Getting to Tomorrow: a Report on Canadian Drug Policy

getting to tomorrow: a report on canadian drug policy

getting to tomorrow: a report on canadian drug policy 2

The authors are grateful to the Policy Working Photo Credits Group and the Steering Committee of the Joe Mabel Canadian Drug Policy Coalition for assistance Mack Male with this document. The following persons pro- Victor Vizu vided detailed review of this document: Wikimedia Commons

Raffi Ballian Design Lynne Belle-Isle Briana Garelli Susan Boyd Walter Cavalieri Project Manager Irene Goldstone Caroline Mousseau Philippe Lucas Michaela Montaner Copyediting Bernie Pauly Douglas Haddow Susan Shepherd Ron Shore Printing Kenneth Tupper Special Screencraft Printers Dan Werb Ltd., Vancouver, bc

The Canadian Drug Policy Coalition wishes This work was made possible to extend its gratitude to the key informants with the support of the mac representing organizations from across Canada aids Fund, the Open Society who wish to remain anonymous. Global Drug Policy Fund, private donors and Steve This document was published by the Canadian Chapman. The Canadian Drug Drug Policy Coalition: www.drugpolicy.ca Policy Coalition also wishes to thank the Faculty This document can also be downloaded as of Health Sciences at Simon a pdf from: www.drugpolicy.ca/progress/ Fraser University and the getting-to-tomorrow Centre for Applied Research in Mental Health and Addiction Canadian Drug Policy (carmha) for their assistance Coalition / cdpc with this project. Simon Fraser University 2400-515 West Hastings St Vancouver, bc v6b 5k3 Email: [email protected] canadian drug policy coalition · cdpc 3 1 2 3 Introduction Substance Services Use: A & Supports Canadian for People Summary who use Drugs

Page 11 Page 17 Page 25 4 5 Harm A Case for Reduction Urgent Action: in Canada Overdose Prevention & Response

Page 39 Page 59 getting to tomorrow: a report on canadian drug policy 4 6 Drug Policy on a Federal Level

Page 65 7 8 The Canada Criminalization on an of Drugs International in Canada Stage

Page 73 Page 91 List of Acronyms Notes Page 97 canadian drug policy coalition · cdpc 5 Executive Summary

The Canadian Drug Policy Coalition is a broad of the overall use of the criminal coalition of non-governmental organizations and law in responding to the use of individuals committed to working with Canadians illegal substances and drug to create an approach to drug problems that will related problems. take a radical new direction—a course that will put the protection of public health and safety, social The findings of this report, based justice and equity at the forefront of Canada’s on interviews with change- response to drugs. The primary goal of this report makers and service providers, is to provide an overview of the state of Canadian and scans of important docu- drug policy by focusing the lens on key issues of ments and research, reveals concern to Canadians: public safety, access to ser- that Canada is at a crossroads vices and supports for people with drug problems, when it comes to drug laws national-level drug policy, and Canada’s escalat- and policies. A new direction ing role in the international war on drugs. in drug policy is required. We can continue to work within the This report highlights the failing role that current paradigm of drug prohibition or federal drug policies play in supporting safety we can begin to explore alterna- and health and draws attention to the acute need tive approaches and chart a new for an improved system of supports for people course that can help save lives, who use drugs including harm reduction. This respect human rights and be report also highlights the patchwork of provincial more cost effective. policies and services that support people with drug problems. These policies, while valiant at- The use of illegal substances is tempts to integrate and streamline services, do a complex issue and people use not always translate into meaningful changes on drugs for many reasons. Most the front lines. This report also calls for a review people do not experience sig- getting to tomorrow: a report on canadian drug policy 6

nificant problems because of their drug use, some First Nations, Métis and Inuit do develop drug problems, and others may ex- citizens. perience clear benefits from illegal drug use. But despite deep public purse investments in enforce- Canada still relies on the ment-based approaches, lifetime use of cannabis criminal law to curb illegal stands at 39.4% and the non-medical use of pre- drug use and stem the growth scription opioids is the fourth most prevalent form of illegal drug markets. These of substance use in Canada behind only alcohol, laws and policies dispropor- tobacco and cannabis. Rates of hiv and hcv asso- tionally target already mar- ciated with drug use are unacceptably high partic- ginalized groups. Canada also ularly among some groups. In 2010, 30.4% of new spends enormous amounts of infections in women versus 13.5 % of new cases in money annually to prevent men were attributed to injection drug use. Cases the purchase, use and distribu- of hiv attributed to injecting drug use among First tion of illegal drugs both inside Nations, Métis and Inuit persons have gone up to Canada and beyond its borders. more than 50 per cent in the period spanning 2001 The federal government has to 2008. allocated $527.8 million for the National Anti-Drug strat- Deaths related to overdose of prescription opiates egy for 2012-2017, much of it on whether used medically or non-medically have enforcement related activities. risen sharply and are estimated to be about 50% This strategy only accounts for of annual drug deaths. But like hiv and Hepatitis a portion of government spend- C infections, overdose deaths are highly preventing on drug control. “Activities able. This report addresses some of the urgent such as rcmp drug enforcement, changes needed to support a comprehensive drug interdiction, and the use harm reduction and public health approach to the of the military in international prevention and treatment of overdose. drug control efforts, drive up policing, military and border secu- Despite often heroic efforts at the provincial and rity budgets. Cannabis remains local levels to improve the system of supports, a key target of these policing many people still wait unacceptably long for ser- activities—cannabis posses- vices. Where sound and relatively safe treatments sion charges numbered 61,406 exist, provincial governments and health authori- in 2011, a rate of 178 per 100,000 ties drag their feet because of outmoded ideas people in Canada. Police re- about some drugs or shortsighted concerns about ported incidents of cannabis finances. The Federal government remains openly possession are far higher than hostile to evidence-based measures like key harm any other illegal drug (21 for reduction services and has clearly taken a puni- cocaine possession and a rate tive approach to addressing drug use problems. of 30 for all other illegal drugs Failure by all levels of government to fully meet combined.) And incidents the needs of people with drug problems, means of cannabis possession have that some groups are still outright denied these increased 16% between 2001 lifesaving services and many community-based and 2011. Cannabis remains a organizations struggle to meet the basic needs lucrative market—annual retail of their clients. These difficulties are particu- expenditures on this substance larly acute for residents in rural areas, women and are estimated to be about $357 canadian drug policy coalition · cdpc 7

million per year in bc alone. for the replacement of the National Anti-Drug Cannabis is a popular drug, and Strategy with one focused on health and human its harmful effects are certainly rights, the decriminalization of all drugs for per- less than alcohol and tobacco, sonal use and the creation of a regulatory system but the potential financial ben- for adult cannabis use. efits of regulated and taxable product like cannabis are com- 2. Support and expand efforts to implement ev- pletely unavailable to federal idence-based approaches to eliminate stigma and provincial treasuries. and discrimination, and social and health inequities that affect people who use drugs. Rather than curbing drug markets, drug enforcement 3. Support the scaling-up of comprehensive has actually been shown to health and social services, including housing escalate drug trade violence. and treatment services that engage people with Canada’s prisons are already drug problems. Increase support for efforts overcrowded and the effects of to reduce the harms of substance use which recently introduced mandatory includes robust educational programs about minimum sentences for some safer drug use, programs for distributing new drug crimes are yet to be fully supplies for injection and crack cocaine use, felt. And because of poor data safer consumption services, opioid substitu- collection we still do not have a tion therapies and heroin assisted treatment. full picture of the effects of the Ensure these services are part of larger public millions of dollars spent every health approach to substance use that respects year on enforcing Canada’s the human rights of people who use drugs. drug laws. Canada has good people working at every level One of the most urgent issues from front line services and organizations to affecting Canadians is discrimi- provincial and federal ministries, whose efforts nation against people who use are severely hampered by fear, lack of leader- illegal drugs. This discrimina- ship, and poorly informed policies based on tion and the accompanying outdated ideas and beliefs about drugs and hostility towards people who the people who use them. At the same time, a use drugs can be felt in the de- global movement of sitting and former politi- rogatory statements that appear cal leaders is emerging that acknowledges the routinely in media reports of over-reliance on the criminal law in address- public debates about services. ing drug problems is causing more harm than The recommendations in this good. Canada must join the chorus of voices report address the need for around the globe calling for change. This report urgent change in three key is a call for Canadians to meet these challenges areas: drug law reform, discrim- head-on with creative thinking and brave ination, services and supports. policy changes.

1. Modernize Canada’s legislative, policy and regulatory frameworks that address psychoactive substances. We call getting to tomorrow: a report on canadian drug policy 8 recommendations

It is clear that Canada needs a new approach ■ Federal: Promote a public health and human to drug policy, nationally and internationally. Policy rights approach to drug policy at international frameworks in place today reflect outdated under- forums including within the United Nations Office standing of the problems related to substance use. on Drugs and Crime and at the un Commission Drug policies need to be reviewed, evaluated and on Narcotic Drugs. updated where necessary. ■ Federal: Eliminate mandatory minimum sen- The cdpc is committed to working with Canadians tences for drug crimes. They do not work, they to create an approach to drug problems that will are costly and they create unintended negative take a radical new direction—a course that will put consequences. the protection of public health and safety, social justice and equity at the forefront of Canada’s ■ Federal: Remove cannabis from the Controlled strategy. Drugs and Substances Act and create a regulatory framework that devolves responsibility for the There are four broad areas where improvements regulation of cannabis to provincial authorities. must be made if Canada is to adequately address public health and safety issues related to drug ■ Federal: Decriminalize all drugs for personal use markets and substance use in communities. as the first steps towards creating a drug strategy based on a public health and human rights ap- 1. Modernize Canada’s legislative, policy proach to addressing substance use. and regulatory frameworks that address psychoactive substances. ■ Federal and Provincial: Increase access to diversion programs and alternative justice strategies for ■ Federal: Eliminate the National Anti-Drug people accused and convicted of drug crimes, es- Strategy and replace it with a socially just, public pecially for First Nations, Métis and Inuit persons. health approach to substances that includes prevention, harm reduction, treatment, education, ■ Municipal: Repeal bylaws that restrict the health promotion and enforcement. Ensure that implementation of harm reduction and opioid funding to these components is equitable. substitution programs and work with all groups to canadian drug policy coalition · cdpc 9

challenge the discrimination against people who ity is provided for First Nations, use drugs that so often shapes public opposition Métis and Inuit persons. to these services. ■ Provinces: Continue to ■ Federal/Provincial: Develop policies to enable promote system change across and guide the implementation of street drug all sectors responsible for sub- testing programs to prevent injury and death stance use, and recognize the among those who purchase drugs from unregu- principles articulated in the lated dealers. National Treatment Strategy.1 Ensure that the planning and 2. Support and expand efforts to create evi- implementation of programs dence-based approaches to eliminate stigma and and services adhere to the prin- discrimination, and social and health inequities ciples and practices for cultural that affect people who use drugs. safety outlined by First Nations, Métis and Inuit Groups. ■ All Jurisdictions: Develop programs that encourage, assist and support the development of local ■ Provinces: Fully integrate ser- groups of people who use drugs. vices for substance use into the larger health care system. The ■ All Jurisdictions: Create and implement policy historical distance between the that requires agencies and authorities to seek the larger health care system and inclusion and participation of groups of people drug services must be eliminat- who use drugs as recognized stakeholders in de- ed. Ensure that the grassroots signing, delivering and evaluating services and harm reduction philosophies supports, and include people with experience of equality, non-judgment and as consumers in policy, planning and regulatory access are at the forefront of bodies. drug services.

■ Federal/Provincial: Focus resources and ■ Provinces: Promote equitable program initiatives on programs that enhance the access to all aspects of an evi- quality of life and address the social determinants dence-based system of supports of health including safe housing, employment, for people who use drugs includ- and education. ing harm reduction, treatment and other supports. Ensure that 3. Support the scaling-up of health and social a variety of treatment modali- services at the provincial level that engage ties are available that reflect the people with drug problems and support their needs and aspirations of clients. efforts to change, and support work to reduce the Ensure that trauma-informed harms of substance use: approaches to care are integrated across the system of ■ Federal/Provincial: Implement needle distribu- supports. tion programs and expand a range of drug treatment services in federal and provincial prisons. ■ Provinces: Scale up a compre- Meet the commitments set out in Section 81 and hensive package of harm reduc- 84 of the Corrections and Conditional Release Act tion services which includes and ensure that adequate Healing Lodge capac- robust educational programs getting to tomorrow: a report on canadian drug policy 10

about safer drug use, programs ■ All Jurisdictions: Ensure that funding for preven- for distributing new supplies for tion/health promotion activities is based on clearly injection and crack cocaine use, defined principles substantiated by evidence of what safer consumption services, works. opioid substitution therapies and heroin assisted treatment. ■ Provinces: Where necessary create a central Ensure these services are part mechanism for the purchasing and distribution of larger public health approach of harm reduction supplies. Ensure that informa- to substance use that respects tion about the scope of supply distribution is made the human rights of people who publicly available. use drugs. ■ Provinces: Implement a women/mother-centred approach to care for women with substance use ■ Provinces: Develop, promote problems that focuses on the mother-child as a unit and evaluate a comprehensive before, during and after pregnancy. Challenge the public health approach to pre- stigma and discrimination against women who use venting overdose that includes drugs, and recognize that this stigma increases the the following: education and risks of pregnancy and drug use. training for responding to and treating overdose in a variety of ■ Provinces: Create a consistent, transparent settings, including community funding and management system for all elements based programs, people who of opioid substitution therapy. This must include use drugs and a variety of first prescribing, dispensing, drug costs, travel costs, responders and others. Address and funding for counselling as well as case man- the unique difficulties of ex- agement. In particular, ensure that a variety of panding overdose prevention entry points into this treatment modality are iden- programs in rural and remote tified and coordinated across health care sites. areas. Work with the prov- Engage clients in the design and implementation inces and territories to establish of this system and ensure that this system cooper- guidelines for the sale and/or ates fully with the larger health care system and distribution of naloxone that with necessary systems of psychosocial supports. would help get this medication into the hands of those most 4. Improve the collection of data on substance affected by overdose including use and its effects across jurisdictions. co-prescribing with opiates for persons at risk of overdose. ■ Federal and Provincial: Work with key partners to standardize the elements of a data collection ■ Federal: Reduce the barriers to system that can measure prevalence of drug use calling 911 during a drug over- and its harms. Ensure that data analyses are re- dose episode by implementing ported in a timely manner and are sufficiently Good Samaritan legislation to robust that they can inform planning for services provide protection from arrest at the local level. and prosecution for drug use and possession charges if the ■ Federal: Continue work on National Treatment evidence is gained as a result of Indicators and provide mechanisms for reporting the person calling 911. publicly on the scope of services available, their costs and wait times. p.141 Definitions and Concepts Used in this Report 11 Introduction p.29 p.142 canadian TheOverall Limits drug Crime policyof RatesData coalition AvailabilityFall While · cdpc Drug Crime Increases p.30 3 p.14 DrugsMandatory and Drug Minimum Policy Sentences—Are in Summary we any safer? p.31 4 p.15 OurPrison Approach Overcrowding to Substance is Already Use a Reality p.33 5 Prison Sentences Are Inequitable p.34 p.16 What is a Comprehensive Health and Human 6 RightsThe Negative Approach Effects to Substance of Prohibition Use? p. 36 7 p.16 TheCannabis Organization as a Case of in this Point Report p.37 8 Creating Greater Safety—Alternatives to Prohibition p.38 9 Case Study: Waterloo Crime Prevention Council p.40 12

SECTION ONE

Introduction canadian drug policy coalition · cdpc 13 In February 2012, the Canadian Drug Policy Coalition (cdpc) launched Changing the Frame: A New Approach to Drug Policy in Canada. This document opens a dialogue about the harms of our current approach and its most prominent feature—prohibition and the use of the criminal law to control the use of some substances.

