Drug Policy in Canada: Moving Forward

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Drug Policy in CanadaMoving Forward

• Thomas Kerr
• Canadian HIV/AIDS Legal Network

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Todays Presentation

• Drug-related harm in Canada
• Recent developments in harm reduction
• The role of enforcement in Canadas drug policy
• The way forward for drug policy in Canada

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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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Harm Reduction in Canada
Canadas Drug Strategy (1998) states because
substance use is a primarily a health rather than
an enforcement issue, harm reduction is
considered to be a realistic, pragmatic, and
humane approach as opposed to attempting solely
to reduce the use of drugs
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Demand Reduction

• A range of programs and services have been
  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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Demand Reduction

• 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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Harm Reduction in Canada
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Harm Reduction in Canada
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Whats Wrong with Drug Policy in Canada

• Despite recent developments, drug-related harm
  has not decreased substantially
• in Canada

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HIV Prevalence Among IDU in Canada and Western
Europe
Fischer, Rehm, Blitz-Miller, CMAJ, 2000
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Fatal Overdose Among IDU in Canada and Western
Europe
Fischer, Rehm, Blitz-Miller, CMAJ, 2000
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Number of Patients Receiving methadone in Canada
and Western Europe
Fischer, Rehm, Blitz-Miller, CMAJ, 2000
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Whats Wrong with Drug Policy in Canada

• Canadas drug policies are rooted in a long
  history of prohibition and enforcement
• 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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Conventional Enforcement Strategies

• Criminalize drug production in an effort to limit
  supply
• Seize drugs in an effort to drive up price
• Criminalize drug use in an effort to limit
  behavior and prompt drug users to enter treatment
• Instill the belief that this works and that there
  are no alternatives!

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Impacts of Prohibition

• Increased drug production
• Increased purity of drugs
• Decreased price of drugs
• Increased organized crime
• Changes in trafficking routes that have sparked
  new epidemics of injection drug use HIV/AIDS
• Feb. 2000, 2 million Americans incarcerated
• 75 non-violent drug offenders
• Incarceration is a predictor of HIV incidence and
• antiretroviral therapy interruption

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Displacement into unsafe environments

• The risk of criminal sanctions against IDU is
  known to drive users physically and socially into
  higher risk environments
• The classic example is the shooting gallery
  which led to HIV prevalence levels of 50 in New
  York
• If the HIV prevalence rose from 30 to 50 in
  Vancouvers Downtown Eastside, the additional
  healthcare costs would be approximately
  150,000,000

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The Vancouver Sun September 6, 2000
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Percent
Wood et al. Can Med Assoc J 2003168(2)165-9.
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VANDU Exchange Tent
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Wood et al. Journal of Urban Health 2003 80(3)
455-464.
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Wood et al. J Acquired Imm Def Synd 2003
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The impact of restrictions and police presence
on willingness to use a safe injection site
422 (92) willing to use a SIF
296 (64) willing to use a SIF if sharing of
drugs is prohibited
282 (62) willing to use a SIF if assisted
injection is prohibited
246 (54) willing to use a SIF if registration
is required
103 (22) willing to use a SIF if police are
stationed near entrance to SIF
141 (31) willing to use a SIF under Health
Canada guidelines
59 (12) willing to use a SIF under HC
guidelines and police presence
Kerr et al CMAJ, 2003
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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 integrated and focused on the
  goals of public health
• This will require that resources be shifted away
  from enforcement to harm reduction and treatment
• This also means giving up on a long and well
  established tradition of control and punishment

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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 integrated and focused on the
  goals of public health
• This will require that resources be shifted away
  from enforcement to harm reduction and treatment
• This also means giving up on a long and well
  established tradition of control and punishment

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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