion, but
  primarily among politicians, not among scientists
• first safe injection facility opened in 2003
• methadone maintenance treatment vastly expanded
  since the mid 1990s
• ARV treatment programs for most marginalized
• decriminalization of possession of small amounts
  of marijuana planned

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Pragmatic policy

• A range of programs and services must be
  implemented
• to address health problems associated with
  drug use
• These can be categorized as low, medium, or high
• threshold
• Threshold refers to the criteria for entrance
  into programs,
• and the state of readiness to participate and
  meet program
• demands

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Pragmatic policy

• High Threshold Detox,residential drug treatment
• Medium Threshold Methadone, outpatient
  counseling
• Low Threshold Needle exchange, outreach,
  peer-driven programs, safe injection sites

A range of services are needed Most drug users
will make several attempts to quit using drugs
Many drug users quit using drugs without
treatment Only a small number of drug users are
in treatment at any time
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Reach of traditional system of care for people
who use drugs
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Reach of a comprehensive system of care
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Number of Patients Receiving methadone in Canada
and Western Europe
Fischer, Rehm, Blitz-Miller, CMAJ, 2000
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The way forward

• Much more remains to be done.
• In 2001, 95 of all federal expenditures on the
  drug problem were accounted for by
  enforcement-based initiatives
• Most of this money is used for policing and
  incarceration

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Moving Forward

• The full impact of harm reduction programs has
  not been realized due to an ongoing emphasis on
  enforcement and incarceration
• In order to move forward, drug policy in Canada
  must become more focused on the goals of public
  health
• federally funded heroin maintenance pilot
  project
• prison-based needle exchange programs
• This will require that resources be shifted away
  from enforcement to harm reduction and treatment
• Canadian studies have provided clear evidence of
• ineffectiveness of enforcement in terms of
  reducing supply
• how police crackdowns can lead to increased
  harms

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Moving Forward

• a coordinated effort is necessary to address key
  determinants of drug use, such as poverty,
  homelessness, childhood abuse, and cultural
  dislocation
• any meaningful change in drug policy will
  necessarily require changes in social policy -
  otherwise it will remain a band-aid approach
• drug users use drugs for a reason

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Moving Forward

• Enforcement and harm reduction programs can
  compliment each other however, this requires
  changes to conventional enforcement approaches
• Police should ensure that their activities do
  not produce harm
• Police should avoid drug users when they are
  injecting and accessing harm reduction programs
• Police should use their discretionary powers in
  a way that minimizes harm
• Police should use referrals to harm reduction
  services and treatment rather than arrest drug
  users for possession of drugs
• Incarceration of drug users should be avoided at
  all costs

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Summary

• Illicit drug use and the war on drugs are
  responsible for considerable human, social, and
  fiscal costs
• The majority of money used to address problem
  drug use is spent on expensive and ineffective
  enforcement efforts
• Enforcement-based strategies will not solve the
  problem and in many cases make problems worse
• A range of services is needed to serve all drug
  users, including the majority who are not in
  treatment
• Harm reduction programs help reduce harm to users
  most at risk for illness and death and help to
  increase the number of drug users entering
  treatment

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Summary

• Governments must acknowledge that new approaches
  to dealing with illicit drug use are urgently
  needed
• Policy makers and health care provides must
  acknowledge the major limitations of enforcement
  and purely abstinence-based approaches to drug
  treatment
• We need evidence-based drug policies that
  emphasize public health above all other goals
• Success requires an expansion of services to
  include harm reduction programming
• Moving forward will reduce human suffering as
  well as the massive financial costs associated
  with drug use and enforcement-based strategies