Changing the Frame calls for a new approach to The primary goal of this docu- drug policy in Canada and a national dialogue to ment is to provide an overview engage Canadians in building a more comprehen- of the state of Canadian drug sive and effective response to problems related policy drawing on the principles to drugs. Canadians need to talk about how best outlined in Changing the Frame. to manage the many drugs, both legal and illegal, This paper focuses on key that are part of the Canadian landscape today and issues of concern to Canadians: will be part of it in the future. Some progress has public safety, access to services, been made in recent years to address problematic national-level drug policy, and substance use. At the same time there is a con- Canada’s escalating role in the tinuing and persistent resistance to innovations international war on drugs. Our in the field that have been shown to save lives, report highlights the failing role prevent disease and engage those who have been that current federal drug poli- marginalized by current approaches. In addition cies play in supporting safety a discussion of the structural and systemic bar- and health and we draw atten- riers to progress is urgently needed. Prohibitive tion to the acute need for an im- drug laws have been in place for over 100 years. proved system of supports for A global movement is beginning to emerge that people who use drugs including acknowledges the over-reliance on the criminal harm reduction. law in addressing drug problems. This movement is opening a space for consideration of alternative To compile the information for approaches to regulating and controlling sub- this report we used a number stances drawing on a public health and human of approaches. We established rights framework. Canada needs to be a part of a group of key informants from this discussion. across the country who helped getting to tomorrow: a report on canadian drug policy 14

identify crucial issues facing beneficial use. We also use the phrase “people people who use drugs. Many who use drugs” rather than “drug user” or “addict”. of these informants work in Words like “addict” are stigmatizing and do not harm reduction or treatment respect the dignity of people who drugs nor do programs; some work as policy they acknowledge that drug use is only one part advisors and some are respon- of a person’s life. It is important to recognize that sible for research programs; that not everyone who uses illegal drugs is depen- most importantly some are dent or “addicted”. people who use drugs who have first-hand experience of the limits of data availability the issues we discuss in the following pages. We also drew on Ideally we could frame our report on Canadian the extensive body of research drug policy in a full understanding of how on substance use produced Canadians use drugs. Despite pockets of excellent mainly by Canadian scholars, research, Canada lacks comprehensive national as well as on a review of policy data on the prevalence, harms and severity of sub- documents and other jurisdic- stance use. The Canadian Alcohol and Substance tional scans. We have excluded Use Monitoring Survey (cadums) conducted by consideration of alcohol and Health Canada on a biannual basis relies on a tobacco from this report not random survey of households in Canada using a because they are unimportant, land-line telephone; this approach excludes the but because they deserve more homeless, institutionalized persons and individu- in-depth consideration that we als without home telephones.3 cadums data are can provide in this first report.2 likely underreporting illegal drug use especially for young people between the ages of 15-34 who definitions are less likely to have a home telephone. The & concepts used response rate—i.e. the number of people who ac- in this report tually responded to the survey—was a low 45.5% in 2011. The broad national population data avail- We use both the term “drug” and able through cadums are also not applicable to “substance” interchangeably local contexts. The challenges with the cadums to refer to all mind-altering or survey highlight the urgent need for better nation- psychoactive substances. This al data on the prevalence of substance use and its report avoids the use of the term associated harms.4 Canada also lacks comparable drug “abuse” mainly because it data on key issues including the availability of simply does not describe the treatment services, use of prescribed opioids, and experience of many people who all fatal and non-fatal drug overdoses. use drugs. This term is often used to describe all illegal drug drugs & drug policy in summary use regardless of its effects on the individual or their sur- Though humans have used substances to alter roundings. Instead we use the their mood for thousands of years, since the 19th term “problematic substance century the array of drugs available has increased use” to describe harmful drug tremendously due to colonial expansion, global use and to separate out harmful travel, emergence of synthetic drugs and the from both non-problematic and modern-day pharmaceutical industry.5 canadian drug policy coalition · cdpc 15

Attempts to prohibit many cur- canada spends enormous rently illegal drugs have only been implemented in the past amounts of money annually to 100 years. Drug policy is an prevent the illegal purchase overarching set of guidelines that shape the decisions that and/or distribution of governments make about how prohibited drugs both inside to spend public monies, the types and levels of services to canada and beyond its borders. offer, and the laws and criminal substances continue to be justice activities to be under- taken by police, courts and cor- available despite these efforts. rectional systems.

Canadian drug policy is a depressant and “hallucinogenic” compounds that multijurisdictional matter. can be “abused.” Despite such attempts at control, The federal government, the Canada spends enormous amounts of money an- provinces, provincial health nually to prevent the illegal purchase and/or dis- authorities, municipal govern- tribution of prohibited drugs both inside Canada ments, and police all play a role and beyond its borders. Substances continue to be in deciding which issues will be available despite these efforts. Indeed, the avail- a priority, how drug use issues ability and purity of many common illegal drugs will be understood and ap- is now greater than 30 years ago.6 proached, how the illegal drug trade can be limited, and how our approach to substance use public funds will be allocated. Drug policy decisions also Our approach to substance use is oriented around cut across a number of other a public health framework that explicitly acknowl- policy areas including policing, edges that not all drug use is problematic. People justice, lawmaking, the use of use drugs for a variety of reasons: to feel good, military force, interpretation to feel better, to achieve more, for curiosity and of law and the decisions of social interaction, to quell emotional and physi- judges. And elements of drug cal pain and to broaden their spiritual horizons. policy are also found in public Only a small portion of this use becomes prob- policy areas such as health, lematic. Drug use also describes a wide range of housing, social assistance, different patterns or methods of use. Substance education and immigration and use occurs along a spectrum that stretches from citizenship. beneficial on one end to problematic use on the other. Substance use may begin at any point on In Canada, contemporary drug a spectrum and stay there, or move either slowly policy is expressed formally or quickly to another point. People may use one in part through federal laws substance in a non-harmful way and another namely the Controlled Drugs and substance in a harmful way.7 And the harms of Substances Act, which attempts drug use might be caused by one time heavy use to control the distribution and resulting in injury or overdose, infection with a prevent the use of stimulant, communicable disease, or by chronic long-term getting to tomorrow: a report on canadian drug policy 16 FIGURE 1: THE SPECTRUM OF SUBSTANCE USE

beneficial non-problematic problematic chronic dependence

Use that has positive Recreational, Use that begins Use that has become health, social or casual, other use to have negative habitual and spiritual effects. that has negligible consequences for compulsive despite health or social individuals, friends/ negative health and effects. family or society. social effects.

Adapted from: Health Officers Council of BC, 2011.

heavy use. Problematic substance use may also opportunities, working conditions, income, social be episodic and then return to non-problematic support networks, safe housing, education, access use. Indeed many people use currently illegal to health services, and discrimination based substances on an occasional basis and suffer no on gender, race, sexual identity, or physical and harms.8 mental abilities.10 A health and human rights approach to drug use also recognizes the legitimate what is a comprehensive right of people who use drugs to participate in the health & human rights planning and implementation of programs and approach to substance use? supports.

According to the International Covenant on the organization of this report Economic, Social and Cultural Rights, a widely ratified un treaty, all people have the right to This report is organized around key themes, each the enjoyment of the highest attainable standard of which was identified as critical in our scan of of physical and mental health. Countries must relevant policy documents, research, and in- ensure that this right is exercised without dis- terviews with key informants from across the crimination of any kind.9 country. These themes reflect places where efforts are urgently needed to reorient policy approaches A comprehensive health and human rights so that the needs of all Canadians who are affected approach recognizes that harmful substance use by substance use and drug policy related harms is a health not a criminal matter. This means that could be effectively met. Together these themes people who have substance use problems have and our recommendations comprise cdpc’s first the right to quality, accessible and appropriate annual report on drug policy in Canada. Future health care. This approach explicitly acknowl- iterations of this report will return to the issues edges two distinct issues: 1. That the harms of drug identified in this document and will supplement use are borne inequitably by some groups more our understanding of the state of drug policy in than others, and 2. That a broad range of social Canada with new quantitative and qualitative factors contribute to the context of substance data as they emerge. use and can exacerbate harm or help to reduce or limit potential harm. These include: employment p.19 Substance Use in Canada p.20 Non-Medical Use of Prescription Drugs p.21 Youth p.22 Harms of Substance Use p.22 Other Issues of Concern p.23 Benefits of Substance Use p.24 Conclusions getting to tomorrow: a report on canadian drug policy

SECTION TWO

Substance Use: A Canadian Summary canadian drug policy coalition · cdpc 19 The 2011 Canadian Alcohol and Drug Use Monitoring Survey (cadums) pegs average use of all illegal substances for individuals over 15 years of age at 40.9% for lifetime use, and 9.9% for past year use. In 2011, men were more likely to use illegal drugs than women (men—13% and women—6.9%), although women were more likely to report the use of all types of pain relievers (17.4% for women and 15.8% for men in 2011).11

Overall, cannabis was the most high sampling variability. But data from 2008 in- widely used illegal drug with dicate that cocaine and crack use was about 2.3% 39.4% of Canadians indicating in the general population.12 they have used this drug in their lifetime and 9.1% in 2011. These As far as we can determine with current data, figures vary by province with the use of drugs like heroin and crack cocaine is British Columbia having the mainly concentrated in marginalized popula- highest rates of lifetime use at tions. Data suggest that since the 1990s use of 44.3% and Nova Scotia having stimulants such as crack or methamphetamine the highest rates of use for the among street-involved users has increased, pri- past year at 12.4%. Overall men marily due to their easy availability. Among these are somewhat more likely than drugs, crack is one of the most commonly used.13 women to report having either The 2006 report of the I-Track study reported that used cannabis in their lifetime the most common injected drug, reported by an or in the last year. average of 77.5% study participants, was cocaine (range 58.4%- 92.5%). Just under half of study Data from the 2011 cadums on participants (45.9% on average) reported inject- the usage of other illegal sub- ing non-prescribed morphine; slightly less than a stances such as methamphet- third reported injecting crack and Dilaudid (31.9% amines/crystal meth, heroin, and 32.9% on average, respectively). Just over one- cocaine/crack,“ecstasy,” “speed,” quarter of study participants reported injecting hallucinogens, are difficult to heroin (27.6%).14 A study of crack use in Vancouver report because many of the demonstrated a large increase in crack use (at estimates are suppressed due to baseline, 7.4% of participants reported ever using getting to tomorrow: a report on canadian drug policy 20 TABLE 1: CANNABIS USE — CANADA 2011

newfoundland 1,008 ontario 1,009 canada 10,076 Lifetime Use Past Year Use Lifetime Use Past Year Use 34.8% 10.0% 37% 7.9% 39.4% pei 1,008 manitoba 1,008 35.1% 8.9% 36.1% 10.4% Lifetime Use nova scotia 1,008 saskatchewan 1,007 43.7% 12.4% 36.5% 8.8%

new brunswick 1,009 alberta 1,008 9.1% 37.4% 9.0% 43.1% 8.4%

quebec 1,007 british columbia 1,009 Past Year Use 39.7% 9.0% 44.3% 12.1%

Adapted from: Health Canada, Main 2011 CADUMS Indicators - Drugs.

crack and this rate increased to opiates was more prevalent than the use of heroin 42.6% by the end of the study in every setting except Vancouver and Montreal.17 period) among injection drug Another study observed a relative increase of 24% users between 1996 and 2005.15 from 2002 to 2005 in the proportion of the street- drug using population who used non-medical non-medical use prescription opioids only.18 A more recent study of prescription drugs found that the availability of prescribed opioids among people who use drugs in a Canadian Non-medical use of prescribed setting increased markedly over a relatively short opiates is now the fourth most timeframe (2006-2010), despite persistent and prevalent form of substance high availability of heroin and cocaine.19 Data use in Canada behind alcohol, also suggest that the harms associated with pre- tobacco and cannabis.16 scribed drug use, particularly opioids, are dispro- Between 500,000 and 1.25 portionally high for some groups including some million people are estimated to Aboriginal communities. Women are also more use prescription opioids non- likely to be prescribed psychoactive drugs than medically in Canada. A study men, and men are more likely to use prescribed conducted in five Canadian stimulants.20 cities indicated that the non- medical use of prescription canadian drug policy coalition · cdpc 21

youth provinces separate out cocaine from crack. In BC 4.4% of stu- Most provinces conduct school-based surveys of dents have used crack/cocaine. youth substance use, though the frequency and In three other provinces life- the types of questions asked on these surveys time usage rates vary from 3.3% can vary from province to province. Notably nine to 4.2% for cocaine and 1.3% to provinces conduct regular surveys including 2.1% for crack. bc, Ontario, Alberta, Manitoba, Quebec, and the Student Drug Use Survey in the Atlantic Provinces ■ Data on use of crystal meth- (including New Brunswick, pei, Nova Scotia and amphetamine range from .9% Newfoundland and Labrador). The Canadian to 1.5% Centre on Substance Use (ccsa) sponsored a reanalysis of data from the 2007/08 round of these ■ The cadums data for 2011 surveys to create comparable measures across the found that young people country. Key findings from the2007 /08 school- between the ages of 15 and 24 based surveys include the following: were the most likely age group to use illegal substances at ■ Increase in use of alcohol and cannabis between 23.1%.21 grade 7 and grade 12. In grade 7, depending upon the province, 3% to 8% report past year cannabis ■ Substance use among street- use versus 30% to 53% among grade 12 students. involved youth is much higher than other youth. Surveillance ■ Alcohol use is almost twice as prevalent as can- data from seven urban centers nabis use (46%-62% of students report alcohol use across Canada suggests a life- and 17% to 32% report use of cannabis in the past time prevalence of illicit drug year). Consistently more boys than girls use canna- use of 95.3% among street- bis, though in some provinces girls report more life- involved youth. Additionally, time alcohol use than boys in grades 7 through 12. 22.3% of street-involved youth ■ Aside from alcohol and cannabis, ecstasy (or had injected drugs at some time what is supposed to be ecstasy) is the most preva- in their life.22 lent drug (4% to 7% lifetime use.) ■ Other data sources suggest ■ Data on use of other substances are not consis- that non-medical prescription tently available across the provinces due to survey drug use is also becoming an design issues and low rates of response. Other than issue for youth. According to alcohol and cannabis, data are not available by the 2009 Ontario Student Drug gender or by age. Use and Health Survey, 22% of Ottawa students said they ■ 2.6% to 4.4 of students in some provinces for had used a prescription drug which data are available reported using inhalants. non-medically in the past year. Of these, 70% said they got the ■ Steroids are used by 1.2% to 1.4% of students; drugs from home and a study lifetime use of heroin is only reported for four of Toronto youth suggests that provinces and ranges from .8 to 1.3% of students. recreational use of prescribed Only four provinces provide comparable mea- opioids is on the increase.23 sures of cocaine and crack use and three of these getting to tomorrow: a report on canadian drug policy 22 harms of substance use experienced some of the largest increases in the province. hiv continues to disproportionately Harms from substance use po- affect marginalized populations, including young tentially include blood-borne Aboriginal women and street-involved individu- viruses such as hiv or Hepatitis als. According to 2009 data, 77% of new cases C (hcv), skin and respiratory of hiv diagnosed in the province were among problems, overdose, and dis- individuals who inject drugs, and of this group, ruption of personal life includ- 84% were of Aboriginal ancestry.26 In response to ing troubles with family, friends increasing concerns about hiv in Saskatchewan, co-workers and police. the province released a multi-year hiv strategy, aimed at both reducing new cases of hiv and im- Sharing used syringes and other proving the lives of those already living with the drug use equipment is the main disease. modes of hiv and hcv transmission among people who The majority of hcv cases in Canada are among use drugs. Of the 2,358 new people who inject drugs. As of 2009, injection drug infections reported in Canada use was associated with 61% of newly acquired in 2010, 16.8% were attributed hcv cases with known risk factor information. In to injection drug use. These British Columbia, hcv infection related to injec- figures differ considerably from tion drug use has decreased over the past decade province to province, between due to increased harm reduction and other preven- men and women overall, and tion measures. Elsewhere in Canada studies show for Aboriginal people com- that people who inject drugs are infected with hcv pared to other Canadians. In within one to two years of initiating drug injecting 2010, 30.4% of new infections behaviour, leaving a short but important period of in women versus 13.5 % of new time for interventions to prevent the transmission cases in men were attributed to of hcv.27 A discussion of the harms related to drug injection drug use. Cases of hiv overdose are included in chapter 5 of this report. attributed to injecting drug use among Aboriginal persons have other issues of concern gone up to more than 50% in the period spanning 2001 to 2008.24 Data on the nonmedical use of prescription drugs and the health, social and economic impacts Rates of hiv infection related among First Nations people in Canada is very to injection drug use vary limited, but concerns about use of these drugs has by location and population risen in recent years. Recent data on prescription group. In Saskatchewan, for drug use suggests that 18.4% of Inuit youth aged example, results from the 12-17, 11% of Aboriginal youth, and 8.9% of Metis 2009 Canadian Alcohol and youth living in urban Canada, compared to 5.6% Drug Use Monitoring Survey of non-Aboriginal youth, report using prescrip- suggest that rates of drug and tion drugs for non-medical purposes.28 In early alcohol use in Saskatchewan 2012 Cat Lake First Nation in Ontario was the were lower than the Canadian latest First Nations community to declare a state average for that year.25 But rates of emergency to federal and provincial officials of hiv in Saskatchewan have due to the widespread use of prescription drugs. been rising, and Saskatoon has The nonmedical use of prescription drugs has canadian drug policy coalition · cdpc 23

most drug research ignores the even if the substances used are illegal and deemed of no reasons people choose to take medical or scientific value. Of drugs, and why they value them. course, many psychoactive but illegal substances are also systematically assessing both the used medicinally or in thera- medical and non-medical benefits of peutic settings (i.e. lsd, mdma, Ayahuasca) to great benefit, substance use might shed more light including opioids for pain on why people use drugs and provide relief, stimulants for add and adhd, and cannabis for relief information that can help prevent the of many symptoms of illness. In harms associated with substance use. fact, the federal government in Canada operates a medical cannabis program for patients who use this drug for therapeutic been linked with the impoverished health status purposes. Reported anecdotal of First Nations across Canada.29 benefits from non-medical uses of different kinds of substances In addition, the bc Centre of Excellence for include pleasure and relaxation, Women’s Health has cautioned that women as a cognitive or creative enhance- group, and First Nations women in particular, are ment, heightened aesthetic ap- overprescribed benzodiazepines (anti-anxiety preciation (food, music, art, sex), medications) and sleeping pills. Data estimate mystical or spiritual experienc- that 3 to 15% of any adult population is using and es and pain relief. However, the may be dependent on this class of drugs and of politics of drug research mean this group 60 to 65% are women. As researchers that few researchers think suggest, physicians “prescribe benzodiazepines about or inquire into benefits (tranquilizers) and sleeping pills to help women of substance use, and few have cope with work or family stress, pre-menstrual systematically developed an syndrome, grief, and adjustment to life events approach for measuring such such as childbirth and menopause, or for chronic benefits. illness and pain. Non-drug treatments for these circumstances and conditions are under- pro- Intellectually, this means that moted and under-used.”30 In addition, women who most drug research ignores the inject drugs have twice the number of deaths than reasons people choose to take men.31 These findings suggest that any strategy to drugs, and why they value them. address drug use must account for population dif- Systematically assessing both ferences such as gender and First Nations status the medical and non-medical and must be rooted in an examination of the benefits of substance use might social determinants of substance use. shed more light on why people use drugs and provide informa- benefits of substance use tion that can help prevent the harms associated with sub- There are undoubtedly perceived and sometimes stance use.32 real benefits of psychoactive substance use, getting to tomorrow: a report on canadian drug policy 24 conclusions

Clearly, illegal substance use is part of everyday life for many Canadians. Substance use also brings both benefits and harms. But the harms of drugs are compounded and in some cases wholly created by drug policy. The unique pharmacology of any drug is only part of the story. The user’s mindset and the environment of use also shape the effects of drugs; drug policies and drug laws are key components that also shape the environment of use. Social factors like homelessness, imprisonment and law enforcement activities have been found to exacerbate the harms of drug use. Use of injection drugs in public, for example, can lead people to rush and/or disregard practices of safer use because of fear of police or public detec- tion, leading to infections and overdose.33 And the reasons people use drugs in public are likely related to lack of housing and/or available private spaces. What this means is that we need to be careful about conflating the harms of drugs with the harms posed by policy contexts. The challenge for drug policy is then to create a climate that maximizes safety while minimizing harm. This is not an easy challenge but one that Canadians must undertake. In the next sections of this report we review some of the key areas of concern for Canadian drug policy including services for people who use drugs, drug policy at the federal level and Canada’s on-going participation in the international war on drugs. p.27 What Are We Doing Well? p.28 Organization of Services in Canada p.29 Key Pressure Points in the System of Treatment Services p.31 The Integration of Mental Health and Substance Use Services: Some Questions p.33 The Availability of Data on Drug Treatment Services p.34 Drug Courts—Some Key Questions p.35 First Nations Métis and Inuit Communities p.36 Racism in Health Care—What’s it Going to Take for Canada to Change? p.37 Case Study: Organizing for Change—People Who Use Drugs getting to tomorrow: a report on canadian drug policy

SECTION THREE

Services & Supports for People who use Drugs canadian drug policy coalition · cdpc 27 The availability and scope of services is of crucial importance to Canadians seeking help with substance use problems. This chapter focuses on some of the key pressures facing Canadians seeking treatment services for substance use.

There is a large body of research on the effective- the mental and physical health ness of various treatment modalities; there is also of people who use drugs. a great deal of research about how drug-related According to the Canadian hiv/ services should be implemented and organized. aids Legal Network, treatment We acknowledge this important body of litera- for drug dependence shares ture, but this chapter focuses on the issues our three of the principal conditions key informants identified in Canada’s system of identified in international law as supports for people who use drugs. This chapter necessary for the full realization takes a different standpoint from the one that of the right to health: it is an im- readers might find in the above noted literature. portant element of controlling Rather than looking at the person who uses drugs epidemic illnesses because of its from the standpoint of the system, this chapter role in reducing the risk of hiv/ draws on the perspective of people who are in- aids and Hepatitis C; it pro- volved at the ground level including practitioners vides a health service to those and people who use drugs. The issues we identify who are ill; and treatment for below are the ones that most acutely affect these parents and pregnant women people as they attempt to navigate a system of can contribute to improved supports. This chapter focuses mainly on drug health and the development of treatment systems and the next chapter includes a young children.34 detailed discussion of harm reduction. what are we doing well? Access to treatment for drug dependence is an essential element of human rights. Governments In preparing this report we have a responsibility to ensure that all people heard about many problems can access services that will help them attain with the current system of sup- the highest possible level of physical and mental ports for people who use drugs. health. Though drug treatment may not always But we also heard numerous lead to abstinence, research and practice demon- stories about things that are strates that treatment can dramatically improve working well. getting to tomorrow: a report on canadian drug policy 28

Canada possesses a wealth populations. Some of these plans also stress the of expertise when it comes to need for more health promotion and prevention of putting our commitments into the harms of substance use, most notably through action. Many highly skilled, early intervention programs, along with training committed and passionate for people working in these systems, provision of people work very hard to create more services to caregivers, attention to the needs policy, and provide care and of people living in rural and remote areas, and col- services. These include the laboration between service providers, especially many peer groups, profession- for people with complex needs.35 These strategies als in health care and justice, almost universally emphasize the importance educators, and community- of evidence-based and best practice models of based organizations commit- policy development and service delivery. British ted to helping people address Columbia’s plan is exemplary for promoting problematic substance use and efforts to alter its system of services and supports challenging the heavy burden (rather than just focusing on changing people’s of discrimination. Community- behaviour), and it explicitly includes harm reduc- based agencies in particular tion in its system of services. often lead when it comes to putting innovative policy Another bright spot is the existence of the recom- initiatives into action. And mendations of the National Treatment Strategy sometimes they provide this Working Group. Their report,A Systems Approach leadership while under intense to Substance Use in Canada: Recommendations public scrutiny and in commu- for a National Treatment Strategy, lays out a set of nities resistant to change. principles to guide the development of treatment systems, a set of strategic areas that require action A bright spot is the number of including building increased capacity using a provinces that have made public tiered model,36 and supporting a continuum of commitments to improve their services and supports. This report also acknowl- system of supports for people edges the importance of increased research who use drugs. Virtually all capacity about treatment, the importance of provinces and territories have reducing discrimination against people who a strategic plan to address sub- use drugs and the need to measure and monitor stance use either in existence system performance. The principles of this report or under development. Several lay out a model for a person-centred approach of these plans stress the inte- through services and supports that put consent gration of mental health and to treatment at the heart of effective programs.37 substance use services and the The report also acknowledges the important role importance of integrating sub- that leadership must play in moving its recom- stance use services into primary mendations forward, including the involvement of care services such as family people who use drugs. doctors and community clinics. These plans also underline organization of services the importance of accessibil- in canada ity, with emphasis on seamless access to services and reduced Health service delivery is the jurisdiction of wait times for underserviced the provinces and territories, each of which is canadian drug policy coalition · cdpc 29

the system of drug treatment an integrated system of services and supports.40 and detoxification services is still a collection of clinics, Recent policy statements from many provinces suggest plan- hospitals, community agencies ning for a more integrated and private service providers system is underway.41 Despite these positive indications, the developed over time in response system of drug treatment and to local pressures, political detoxification services is still a collection of clinics, hospi- advocacy, and availability of tals, community agencies and funding without a great deal private service providers developed over time in response to of systematic attention to the local pressures, political advo- actual needs for services. cacy, and availability of funding and without a great deal of systematic attention to the responsible for the enactment of laws and poli- actual needs for services.42 The cies related to health and the delivery of health development of these services services. The provinces and territories receive has also been hindered by long- funding for substance use services from their standing moralistic attitudes Ministries of Health. These services are delivered about substance use. either by provincial health authorities (centralized) or by regional health authorities (regional- What this means is that people ized). Many provinces strive to provide a range of who seek help with their sub- services that run the gamut from education, harm stance use often must navigate reduction, prevention, screening, early intervention, a complicated and sometimes withdrawal management (detox), to day treatment, labyrinthine system of ser- residential treatment and supportive recovery vices characterized by long wait services. Generally more intensive and specialized times, lack of coordination and drug treatment services are offered in more popu- questionable accessibility. In lated, urban areas.38 the next section we review some of the key issues that face people The actual structure of substance use services across as they try to navigate these Canada varies widely, for a number of reasons: health systems of care. system regionalization, geographic differences, and differing political priorities related to substance key pressure points in use.39 Across the provinces and territories there the system of treat- are currently 87 “heath authorities” responsible ment services43 for service provision in Canada. Individual health authorities and other jurisdictions have developed Discrimination: Discrimination their own systems of services and supports, with against people who use drugs is little emphasis on consistency and co-ordination one of the main obstacles to re- within or between jurisdictions. The result has ducing substance-related harm. been fragmentation and inconsistency, rather than Discriminatory attitudes and getting to tomorrow: a report on canadian drug policy 30 behaviours by health care providers can be barri- funded health care system. ers to accessible, respectful and equitable care.44 People who use drugs report unmet treatment and Bridging between services is harm reduction service needs, and can be under- lacking in many jurisdictions: medicated or denied medication because they are One of the most acute difficul- labeled as “drug-seeking.”45 ties reported by key informants was the issue of bridging Lack of consistent and meaningful participation of between services. In times of people who use drugs: People who use drugs have transition between services, the set up groups across Canada, and have received risks of gaps in service where support and endorsement from a number of agen- people may “fall between the cies and organizations. These groups promote cracks” are significant. This can both the health and human rights of people who happen when youth transfer to use drugs and their social inclusion. But their adult services, when persons involvement as recognized stakeholders in plan- with concurrent disorders ning and implementing services and supports, transfer between mental health and in helping services evolve to be more person- and addictions services, when centred, is still insufficient. These organizations people transition from with- must be involved in helping to set the direction of drawal management to drug Canadian drug policy. treatment, and when patients are discharged from inpatient The chronic underfunding of services: Despite treatment programs to commu- several well-thought-out provincial strategic nity-based or outpatient servic- plans, many jurisdictions still lack a full con- es and when people are released tinuum of services. While some services are well from jail or prison. This is es- resourced, others still operate continuously in pecially challenging for people “survival mode” and do not have the resources to whose housing is unstable or serve all those who need assistance.46 And access non-existent. Without a safe to services is often still chaotic and confusing for place to stay, chances of relapse people who use drugs and for their families.47 are higher. In addition, lack of Wait times for drug treatment can be long and after-care services is a challenge can also vary significantly from jurisdiction to for many people exiting drug jurisdiction. Long wait times have been shown treatment services.49 to discourage people from seeking treatment. In Canada, publicly available information on wait Gender-based needs are not times is scarce.48 well integrated into planning and implementation: Scholars Privately run services in a publicly funded system: and practitioners in Canada In most jurisdictions, treatment services are still have illuminated the role that provided by a mix of private and public providers gender relations play in shaping and the cost of private treatment is a barrier to problematic substance use. service for many individuals. In Canada, private The bc Centre for Excellence treatment providers are not subject to mandatory in Women’s Health has helped accreditation requirements. Such a mix of public to foreground issues like the and private service providers would not be tolerat- over-prescription of benzodiaz- ed for any other health issue in Canada’s publicly epines to women and they have canadian drug policy coalition · cdpc 31

articulated a set of principles Making a lasting difference depends on addressing for gendering initiatives like the all needs: Key informants repeatedly stressed that National Framework for Action the system of supports lacks the tools to address to Reduce the Harms Associated key issues that increase the harms of problematic with Alcohol and Other Drugs substance use including poverty, homelessness, and Substances in Canada.50 Yet discrimination, and lack of consistent and quality gender-based needs are either community supports like childcare. completely ignored or under- played when planning and de- Funding mechanisms lack transparency: In many livering services and supports. cases, the funding mechanisms used in regional- Services do not exist to meet the ized health care systems lack transparency. For diverse needs of all Canadians: example, it is unclear to many frontline service Many groups such as First providers how provincial ministries of health al- Nations and Métis individuals locate funding, and then how monies are spent at have been under or not served the regional level. Indeed, health care spending by existing systems for genera- on substance use is insufficiently accountable to tions. Lack of access to services the people most affected by the issues. More than can result in a higher burden this, as our discussion of the National Anti-Drug of illness and greater risk for Strategy will reveal, at least at the federal level, substance use problems. Young the lion-share of funding still goes to enforcement people too experience difficul- activities. ties accessing appropriate drug treatment, particularly when No challenges to Prohibition: No province explic- they are homeless.51 In addition, itly challenges the reality of drug prohibition. available services and their Though the legal context for substance use is chosen modalities of treat- not a provincial responsibility, provinces and ment are not always appropri- territories must routinely shoulder the costs of ate. Twelve step programs, for prohibition either through criminal justice costs example, though immensely or through health and social harms of substance valuable for some, may not be use that are exacerbated by the lack of regulation appropriate for others. of substances. The legal framework for substances in Canada constrains the ability of provinces and Rural and remote areas are un- local jurisdictions to respond to substance use in derserved: There are significant innovative ways. differences in the availability of treatment services depend- the integration of mental health ing upon geographic location. and substance use services: This is most acutely the case for some questions rural and remote areas, though there can be significant dif- Most provinces have issued policy statements that ferences between the services support the integration of mental health and sub- offered in medium-sized cities stance use services.52 Impetus for this integration as compared to large metropoli- has been driven by evidence that many people tan areas even within the same who experience problematic substance use jurisdiction. may also experience mental health challenges, and that two independent systems of services getting to tomorrow: a report on canadian drug policy 32 cannot effectively or efficiently it is important to think and act meet people’s needs. Over the comprehensively when it comes years, it has become apparent that people can be bounced to complex and intertwined from one system of services to issues like substance use and another without a holistic approach to their needs. This lack mental health. people should of coordination is most acutely be able to easily access services felt at the service level when mental health services do not that can address the full accept clients who use drugs, spectrum of their needs. the including clients on methadone, while some addiction services integration of mental health do not accept clients on certain and substance use services, types of prescription medications, including antipsychotic however, suffer from the need drugs. These situations add to to acknowledge that substance the already frustrating process of accessing services. issues overlap and are shaped by other key issues like trauma, It is beyond the scope of this report to comprehensively poverty, racism, and drug examine the integration of policy itself. mental health and addictions. There are several excellent reports and literature reviews hensive services to individuals who do not expe- on this issue.53 We can however, rience mental health challenges; and 2. The need raise some important questions to acknowledge that substance use issues overlap about this integration from the and are shaped by other key issues like trauma, perspective of a comprehensive poverty, racism, and drug policy itself. This latter and socially just approach to point is important because the majority of people substance use. who experience challenges with substance use do not have co-occurring disorders.54 Approximately It is important to think and act 20% of people who have mental health issues expe- comprehensively when it comes rience co-occurring problematic substance use. to complex and intertwined The overlap between mental health and substance issues like substance use and use issues is higher in some sub-populations in- mental health. People should cluding incarcerated individuals, and young men be able to easily access ser- diagnosed with personality disorders.55 vices that can address the full spectrum of their needs. The While it is very important to have services that integration of mental health can address this important overlap, systems must and substance use services, protect already existing services that address however, suffer from two inter- the needs of people who experience problematic related challenges: 1. The need substance use and its related issues. Indeed many to continue to provide compre- people accessing services for their substance canadian drug policy coalition · cdpc 33

use have experienced trauma. particular circumstances of substance use, are This trauma is not a mental addressed. It is unlikely that one system or set of illness, but often the lived services can ever address all needs, thus a range of effects of systematic issues like services and systems must be mobilized to address colonialism and residential complex issue like problematic substance use. schools, discrimination and Advocates of “housing first,” for example, stress violence, including systemic its importance because safe and stable housing is forms of violence like violence often the first step to long-term healing.59 against women in intimate relationships and violence the availability of data on against Indigenous women. drug treatment services Services need to be able to deal with the complexity of people’s Effective service planning relies on good data that lives without necessarily medi- can assess what services people need and how calizing substance use issues. clients utilize services. Until now comparable data Most importantly services on Canada’s system of treatment supports has must be offered in a way that been unavailable. Though the Canadian Centre recognizes the need for physi- on Substance Abuse has initiated the process of cal and emotional safety and gathering national data on treatment programs, a choice and control over how report released in 201260 suggests that the avail- interventions will be applied. ability of comparable data from all provinces and Trauma-informed approaches territories is uneven at best and work remains on are similar to harm-reduction- developing comparable data collection systems oriented approaches in that in each of the provinces. The first ccsa report they focus on safety and en- focuses on publicly funded specialized services; gagement.56 (See the following data is available on treatment episodes, usage of chapter for more information on services by treatment type, gender, age, and use of harm reduction.) public opioid substitution by age. The report does not measure community-based, non-specialized The harms of substance use and private service providers. Nor can it assess the are also related to a number of gap between the need for services and the exist- factors including acuity, chro- ing capacity of treatment programs. And to-date nicity, and complexity. In other comparable data is not available on service wait words, harms from substance times. The intention of the National Treatment use can occur from one time Indicators Working Group is to build on this first drug use, from moderate to step in subsequent annual reports by continuing heavy drug use over time and to improve the scope and quality of the data col- may be complicated by other lected. The table to the right shows one portion challenges including mental of the data available in this report—in this case, health status, poverty, and/or individual episodes (not persons) of withdrawal overall health status.58 Mental management and drug treatment in jurisdictions health status may or may not with comparable data. play a role in shaping these issues. Personal well-being can only be enhanced if these un- derlying social issues, and the getting to tomorrow: a report on canadian drug policy 34 TABLE 2: WITHDRAWAL MANAGEMENT & TREATMENT, 2009/1061

withdrawal treatment

Residential Non-residential Residential Non-residential ab 11,402 5,273 30,712 JURISDICTION 24.1% 11.1% 64.8% nb 3,194 351 JURISDICTION 35% 35% 3.8% 61.2% ns 4,063 407 1,107 8,516 JURISDICTION 28.8% 28.8% 7.9% 60.4% on 41,462 1,181 10,535 79,005 JURISDICTION 31.2% 31.2% 7.9% 59.5%

pei 920 407 712 84 1,467 JURISDICTION 28.4% 28.4% 2.6% 45.2% sk 3,733 1,918 12,822 JURISDICTION 20.2% 20.2% 10.4% 69.4% csc 2,719 JURISDICTION 100%

Source: CCSA, National Treatment Indicators Working Group, 2012.

drug courts: some key questions The report does not dismiss dtc’s but raises some serious questions about how they operate and Drug courts are promoted as their effectiveness. a way to reduce drug use and prevent crime. Drug courts have This report found that drug courts use quasi- been set up in Toronto, Edmonton, coercive and punishing methods more akin to Vancouver, Winnipeg, Ottawa the criminal justice system. Applicants to a drug and Regina. Drug treatment court treatment program must plead guilty to a courts (dtc’s) are often touted crime and submit to a mandatory urine screening. as the solution to a cycle of This report also raises serious questions about the drug addiction and crime. But methodology of current research on drug courts. are they? That’s the question Because of the lack of follow-up research on the the Canadian hiv/aids Legal experiences of participants, and the low reten- Network sought to answer in a tion rates in many dtc programs, it is difficult to 2011 publication that reviews conclude at this stage whether or not drug courts the operations of six federally result in decreased drug use and/or recidivism. funded drug courts in Canada. Women are less likely to apply to dtc’s and less canadian drug policy coalition · cdpc 35

likely to graduate at compa- in the justice system, all of which affect the health rable levels to men, partly due and well-being of communities and contribute to to a lack of gender-specific lower social and economic status, crowded living programming and program conditions and high rates of substance use.63 flexibility that accommodates Compounding this is the institutional racism parenting responsibilities. enshrined in federal, provincial and municipal Indigenous women and men are policies, police, rcpm, criminal justice and other also less likely to complete drug professional practices such as health care and court programs due in part to social work, and at the societal level, violence the lack of Indigenous-specific against First Nations women.64 treatment services. The report also questions how voluntary Failure to keep agreements made with First one’s entry to treatment is when Nations, Métis and Inuit groups, along with ju- prison is the alternative and risdictional conflicts between the provinces and access to other treatment is the federal government have also plagued the limited. Drug courts may also development of services for First Nations, Métis violate human rights, specifical- and Inuit persons. The history of colonialism com- ly, the right to health outlined in bined with the numerous authorities involved Article 12 of the International in the provision of health care have resulted in Covenant on Civil and Political a complex policy context and uneven service Rights because participants provision between geographic areas as well as can be denied access to a health conflicts between the federal and provincial service if they do not follow the governments over who should pay for services.65 rules of a dtc program.62 Other challenges facing First Nations, Métis and Inuit communities include differences in access first nations, métis to services between Status and non-Status First and inuit communities Nations between on-reserve and urban First Nations persons, limited access to provincial de- First Nations, Métis and Inuit toxification services, lack of culturally appropri- communities face severe de- ate services, lack of coordination of care between ficiencies in funding for sub- services, and lack of adequate training for service stance use services. Funding providers.66 issues combined with health issues such as higher rates of In 2011, a report entitled Honouring Our Strengths: hiv infection and tuberculosis A Renewed Framework to Address Substance Use compared to other Canadians Issues Among First Nations People in Canada was reflects the colonial history of released. This framework for action was developed Canadian society. Racism and by a comprehensive community-based review of other forms of legal and social substance use-related issues and services driven by discrimination are key issues the Assembly of First Nations, the National Native that affect the health of First Alcohol and Drug Abuse Program (nnadap), and Nations, Métis and Inuit people. Health Canada’s First Nations and Inuit Health Systemic racism has resulted in Branch (fnihb). This framework clearly articu- policies of assimilation, residen- lates culturally based values and principles that tial school, lost culture and lan- should drive a renewal of substance use services guage, and over-representation for First Nations People on reserves. This strategy getting to tomorrow: a report on canadian drug policy 36 offers a comprehensive vision Aboriginal people and their worldviews. Currently for the design, delivery and there is an abundance of evidence to show that evaluation of services required First Nations and Aboriginal people do not receive to meet the needs of First the same quality of health services or report health Nations people. This strategy outcomes on par with other Canadians.”67 shows promise, but there is no guarantee that the work put into This strategic plan recognizes that healing and its development will translate reconciliation between Indigenous and non- into concrete, lasting federal Indigenous Canadians is necessary to further the support for effective programs wellness of all.68 But like the nnadap plan noted despite recent budget increases above, the promise of these words can only be ful- to the National Native Alcohol filled by meaningful follow through on the part of and Drug Program. governments.

Another promising sign is a racism in health care: what’s it going recent strategic plan to address to take for canada to change? bc First Nations and Aboriginal People’s Mental Wellness and As the discussion above indicated, legal and social Substance Use. This plan clearly policies that discriminate against First Nations, recognizes the need to acknowl- Métis and Inuit people in Canada can permeate edge the colonial history of health care settings. Racism can impact health in Canada and the impact of that several ways. Racist treatment and policies are not history on First Nations, Métis only added stressors, but lead to mistreatment in and Inuit people especially education, employment and health care settings. when it comes to understanding Discriminatory policies, attitudes and prac- the context of substance use. tices result in discrimination against Aboriginal The plan also offers the follow- people, misinformation about Aboriginal people ing analysis of the role that cul- and about Canadian history, as well as a lack of tural safety can play in fostering trust between Aboriginal people and non-Ab- change: original Canadians. A recent report by the Health Council of Canada on the experience of health “First Nations and Aboriginal care for urban Aboriginal Canadians, found that people need a range of cultur- many Aboriginal respondents reported that they ally safe services and supports had been treated with contempt and judgment, that respect their customs, and their health concerns were downplayed or values, and beliefs. Cultural ignored due to racist stereotypes. This was es- safety in health care is about pecially true when it came to stereotypes about empowering individuals, fami- substance use. Racist attitudes not only support lies, and communities to take practices and policies that result in discrimina- charge of their own health and tion against Aboriginal people, but also create well-being. It is important to a lack of trust between Aboriginal and non-Ab- note that achieving cultural original Canadians. When accessing health care, safety requires that health in- people are often at their most vulnerable. Racist stitutions and service providers treatment can drive people away from services respect the diversity between and thus exacerbate the harms of problematic and amongst First Nations and substance use.69 canadian drug policy coalition · cdpc 37

The report makes recommendations directed by ensuring these services are at all levels of the health care system including conceptualized, designed and enhancing the cultural competency of workers delivered with attentiveness and organizations, and creating opportunities for to the distinctive needs of the partnerships and collaborations that will enhance clients they serve. These groups cultural safety for First Nations, Inuit and Métis also play an important role in people.70 fostering a liberation perspective by creating a cultural and These attitudes and discriminatory practices have social space for people who been well documented by researchers, Aboriginal use drugs, challenging drug organizations and others in Canada over the years.71 prohibition and the perni- What will it take for all Canadians to listen and cious forms of discrimination change? against people who use drugs, advocating for improved living conditions, and by building CASE STUDY fruitful relationships with local authorities including health, Organizing for Change: education, government, law People Who Use Drugs enforcement, and media.

People who use drugs have been organizing in cities and regions in Canada for a number of years. Groups are active in Vancouver (vandu), Victoria (solid), and Toronto (toduu), Ottawa (dual) and in Quebec (addicq). Two groups— the bc/Yukon Association of Drug War Survivors and aawear in Alberta—operate at the regional level. The Canadian Association of People Who Use Drugs operates at a national level. Though most organizations of people who use drugs remain small and have minimal funding and budgets, they have had key impacts on drug policy. The Vancouver Area Network of Drug Users, for example, emerged in 1998 to play a key role in mobilizing community support for change in response to over 1,000 overdose deaths and high rates of hiv infection among people who injected drugs. People who use drugs have been employed as researchers and have also driven many innovations in harm reduction such as supervised injection facilities. The involvement of people who use drugs in planning and program implementation improves the quality and accessibility of services

canadian drug policy coalition · cdpc p.41 39 What is Harm Reduction? p.42 Case Study: Vancouver and the Four Pillars—Harm Reduction and Low Threshold Services p.44 The Human Rights Context for Harm Reduction p.44 The Elimination of Harm Reduction in the National Anti-Drug Strategy p.45 Harm Reduction—How are We Doing in Canada? p.47 Safer Consumption Services—It’s Time for More Than Two p.48 Syringe Distribution in Federal Prisons p.49 Harm Reduction for Crack Cocaine Use p.50 Opioid Substitution Therapies p.52 Heroin-Assisted Treatment in Canada p.53 Resistance to Harm Reduction in Canada p.54 Case Study: The Toronto Drug Strategy and the Dignity of People Who Use Drugs p.55 Harm Reduction: The Case of Ecstasy p.59 Case Study: The 595 Prevention Team in Winnipeg p.60 Case Study: Mothering, Pregnancy and Drug Use getting to tomorrow: a report on canadian drug policy 40

SECTION FOUR

Harm Reduction in Canada canadian drug policy coalition · cdpc 41 Harm reduction is a key pillar of any strategy to address the harms of problematic substance use. The cdpc sees the reduction of harm to individuals, families and communities as the fundamental goal of drug policy and the standard against which all drug policies should be evaluated. Harm reduction is a proven approach that offers many benefits and the scale-up of harm reduction services is urgently needed in Canada. This section examines the key barriers that prevent the scale-up of harm reduction services across the country.

what is harm reduction?

“‘Harm Reduction’ refers to policies, programmes to prevent and treat overdose and practices that aim primarily to reduce the and methadone and other adverse health, social and economic consequenc- opioid substitution therapies. es of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction involves a Harm reduction benefits people who use drugs, pragmatic, non-judgmental their families and the community.”72 approach to the provision of health services that respects the The evidence supporting harm reduction strate- dignity of people who use drugs gies is significant.73 Harm reduction programs and values their human rights. vary from place to place but may include some or Harm reduction provides skills all of the following services: education about safer in self-care (and care for others), drug use and safer sex, distribution of new sup- lowers personal risk, encourag- plies for injection and inhalation, condoms, safer es access to treatment, supports consumption services and/or facilities, programs reintegration, limits the spread getting to tomorrow: a report on canadian drug policy 42 of disease, improves environments and reduces public expenses. It also saves lives. People who CASE STUDY use drugs were responsible for initiating some of the first harm reduction programs in the 1970s. Vancouver and the These were guerilla groups organized to address Four Pillars: Harm the transmission of Hepatitis C. With the arrival of hiv/aids, harm reduction programs began Reduction and Low to appear in front-line services. These programs Threshold Services were underscored by a strong philosophical belief that people who use drugs are key participants and allies in their own individual and collective In the 1990’s the availability of health. As a result, harm reduction programs are high-grade heroin and cheap often very committed to including people who cocaine combined with poverty use drugs in the planning and implementation of and marginalization in Vancouver’s services.74 Downtown Eastside precipitated a public health disaster marked Harm reduction is both an approach to service de- by escalating rates of hiv infec- livery and a philosophy of care. Both abstinence- tion and overdose deaths. A report based and harm reduction approaches are part by Coroner Vince Cain in 1994 of an integrated continuum of care. But where responded to this emergency by abstinence-based approaches generally require calling for an overhaul of drug people to completely stop using all non-prescribed treatment and a reorientation that drugs and methadone to access drug treatment would see drug use as a health not and to be in a “state of readiness”, harm reduction a criminal matter. Though Cain’s services do not require people to stop using drugs, report did not immediately galva- but meet people “where they are” in terms of their nize leaders it signalled the begin- drug use. Exemplary harm reduction services have ning of a growing movement of minimal requirements for involvement and are people who wanted to change the points of entry to other health and social services. way things were done in Vancouver. Ideally harm reduction services are culturally ap- These changes were driven by a propriate and implemented in a variety of contexts combination of efforts: a grassroots that maximizes people’s positive contact with social movement comprised of these services.75 Harm reduction is not the only people who use drugs, the initiation approach to substance use, but it is a major means of a formal declaration of a public of preventing the transmission of disease and health emergency by the local overdose, connecting people to services, opening health authority and the growing a pathway to change and preserving the dignity of awareness that change was needed all Canadians. Harm reduction services have key by leaders including then-Mayor secondary benefits such as increased access to Philip Owen.77 In 2000 to comple- health services, housing referrals, drug treatment, ment the efforts of other partners, counselling, education, and testing for hiv and the City of Vancouver released a hcv.76 drug strategy: “A Framework for Action: A Four Pillar Approach to Drug Problems in Vancouver.” The strategy called for a comprehensive canadian drug policy coalition · cdpc 43

FIGURE 2: TRIANGLE OF SERVICES & SUPPORTS

low low

high threshold services Residential treatment, abstinence based housing

medium threshold services Number of People Degree of Accesibility Methadone with psychosocial supports, day treatment, daytox

low threshold services high Wet housing, safer drug use supply distribution, high safer consumption services, child care, accessible primary care

approach to address the dire circumstances in old services often required individuals to stop Vancouver and challenged the status quo by using substances before entry into treatment calling for new and innovative interventions services, or created administrative barriers for such as supervised injection sites and heroin-as- people seeking substitution treatment such as sisted treatment programs. The strategy included methadone and other health or medical services. health and enforcement and had as its two main Consequently few people at the street level goals, public health and public order.78 were able to access these services. The results of the traditional approach left thousands of indi- The Four Pillars approach drew on a model viduals out in the cold, effectively without ser- developed by the Swiss in the 1980’s to address vices of any kind, as few were able to navigate the the problems Swiss communities were experienc- “system of care.” The problems the Swiss were ing with open drug scenes, homelessness, high having in the 1980s mirrored the experience of rates of drug overdose deaths and hiv infection Vancouver in the 1990s and beyond. among drug users. Up until that time, services for street-involved people, many of whom were One of the key innovations borrowed from the homeless, relied primarily on a system of high Swiss experience and only partially implemented threshold treatment services. These high thresh- through the Four Pillars Approach was to put a getting to tomorrow: a report on canadian drug policy 44

strong emphasis on outreach and harm reduction the elimination of initiatives to engage people using drugs and bring harm reduction in the them into low threshold services—services that national anti-drug were specially created and immediately acces- strategy sible to people. These services provided an exit from the street and an entry into health, social Despite the positive effects of services, supportive housing and employment these programs, in 2007, the services. These innovations were complemented federal government elimi- by innovations in substitution treatment and the nated harm reduction from the hoped for introduction of heroin-assisted treat- National Anti-Drug Strategy, ment (hat) for long-term heroin users, through and since that time, it has been a clinical trial. These services were meant to either indifferent or hostile to operate as entry points into a larger system of harm reduction services. Many care and provide people with options beyond Canadians are concerned what existed at the time. Figure 2 shows how about this hostility to a well- low threshold services can help people access established health practice other services in the system. supported by global organizations such as the United Nations A combination of efforts by the people who Office on Drugs and Crime, use drugs, the health authority, the city and the unaids, and the World Health Vancouver Police Department put in place an ex- Organization.80 The lack of panded treatment system, more harm reduction federal government support services including needle exchange/distribution for harm reduction has under- program, and a supervised injection site. mined efforts to establish new harm reduction services and to more fully integrate and expand the human rights context currently existing programs for harm reduction into the health care system. In fact, the ccsa recently released Harm reduction services are supported by inter- a strategy to address “prescrip- national human rights conventions. According tion drug misuse” in Canada. to these conventions, all people have the right to This document avoids the use of life-saving health services. The right to health and the term “harm reduction” alto- health services is protected in numerous interna- gether though it nods in several tional human rights documents. The International places to the need to address Covenant on Economic, Social and Cultural the harms of prescribed drug Rights (icescr), which binds Canada, recognizes use by drawing on an evidence- in Article 12, that states must take all necessary based public health approach. steps for “the prevention, treatment, and control of The strategy recommends, for epidemic… diseases.” The right to health “requires example, that Health Canada the establishment of prevention and education and the Public Health Agency of programs for behaviour-related health concerns Canada “develop and promote such as sexually transmitted diseases, including risk reduction programs for in- hiv/aids. These provisions of the icescr support dividuals who use prescription harm reduction as a legitimate and necessary drugs,”81 though no specifics health service.79 about the nature of these “risk re- canadian drug policy coalition · cdpc 45

duction” programs are provided. as an advisory report for the Minister of Health. Unfortunately the open hostil- Alberta’s recent strategy on mental health and ad- ity of the federal government dictions notes that harm reduction will be offered to harm reduction has made it to people with “complex needs.”84 increasingly difficult for both federal agencies and groups Though most provinces and territories provide funded by the federal govern- some form of support for harm reduction, the ment to openly discuss the range of harm reduction services varies consider- merits of this important health ably across the country. Harm reduction services care service.82 are also plagued by a number of issues:

harm reduction: ■ Services are Siloed: In 2013, the “siloing” of harm how are we doing reduction in hiv policy and program areas con- in canada? tinues. Provincial and health authority funding arrangements for harm reduction services usually In Canada, the provinces are flow from programs to prevent the transmission of responsible for the provision of blood-borne pathogens such as hiv and hcv and health care services. But pro- are not integrated with other substance-related vincial commitments to harm program areas (i.e. drug treatment). These funding reduction are mixed and in arrangements partly originate in the historical de- some cases absent. Some prov- velopment of harm reduction services in Canada. inces include harm reduction Due to the slowness of government response to in their overall mental health the hiv epidemic in the 1980s, peer-based and and substance use strategies other community groups created harm reduction and some do not. Some prov- services to respond to this crisis. But due to a lack inces include harm reduction of leadership on the part of governments, services only in hiv strategies such as for the prevention of blood-borne pathogens re- Saskatchewan and Manitoba.83 mained isolated from other drug-related services. British Columbia and Quebec This separation occurs at multiple levels and sites include strong commitments including in policy, funding, information flow, to harm reduction in their approaches to admission to services, and varying strategic documents. On the philosophical approaches to treatment and recov- other hand, Ontario and Nova ery. These programmatic arrangements have been Scotia’s recently released strat- partly responsible for a failure to fully integrate egies on mental health and harm reduction services into the overall system substance use do not mention of health care. They also perpetuate the notion harm reduction, though it is that harm reduction is somehow the opposite of part of Ontario’s public health abstinence-based services rather than both being standards and receives a brief seen as part of a continuum of care. mention in Nova Scotia public health standards. Harm reduc- The result is that many jurisdictions still treat tion is also a key component harm reduction as simply “supply distribution” of the 2012 Ontario document for the prevention of hiv and other blood-borne entitled The Way Forward: pathogens. As the numerous harm reduction Stewardship for Prescription services across the country have demonstrated, Narcotics in Ontario, prepared it is much more than this; because of its philo- getting to tomorrow: a report on canadian drug policy 46 sophical underpinnings in non- provincial government and/or health authority judgmental client-centred care, counterparts for the continued funding of their it is also an exemplary practice services. This is a concern because relationships of health engagement that could can change as people change employment, or as potentially be a model for other political and policy priorities change. health issues. ■ More Rural and Remote Services are needed: In ■ Meeting a Wide Range of many places in Canada there is no comprehen- Important Needs: Because harm sive plan to recognize the harm reduction needs reduction services draw on of people living in rural areas. In many rural non-judgmental and accessible contexts, harm reduction supplies are either not approaches to care, clients rou- available or are available only through secondary tinely request assistance with or “natural helper” distribution.86 These forms of other issues like housing and distribution are often reliant on unpaid helpers income support. But because and are vulnerable because of a lack of formal harm reduction is still seen mechanisms to provide these services. The scale as “supply distribution” many up of services in rural and remote areas is also harm reduction services remain hindered by discrimination against people who grossly underfunded to meet the use drugs. full range of client needs, such as stable housing, employment, ■ Policy Does Not Guarantee Implementation: Even access to income support pro- when provinces have clearly articulated provin- grams, prenatal and antenatal cial level policy frameworks that support harm care, and childcare. Provincial reduction, this does not guarantee that all munici- and/or health authority funding palities or health authorities will support harm mechanisms for harm reduc- reduction services appropriate to their needs. tion services do not always The city of Abbotsford, bc, is one such example; in recognize the broader services 2005 this municipality used its municipal bylaws provided by harm reduction; to “zone-out” harm reduction. Another case in nor do provincial policy and point is the City of Victoria, bc, which has had no funding mechanisms recognize stand-alone fixed needle distribution site since the broader needs of clients. In 2008 when public controversy forced its closure fact social assistance rates are despite the inclusion of both fixed and mobile not adequate for people to find services in bc’s best practices document on harm and keep stable housing and reduction.87 meet basic needs such as nutri- tious foods. The lack of adequate ■ Centralized Supply Purchasing Creates social supports undermines the Efficiencies: Only three provinces have centralized ability of some Canadian’s to the purchasing and distribution of harm reduction live healthy and safe lives.85 supplies including bc, Ontario and most recently Alberta. Centralized mechanisms for supply dis- ■ Good Relationships Can tribution (such as syringes and alcohol swabs) are Change: Successful and effec- cost-effective ways of purchasing and distributing tive harm reduction service supplies. Centralized services can collect data providers are often dependent on the amount and type of supplies distributed upon good relationships with and can assess shifts in supply requirements that canadian drug policy coalition · cdpc 47

may signal emerging drug use funding for harm reduction services detracts from issues. In the absence of these drug treatment programs.89 These claims pit harm centralized mechanisms, harm reduction programs against the rest of the system reduction providers must make of supports for drug use. It cannot be emphasized arrangements with local health enough that harm reduction services are part of a authorities or others to access larger continuum of care that includes other low cost-effective supplies and staff threshold services and treatment and aftercare. time must be allocated to purchasing supplies.88 safer consumption services: it’s time for more than two ■ Women, Pregnancy, and Harm Reduction: Despite im- Since 2003, the city of Vancouver has been the provements, Canada lacks a location of a rigorously evaluated and highly suc- comprehensive system of harm cessful stand-alone supervised injection site (sis). reduction supports for pregnant The vast amount of evidence from the reviews women who use drugs. A harm conducted of Vancouver’s supervised injection reduction approach to preg- site—Insite—suggest that this unique service nancy and drug use focuses on has several beneficial outcomes: it is used by the providing basic needs such as people it was intended to serve, which includes prenatal and antenatal care, over 10,000 clients. And it’s being used by people housing and nutrition and takes who might ordinary inject drugs in public. This a pragmatic approach to drug service has also reduced risk behaviours by reduc- use. This approach recognizes ing the sharing of needles and providing education that discrimination against on safer injecting practices. Insite has promoted pregnant and mothering women entry into treatment for drug dependency and has who use drugs drives them away improved public order. It has also been found to from prenatal and antenatal reduce overdose deaths, provide safety for women care. Most harm reduction pro- who inject drugs, and does not lead to increased grams are not funded to provide drug use or increased crime. 90 these services and in some jurisdictions, services simply do not Vancouver is also the site of the Dr. Peter Centre, a exist for pregnant and mother- combined day and residential program for people ing women who use drugs. (See living with hiv/aids. The Dr. Peter Centre is a mul- case study below for examples of tiservice site offering low-threshold access to care, existing programs.) including counseling, illness prevention, advocacy and referral services. Recognizing the needs ■ Harm Reduction is Still of its many clients who use drugs, the Centre Profoundly Misunderstood added to its harm reduction programs by integrat- by Some: Media reports and ing supervised injection services into its health some key politicians still claim services beginning in 2001. The Centre has been that harm reduction services instrumental in establishing supervised injection operate in opposition to absti- as a legitimate aspect of nursing practice because nence-based and other drug of its intent to provide care, prevent the transmis- treatment programs. In fact sion of illness and prevent death and injury from media reports are not sufficient- overdose.91 ly critical of the suggestion that getting to tomorrow: a report on canadian drug policy 48

Given the relationship in Canada between in- syringe distribution jection drug use and hiv and hcv infections, in federal prisons scale-up of these services is urgently needed. But opposition from the federal government has People do not surrender their stalled the implementation of these beneficial human rights when they enter services. In 2007, the federal government refused prison. Instead, they are de- to grant a continuation of the legal exemption pendent on the criminal justice to Insite (Section 56 of the Controlled Drugs and system to uphold their human Substances Act). Proponents of the site including rights—including their right to the PHS Community Services Society, vandu, and health. Prison health is public Vancouver Coastal Health challenged this refusal health. all the way to Canada’s Supreme Court. In 2011, that Court ruled in favour of the exemption and These statements may seem self- ordered the federal Minister of Health to grant a evident to some, but the right to continuation of the exemption. adequate health care services is the basis of a legal case brought In the light of this court decision, other Canadian against the Canadian federal cities are considering the establishment of similar government. Prison syringe services. To shield clients and staff from crimi- exchange programs are a crucial nal prosecution, each new site will be required component of a comprehensive to submit an application for an exemption to strategy to prevent the spread the Controlled Drugs and Substances Act to the of infectious diseases but the Federal Minister of Health. These applications federal correctional service are time-consuming to prepare and there is no does not permit this life-saving guarantee that the federal government will look health service in Canada’s federal favourably on these applications. To-date Health prisons. To challenge this policy, Canada has not issued clear criteria for how it will the Canadian hiv/aids Legal assess these applications. Provincial governments Network, Prisoners with hiv/ have also been tight-lipped about whether or not aids Support Action Network they support establishing these important health (pasan), catie, the Canadian services in their jurisdictions. Aboriginal aids Network (caan) and Steven Simons, a former Notable exceptions are the bc Ministry of Health federal prisoner, launched a and the Quebec Ministry of Health. The bc lawsuit in September 2012, against Ministry has signalled its support of these services the Government of Canada over by revising and reissuing its “Guidance Document its failure to protect the health for Supervised Injection Services” while the of people in prison through its Quebec Ministry of Health has recently drafted a ongoing refusal to implement similar document. Written for health care profes- new clean needle and syringe sionals, these documents provide advice to health programs. In fact, this case authorities and other organizations that plan to challenges Canada’s federal cor- submit an application for supervised injection rectional system to ensure that in- services in their local areas.92 carcerated persons are provided with equivalent access to health care as other Canadians.93 canadian drug policy coalition · cdpc 49

Drug use in prisons is a reality. A 2007 survey by because syringe exchange the Correctional Service of Canada (csc) revealed reduced the likelihood of a that 16% of men and 14% of women had injected needle stick they realized that drugs while in prison.94 Some prisoners are not distribution of sterile injection ready to partake in treatment, treatment may be equipment was in their own in- unavailable or treatment may not be appropri- terest, and felt safer than before ate. Despite the fact that drug use and possession the distribution started.98 is illegal in prison and despite efforts to prevent drugs from entering the prisons, drugs remain The vast majority of prison- widely available. In fact, no prison system in the ers eventually return to the world has been able to keep drugs completely out. community, so illnesses that Sharing syringes is an efficient way of sharing are acquired in prison do not blood-born illnesses. In a 2007 nationwide survey necessarily stay in prison. by the Correctional Service of Canada, the rates of This means that when we hiv and hcv among federally imprisoned women protect the health of prison- were 5.5 and 30.3 percent, compared to 4.5 and ers we protect the health of 30.8 percent among federally incarcerated men. everyone in our communities. Aboriginal women reported the highest rates of hiv and hcv, at 11.7 and 49.1 percent, respective- harm reduction for ly.95 This means that people in prison have rates of crack cocaine use hiv and Hepatitis C (hcv) that are at least 10 and 30 times higher than the population as a whole, Crack cocaine use remains and much of this infection is occurring because prevalent in Canada. The bc prisoners do not have access to sterile injection Centre for Disease Control, for equipment.96 example, reports that the prevalence of local crack cocaine This legal case challenges the belief that people smoking has been rising revoke their rights when they enter a prison and amongst injection drug users. are thus not entitled to equitable access to health Crack smoking is independently care. In fact, prisoners retain all the human rights associated with hiv and hcv that people in the community have, except those status and linked to outbreaks of that are necessarily restricted by incarceration. tuberculosis and streptococcus This includes the right to the highest attainable pneumonia. Harm reduction for standard of health, a right enshrined in several un crack use remains a neglected Treaties and Conventions. This right encompasses issue even in comparison to measures such as syringe exchange that have other underfunded harm reduc- been shown repeatedly to prevent the transmis- tion services.99 sion of diseases.97 These services are available in many parts of the world and evaluations have Given the prevalence of harms found that they reduce needle sharing, do not lead associated with crack cocaine to increased drug use or injecting, help reduce use and the lack of a widely de- drug overdoses, facilitate referrals of users to drug liverable treatment option, there treatment programmes, and have not resulted in is an urgent need for health- needles or syringes being used as weapons against oriented interventions such staff. When these services were introduced in as harm reduction programs Swiss prisons, staff were initially relunctant, but that deliver safer smoking sup- getting to tomorrow: a report on canadian drug policy 50

given the prevalence of The availability of safer crack use harms associated with supplies varies greatly across the country. A recent study sug- crack cocaine use and the gests that a substantial propor- lack of a widely deliverable tion of people who smoke crack have difficulty accessing crack treatment option, there is pipes in a setting where pipes an urgent need for health- are available at no cost, but are limited in quantity.104 Some pro- oriented interventions such grams in Newfoundland, New as harm reduction programs Brunswick, Ontario, Quebec, Manitoba, Alberta, and British that deliver safer crack use Columbia provide safer crack programs that include safer supplies on a routine basis. bc’s Harm Reduction Supply smoking supplies. Program makes three sizes of mouthpieces and push sticks available but pipes are not avail- plies. A recent study on the distribution of safer able. Vancouver Coastal Health crack use kits in Winnipeg shows that this harm has recently begun a pilot reduction service is cost effective over both the project to distribute safer crack short and long run. Average costs of kits were 59 use kits including glass pipes in cents while the costs of treating one patient with Vancouver.105 Other programs hcv over one year were $10,000 ($100,000 over throughout the country offer a lifetime). As this report notes, preventing “only safer crack supplies as their one case of hcv or hiv infection annually with the budgets permit, though often use of safer crack use kits can translate into a very the distribution of these sup- cost effective harm reduction program.”100 Safer plies is done quietly because of crack use supplies have also been found to help public opposition. In fact, oppo- reduce unsafe smoking practices that can lead to sition to the distribution of safer hiv/hcv infection including pipe sharing and use crack supplies has resulted in the of broken supplies, and to engage marginalized closure of programs in Ottawa individuals in health care services.101 and Calgary, and Nanaimo though the project in Ottawa was More importantly, people who use crack are on the reinstated.106 blunt end of discriminatory practices and are often extremely marginalized. The distribution of safer opioid substitution crack use kits offer an important means of engaging therapies a marginalized population to provide education and refer people to health, treatment and other Pharmacotherapy for opioid de- services.102 A recent review of the safer crack use pendence includes substitution kit distribution in Winnipeg found that relation- medications like methadone ships of trust were developed between people and buprenorphine. In Canada, who smoke crack and service providers through most provinces support opioid outreach and supply distribution.103 substitution therapy including methadone maintenance canadian drug policy coalition · cdpc 51

therapy (mmt) programs. Best considerably between urban and rural areas. In practices for these programs rural areas, lack of transportation to services, few typically suggest that a multi- pharmacies that dispense methadone, and shorter disciplinary approach is needed pharmacy hours may affect the success of mmt that includes physician pre- treatment. Unlike most other health care services, scribing, pharmacy dispensing, in most jurisdictions, mmt is offered through a and provision of psychosocial mix of public and private settings, meaning that supports (e.g. counselling, some people must pay for this essential health housing, etc.), though the psy- service. In many cases, private providers are not chosocial support services integrated with other important services and sup- are often in short supply. mmt ports in the health care system and beyond. But in requires pharmacist observed some areas, private providers are the only source daily dosing until a patient is of services. stabilized, after which time, take home doses may be granted. In Methadone can only be made available by a pre- Canada, the organization and scriber who has an exemption to the Controlled implementation of opioid sub- Drug and Substance Act. To receive this exemption stitution therapies is plagued by prescribers must obtain specialized physician several key problems.107 training usually offered by provincial Colleges of Physicians and Surgeons or in Ontario by the Services can vary considerably Centre for Addiction and Mental Health. Not all from province to province; some provinces and territories provide this training offer more comprehensive ser- thus decreasing the number of available prescrib- vices including low threshold, ers. This exacerbates the problem of already long intensive and primary care wait lists for services in some regions. At the same services and some do not. time, opportunities to access opioid substitution Low threshold services remove therapy in settings like emergency rooms and barriers that can limit or delay primary care can be limited by a lack of accredited access to mmt and usually have prescribers. an open referral processes meaning people can be referred mmt programs are plagued by a lack of public from many places in the system. accountability for the implementation of psycho- Conversely, high threshold social supports, the role of physicians and phar- services, offer psychosocial sup- macists in the system, and oversight of physician ports and can be thus be more services and billing and pharmacy dispensing limited by the availability of re- fees. sources.108 As of 2012 there were approximately 65,000 people on Retention rates in treatment can vary considerably opioid substitution therapy in both within and between jurisdictions. Retention Canada.109 rates are affected by how services are organized and by issues like discrimination. Clients report Some family physicians offer that the attitudes of some health professionals mmt, and it is also available can be shaming, and that practices like manda- through private clinics, and in tory and observed urine screening effectively prisons. Even within the same treat individuals as criminals rather than people jurisdiction, services can vary in need of health care.110 Likewise, in some cities getting to tomorrow: a report on canadian drug policy 52 and towns, proposals for methadone services tually opened its doors in the have been met with community hostility due to Downtown Eastside Vancouver, discrimination against people who use drugs. This bc and Montreal, Quebec. can even take the form of discrimination against prescribers of methadone. The target population for naomi included individuals over the Most jurisdictions do not cover the costs of bu- age of 25 who were “chronic, prenorphine except for patients who cannot opioid dependent, daily idus” tolerate methadone. Buprenorphine may be an and who had previously been appropriate approach for some people because unsuccessful with methadone the risk of overdose is less than methadone and it maintenance and other treat- does not always require daily dosing. But recent ment modalities. Researchers reanalysis of research comparing these medi- randomized participants in cations indicates further research is needed to the naomi study to one of two determine the comparable safety risks between groups: one received injections methadone and buprenorphine.111 of diacetylmorphine (heroin) or hydromorphone (Dilaudid a Clearly there is an urgent need to streamline the licensed medication), and the opioid substitution system and address the con- other received oral methadone. cerns expressed by patients and service providers. The naomi study provided heroin/hydromorphone for 12 heroin-assisted treatment months, followed by a 3-month in canada transition period.

Heroin-assisted therapy as a treatment modality People in the heroin arm of for drug dependence can be very challenging for the naomi study experienced some people who advocate only for abstinence- marked health and other based services. But several research trials, along improvements, including de- with the continued existence of programs that creased use of illicit “street” provide pharmaceutical-grade heroin, have dem- heroin, decreased criminal onstrated clear benefits. activity, decreased money spent on drugs, and improved Recognizing that methadone maintenance physical and psychological therapies (mmt) and abstinence–based treat- health.113 Yet, naomi patients ments programs do not work for some people, were not kept on hat following Switzerland implemented heroin-assisted therapy the study’s termination. Canada (hat) in several cities in the 1990s. The uk has long is the only country that did not had heroin prescription as part of their treatment continue to provide hat to its services, and the success of the Swiss program led patients following its clinical other countries to adopt similar models, including trial, rather, they were returned Germany, the Netherlands, Spain, Belgium, and to methadone or other conven- Denmark. There is now a large evidence base on tional treatments—treatments the safety and effectiveness of hat.112 In 1998, the that had not worked for them in first North American Opiate Medication Initiative the past. (naomi) Working Group was formed to conduct a hat trial in the us and Canada. naomi even- In December 2011, another canadian drug policy coalition · cdpc 53

clinical trial, the salome study (Study to Assess nent hat programs to be set up Longer-term Opioid Medication Effectiveness) in Canada. opened its doors in the downtown Eastside of Vancouver, BC. The study compares the effective- resistance to harm ness of six months of injectable diacetylmorphine reduction programs (heroin) with six months of injectable hydromor- in canada phone (Dilaudid) and the effects of switching from injectable to oral heroin or Dilaudid. Participants Harm reduction programs in will be in the study for one year, followed by a Canada are sometimes on the 1-month transition period where they will be en- receiving end of public back- couraged to, once again, take part in conventional lash. Resistance by community treatments such as methadone maintenance, groups, municipalities and even drug-free treatments, and detox programs (treat- Medical Health Officers can lead ments that have proven to be ineffective for these to delays or denial of harm re- participants). Like the naomi study, the repeated duction services. Municipalities failure of other treatment efforts for participants is have become another site for in fact, part of the criteria for selection of partici- public conflicts over the provi- pants in salome. sion of harm reduction and methadone services. Since In response to Vancouver hat clinical trials failing 2005, some municipalities in to incorporate plans for permanent programs, in British Columbia have become January 2011, Dave Murray, a participant in the involved in regulating illegal naomi trial organized a group of participants from substances through the use of the heroin stream of the naomi clinical trial. The bylaws and residential inspec- independent group, naomi Patients Association tion programs. These activities (npa), currently holds its meetings every Saturday have focused mainly on using at offices of the Vancouver Area Network of Drug municipal bylaws to control Users (vandu). In 2012, many salome partici- the cultivation of cannabis pants joined the npa. The npa has been at the fore- and the production of meth- front of advocating for permanent hat programs amphetamines. But bylaws to be set up in Canada.114 From the perspective and zoning provisions have of people who had been enrolled in the naomi also been used to restrict the research trial, ending the trial without the imple- availability of harm reduction mentation of a permanent program was respon- services. In 2012, Mission, bc, sible for significant declines in health and social passed a bylaw that prevents the status of some participants. npa recognized that establishment of pharmacies in were this any other health issue, people would not its downtown area effectively be denied access to an effective treatment and that preventing methadone dispens- by not putting in place an adequate exit strategy, ing in their Core Commercial the study is putting marginalized and vulnerable Downtown Zones.115 In 2005, people at further risk. The npa continues to raise Abbotsford, bc passed an these concerns with the authorities responsible amendment to its zoning bylaws for this research. that restrict harm reduction services (needle exchanges, mobile The evidence base for hat is well established and dispensing vans, supervised in- it is time for research trials to stop and for perma- jection sites) in its municipality. getting to tomorrow: a report on canadian drug policy 54

In Coquitlam, bc a 1996 bylaw restricts the location of metha- CASE STUDY done clinics and another Bylaw designates methadone clinics The Toronto Drug as “undesirable businesses.” 116 Strategy and the Dignity In Ontario, resistance to harm of People who Use Drugs reduction services and opioid maintenance programs has occurred in several communi- In 2005, the City of Toronto developed a drug ties in recent years, sometimes strategy encompassing prevention, harm reduc- spearheaded by local politi- tion, treatment and enforcement. The Toronto cians. Several municipalities, Drug Strategy (tds) is a multifaceted effort to for example, including Windsor, address the harms of substance use drawing on Pembroke, London and Oshawa, health and other policy approaches. Like other have also passed bylaws or land- municipal drug strategies in Vancouver, Thunder use requirements that restrict Bay and the Waterloo Region, the tds does not methadone clinics. 117 shy away from the importance of harm reduction services as part of a full continuum of care for In a 2012 review of the safer people who use drugs. The tds also centres the inhalation program in Ottawa, rights and dignity of people who use drugs in its the author, Dr. Lynne Leonard, vision statement and principles and draws at- noted what she called the “dem- tention to the role that discrimination plays in onstrated capacity of individual undermining health. Medical Officers of Health to prevent the full implementation In 2010, the tds conducted focus groups to of the program in their region”. hear directly from people who use alcohol/ Reportedly one third of public other drugs about their experiences of stigma health units in Ontario do not and discrimination. The purpose of the research distribute harm reduction sup- was to identify types and sources of stigma and plies despite the inclusion of discrimination experienced by people who use this requirement in the prov- alcohol/other drugs, document the impact of ince’s Public Health Standards. these experiences, and identify strategies to As this author notes, this non- help reduce their negative impacts. Six focus distribution of harm reduction groups were held at a range of community- supplies has significant impacts based agencies across Toronto, with a total of on the sharing of drug use 60 participants. People who are homeless and/ equipment.118 or otherwise living in poverty were the main focus of this study as they represent the most This resistance is fed by lack of marginalized group of people who use drugs in understanding—or the resis- our society. Key findings of this study included tance to understanding—the the following: effectiveness of these services › Families are the most significant source of and by discriminatory attitudes discrimination, with the most negative impacts. and behaviours against people › People are facing multiple forms of discrimination who use drugs. Media coverage at the same time (e.g., related to their substance canadian drug policy coalition · cdpc 55

use, poverty, race, gender and age), and the is often tainted with potentially compounded effect intensifies the severity of damaging chemicals. In 2011 the stigma and discrimination. and 2012, 5 people in bc died › Discrimination creates barriers to accessing as a result of ingesting ecstasy, services people need to stabilize their lives, and causing uproar in the health discrimination stops people from seeking help and enforcement community due to fear of how they will be treated. about how to best respond to › Peer support is an important coping strategy this situation. Toxicology for people affected by stigma and discrimination, results showed that the mdma and people need to be better informed of their purchased by these people was rights to access services, and language about tainted with pmma (parame- substance use needs to be more neutral and less thoxy-metamphetamine).120 judgmental. These deaths created a new, and a familiar dilemma: we Recommendations for action in this report to know that despite drug prohibi- help reduce stigma and discrimination include tion, people will use ecstasy on the following: training and education for health a regular basis and we know and social service workers; storytelling and peer that this drug will be purchased initiatives; support and education for family from an unregulated market. members; and, promoting expanded delivery of Given these realities, how do health services in community-based settings.119 we best respond to minimize or significantly reduce the risks of backlash against these services can exacerbate associated with the act of ingest- tensions between people who use drugs and other ing ecstasy of unknown potency, community members. This backlash and subse- composition, and quality that quent media reporting can reinforce common has been purchased from an myths and stereotypes that contribute to exclu- unregulated source within an sionary public policies. illegal unregulated market?

harm reduction: Traditional approaches try to the case of ecstasy ensure that drugs are not available to young people. Typically On any given night in Canada thousands of young one approach is to use secu- people are attending dance events or parties held rity and policing efforts to make in clubs or private homes. A significant number of events drug and dealer free. these party goers will choose to use substances Despite these efforts, drugs to enhance their experience including alcohol, like ecstasy are often avail- cannabis, ecstasy and other mood-altering sub- able at dance events, clubs and stances, some illegal and some legal. One of the private parties. Or they may be more popular substances used at these parties is purchased in advance of the ecstasy. Ecstasy is also a street name for mdma event. Some efforts have been (methylenedioxymethamphetamine). Since made by non-profit volunteer illegal psychoactive substances used for non- organizations to either test pills medical purposes are not subject to government using rudimentary tests that de- regulations for safe manufacture and distribu- termine if mdma or other drugs tion, ecstasy created in clandestine laboratories are present in substances that getting to tomorrow: a report on canadian drug policy 56 are supposed to be ecstasy.121 a street drug testing service that Testing programs recognize the reality of drug use but prioritize provides quick feedback to clients health effects and outcomes. creates a level of accountability It may be time to acknowledge that young people in our society between the consumers of street will continue to experiment drugs and those who supply them. with ecstasy, and that to better protect these people pill testing when consumers of street drugs services should be a part of our are able to have their drugs monitoring and early warning system. The Dutch have had a tested for purity and quality, system of pill testing available or to test them themselves, they to people who use drugs for many years and attribute their are empowered to boycott those extremely low rate of injury dealers who sell poor-quality or and death from “bad” drugs at dance parties to the increased heavily adulterated products. knowledge that young people have of the risks of ecstasy and their desire to test what they surveillance of which are otherwise notoriously buy on the street before they difficult. A street drug testing service that provides use it. They also maintain that quick feedback to clients creates a level of account- testing these pill products helps ability between the consumers of street drugs and to “clean up” the illegal market those who supply them. When consumers of street in that dealers who sell toxic, drugs are able to have their drugs tested for purity dangerous or poor products are and quality, or to test them themselves, they are quickly exposed which rewards empowered to boycott those dealers who sell poor- those in the business who sell quality or heavily adulterated products. safer drugs.122 In a comprehensive review of street drug testing, A comprehensive street drug the European Monitoring Centre on Drugs and testing service is an important Drug Addiction concluded that it is an important part of a continuum of harm measure to contact hard to reach populations reduction responses to illegal and raise their interest in preventive and harm drug use. Drug testing that reduction messages. The review found that street provides feedback to clients drug testing is an important source of informa- and allows them to make tion on new substances and consumption trends. better-informed decisions, It stressed that testing should be closely linked to which contributes to improved the provision of safer use messages through a wide self-determination and safety. range of information supports.123 Drug testing also gives health and other service providers a The tragic outcome of our current drug policies means to collect and assess which perpetuate a strict prohibition on assist- information about illegal drug ing young people to determine the safety of their markets, the monitoring and drugs, is that some will needlessly be injured or canadian drug policy coalition · cdpc 57

die as a result of tainted unregulated and untested process that includes communities, participants, products. Current prohibitionist policies rely on and service providers. All workshops have a the sacrifice of some young people in an attempt foundation of consistent core information, and to keep drugs out of their hands, and to create the are tailored to ensure that specific community perception that taking illegal drugs is always a needs are addressed. Workshops have been high-risk activity. delivered throughout Manitoba as far north as Thompson and are thoroughly evaluated. Since It appears that we have a choice to make as a 2008 they have trained over 1200 service society: since we know that drug taking by young providers. http://www.the595.ca/ people will continue to occur, will we continue to rely on enforcement and scare tactics to discourage this activity from taking place or is it time to implement a system that will help young people CASE STUDY gain knowledge of what they are buying, the as- Mothering, Pregnancy, sociated risks of drug use and safer practices in taking these drugs and at the same time, put and Drug Use dealers and producers on notice that they will be exposed if their products are tainted. In Canada, there are excellent examples of harm reduction oriented and pragmatic care for CASE STUDY pregnant and mothering women. Sheway is a Pregnancy Outreach Program (p.o.p.) located The 595 Prevention in the Downtown Eastside of Vancouver. The Team in Winnipeg program provides health and social service supports to pregnant women and women with infants under eighteen months who are dealing with drug and alcohol issues. The focus The 595 Prevention Team is a network of of the program is to help women have healthy over 100 member organizations interested pregnancies and positive early parenting ex- in addressing the determinants of health and periences. Fir Square, a maternity unit at bc preventing the transmission of sexually trans- Women’s Hospital, offers a harm reduction mitted infections and blood borne infections approach for women unable to practice absti- (stbbis), primarily hiv and hcv, in Manitoba. nence during pregnancy. Fir Square has 11 beds The mandate of The 595 is to work with peers, mixed between antepartum and postpartum network members, policy makers, and communi- care for women who want to stabilize or with- ty leaders to make recommendations regarding draw from drug use during pregnancy. The Jean the development, implementation and evalu- Tweed Centre in Toronto provides counselors at ation of stbbi prevention initiatives based on multi-sites to offer support services to women evidence and best practice with priority popu- and children and connect mothers with local lations. Core values of the 595 include client resources. The Healthy Empowered, Resilient centred and non-judgmental care, relationship Pregnancy Program (h.e.r.) program operations building and creating supportive environments in conjunction with Streetworks in Edmonton. for people who use drugs. The 595 believes in Other programs are in the process of opening best practice, especially when working with including Herway Home in Victoria and the underserved populations. They offer a selection Mothering Project in Winnipeg. of workshops in conjunction with a consultation

canadian drug policy coalition · cdpc p.61 Prescription Drugs are Part of the Problem 59 p.63 Overdose Deaths are Preventable p.63 We Can Reduce the Barriers to Calling 911 p.64 Case Study: Toronto Public Health—Education and Training to Prevent Overdose getting to tomorrow: a report on canadian drug policy 60

SECTION FIVE

A Case for Urgent Action: Overdose Prevention & Response canadian drug policy coalition · cdpc 61 Across Canada, far too many people are dying from drug overdoses. Unintentional overdose among people who use opioids (both licitly and illicitly) contributes significantly to the illness and death of Canadians. The tragedy is that many of these deaths could have been prevented. Clearly policy changes and interventions aimed at improving these disturbing statistics are urgently needed.

Recent data suggest that rates of overdose are annual drug deaths.126 Increases unacceptably high in Canada, especially since in the use of prescribed medi- overdose can be prevented. Overdose can occur cations like Oxycodone have during the use of illegal drugs, non-medical use also precipitated increases in of prescription opioids and even when opioids are overdose. In October 2012, used as prescribed. the bc-based Interior Health Authority released a warning Though no comprehensive national data exists that overdoses in southeastern on overdose, pockets of research have illustrated bc were about twice the rate in a growing problem in Canada. For people who the rest of the province. Most of inject illegal opioids, the annual rate of fatal these overdoses were accidental overdoses is estimated to be between 1% and 3% and were associated with the per year.124 Between 2002 and 2010 there were legal use of prescribed medica- 1654 fatal overdoses attributed to illegal drugs in tions.127 The rate of prescription bc and between 2002 and 2009 there were 2,325 overdose deaths in one health illegal drug-related overdose hospitalizations.125 region (2.7 per 100,000 persons) in bc is similar to that of the prescription drugs are number of residents killed in part of the problem any given year in motor vehicle accidents involving alcohol Deaths related to overdose of prescription opiates in the province.128 In Ontario, whether used medically or non-medically have prescriptions of Oxycodone in- risen sharply and are estimated to be about 50% of creased by 850% between 1991 getting to tomorrow: a report on canadian drug policy 62

and 2007, and each year between 300 and 400 of the estimated 1–2 million people die from overdose involving prescription individuals using non-medical opioids—most commonly Oxycodone.129 prescription opioids turned to other drugs such as morphine, Research found that in Ontario the addition of heroin, fentanyl, and codeine. long-acting oxycodone to the drug formulary was Many of these drugs carry the associated with a 5-fold increase in Oxycodone- same or higher risks of over- related mortality and a 41% increase in overall dose. These shifts in drug use opioid-related mortality.130 This same study could potentially trigger shifts showed that in 56.1% of overdose deaths between to higher-risk activities such as 1991 and 2004, patients had been prescribed an increased needle sharing and opioid within four weeks before death. A study of overdose. Indeed, anecdotal patients admitted to the Centre for Mental Health reports suggest that the delist- and Addiction in Toronto for opioid dependence ing of Oxy products appears to found that 37% received opioids by prescription, have increased the street prices 26% from both a prescription and from the street for this drug, and increased and 21% exclusively from street sources.131 A re- drug market volatility and cently released strategy on the misuse of prescrip- related crime.133 tion drugs reports that opioid-related deaths in Ontario nearly tripled over an eight-year period, The ccsa in conjunction with from 168 in 2002 to 494 in 2010. Of the total 3,222 the National Advisory Council opioid-related deaths reported during this period, on Prescription Drug Misuse deaths related to oxycodone (n=970) were found recently released a strategy that to be the most prevalent, followed by morphine calls for action to address the (n=722) and methadone (n=595).132 increasing harms associated with prescription medication The challenges presented by prescription use.134 The strategy focuses on opiates constitute a potentially tragic ‘natural’ opioids, sedative-hypnotics experiment in drug policy options. In response (i.e. diazepam) and stimulants to high rates of prescription of the opiate drug and makes a series of recom- OxyContin—more than 30% of all strong pre- mendations to government to scribed opioid prescriptions in 2012 (about 2.2 ameliorate the harms of these million) were for OxyContin products—two major substances. The strategy also events occurred. In February 2012, the drug’s attempts to address the harms manufacturer, Purdue Pharma, announced that of prescription drug use while OxyContin would be replaced by a new and sup- acknowledging their beneficial posedly tamper-proof formulation, OxyNeo. In medical purposes especially for response, seven provinces announced that both the relief of pain. The strategy OxyNeo and OxyContin would be removed from includes 58 recommendations provincial drug formularies. Health Canada also focused on prevention, treat- implemented the same for its federal drug plan. ment, education, monitoring The rationale behind these provincial and federal and surveillance (data collec- changes was the suppression of the widespread tion). While the strategy makes use of these drugs and the prevention of their di- excellent recommendations version to an illegal market. But, early anecdotal about the need to collect better reports from across the country suggest some data, and address prescribing canadian drug policy coalition · cdpc 63

practices, educate prescribers, Take home programs were pioneered in Canada patients and family on the ap- by Streetworks in Edmonton in 2005. The Works propriate use of medications, (a harm reduction program at Toronto Public it does not give significant at- Health) began a peer-based program in 2011. This tention to two key activities program dispensed 610 kits since its inception that can help prevent overdose. and peers have reported 65 administrations of Though mention is made of the naloxone.138 In 2012 Ontario launched a provincial need to review the evidence for program to provide naloxone education and kits community-based take-home through harm reduction services. bc’s program, naloxone programs,135 the which began in 2012, is modeled on these pre-ex- strategy does not recommend isting initiatives and combines education on pre- a comprehensive health and vention, identification and response to overdose, human rights approach to over- with take-away naloxone kits for people who are dose prevention and treatment; using opioids. These training programs combined nor does it call for improved with the availability of naloxone help people to be access to naloxone or the need prepared in the event of an opioid overdose.139 for federal 911 Good Samaritan legislation. Below we discuss Naloxone, a safe and simple medication that re- the importance of each of these verses opioid overdoses, has been used in emer- measures. gency settings for over 40 years in Canada and is on the who List of Essential Medicines. The bc overdose deaths ambulance service administered naloxone 2,367 are preventable times in 2011.140 Unfortunately, efforts to increase the reach of this drug are hindered by legal and Community based programs jurisdictional issues. Naloxone is not covered by that provide training on how to provincial drug plans; nor is this drug as widely recognize the signs of overdose available due to its cost even though its patent has and treat overdose have been expired. And naloxone is a regulated substance shown to be highly successful at available only by prescription in most provinces. preventing death and injury. Theu.s. has over 180 Take Home we can reduce the Naloxone programs to train barriers to calling 911 friends and family to resuscitate overdose victims and adminis- Most overdoses occur in the presence of other ter naloxone. Scientific studies people. The chance of surviving an overdose, like of these programs have dem- that of surviving a heart attack, is almost entirely onstrated that they are effective dependent on how fast one receives emergency at reducing overdose deaths.136 medical services (ems). Though witnesses to heart Several u.s. jurisdictions also attacks rarely hesitate to call 911, witnesses to an have best practice policies overdose too often waver on whether to call for for physicians to support co- help, or in many cases simply don’t make the call. prescribing naloxone with any Many overdose deaths occur because those who opioid for people at-risk of an witness overdoses are fearful of arrest and will overdose.137 avoid calling even in urgent cases where ems are needed for a friend or family member who is over- getting to tomorrow: a report on canadian drug policy 64 dosing. Anecdotal reports from across the country have also found that victims of overdose will often CASE STUDY ask friends not to call 911 because they fear police interaction, and/or because they are on parole Toronto Public Health: or do not want to go to jail. In addition, recent Education and Training to amendments to Canada’s Controlled Drugs and Substances Act stipulate mandatory minimum Prevent Overdose prison sentences for some drug-related offences. These provisions will unquestionably intensify fear of prosecution for witnesses of drug overdose In spring 2012, Toronto Public Health (The and increase rates of preventable overdose deaths. Works) created educational webinars on peer- The more practical solution to encourage overdose based naloxone training, prescription and witnesses to seek medical help is to provide ex- distribution to supplement its already exist- emption from criminal prosecution, an approach ing peer-based training program on overdose commonly referred to as “911 Good Samaritan prevention and treatment. Staff at community Immunity” legislation. In general, this law could health centres, hospitals, prisons, First Nations provide protection from arrest and prosecution for communities and methadone programs viewed drug use and possession charges if the evidence is these webinars across Ontario. Training and gained as a result of the person calling 911. consultation were also provided for agency administrators. This action came in response 911 Good Samaritan legislation is a step toward to concerns about the potential impact of saving lives and urgent action is needed to enact OxyContin™’s removal from the market in this legislation in Canada.141 States south of the Ontario, and the increased risk of overdose as border—including California, New Mexico, people transition to other, potentially more Colorado, Washington, Illinois, New York, Rhode harmful opiates such as fentanyl. In addition, Island, Connecticut, Massachusetts and Florida— The Works and the Toronto Harm Reduction have all passed Good Samaritan legislation in the Task Force (thrtf) also partnered to produce last four years. In states like New York and Florida, a short film, entitled The First 7 Minutes, which support for these laws was bipartisan and these promotes developing and implementing overdose bills passed nearly unanimously. These laws send protocols at agencies that serve marginalized the message that accidental drug overdose is a populations. The video can be used in combina- health issue, and that fear of criminal justice in- tion with a broader peer-based overdose volvement should not be a barrier to calling 911 in prevention curriculum in trainings with peer the event of an overdose. workers, people who use drugs, and frontline workers. Eight training sessions have been conducted since spring 2010 with a total of 223 participants.142 canadian drug policy coalition · cdpc 65 p.67 The National Anti-Drug Strategy p.68 What Does Canada Spend on the National Anti-Drug Strategy? p.69 Policing and Courts and the National Anti-Drug Strategy p.70 Drug Prevention Programs at the Federal Level p.71 Promising Practices in Prevention/Health Promotion p.72 Case Study: Thunder Bay Drug Strategy getting to tomorrow: a report on canadian drug policy 66

SECTION SIX

Drug Policy on a Federal Level canadian drug policy coalition · cdpc 67 Beginning in 1987, a series of drug strategies outlined the principles of federal policy. By 2003, the Liberal federal government announced an investment of $245 million over the subsequent five years to renew its drug strategy by focusing on four broad areas including enforcement, prevention, treatment, and harm reduction. These strategies reflect a long debate about how to address drugs—as a health issue or as a criminal matter.

As recently as 2005, this debate National Anti-Drug Strategy was removed from culminated in a number of Health Canada and relocated within the Justice policy decisions that empha- Department. nads also downplays the impor- sized the health aspects of drug tance of robust health promotion programs and use including a renewed frame- does not address the harms associated with legal work for action on substance drugs like alcohol. use that included expanded harm reduction, treatment and the national anti-drug strategy other supports.143 The National Anti-Drug Strategy is a “horizontal However, beginning in 2007, initiative” comprised of 12 federal departments the federal Conservative gov- and agencies, led by the Department of Justice ernment initiated the National Canada. The initiation of this strategy was in- Anti-Drug Strategy (nads), a formed by antagonism against previous attempts $527.8 million effort to address by the Liberal government to decriminalize pos- illegal drug use. This strat- session of small amounts of cannabis. When the egy was accompanied by other new strategy was announced, Tony Clement, “tough-on-crime” efforts that Minister of Health in 2007, reportedly stated, “In expand a punitive approach the next few days, we’re going to be back in the while doing little to address the business of an anti-drug strategy,” Clement told root causes of crime. Further The Canadian Press. “In that sense, the party’s amplifying this shift, in 2008 over.”144 Clement’s comments echoed the get- the leadership for the new tough stance of the new Conservative govern- getting to tomorrow: a report on canadian drug policy 68

ment. The stated priority areas of the strategy changes in the priorities of the include prevention, treatment and enforcement. nads. Funding for the Drug As we noted previously, nads excludes federal Treatment Funding Program support for evidence-based harm reduction (dtfp) and the Drug Strategies programs recommended by the World Health Community Initiatives Fund Organization and actively opposed the existence (dscif) has been decreased and of Vancouver’s supervised injection site.145 funding for Crime Prevention Programs has also been This strategy is not national, in that it was not eliminated.151 Despite concerns developed in collaboration with, or endorsed by, about the overall direction of provinces and territories. More accurately, it is a the nads, other jurisdictional federal government strategy. And many groups in scans suggest that the dtfp Canada have expressed concerns about key fea- funding has been an impor- tures of the nads including the Canadian Nurses tant driver of innovation. An Association and the Centre for Addiction and example is the “Needs-Based Mental Health in Ontario among others.146 Planning Model” research un- dertaken at Centre for Addiction what does canada spend on the and Mental Health in Toronto. national anti-drug strategy? This project is developing methods for estimating the In 2007, the nads was rolled out with a five-year actual population-based need plan for funding that totalled of $578.6 million for substance use services and dollars. It was renewed in 2012 with another five- supports in Canada.152 Despite year commitment of $527.8 million.147 Even before promising efforts, funding for the initiation of the nads, Canada’s federal drug the dtfp has decreased from strategy favoured the use of enforcement and other $124.7 in 2007/12 to $80.4 criminal justice approaches to address illegal million in 2012/2017. The one substance use despite mounting international, bright spot is a funding increase peer-reviewed evidence of the ineffectiveness of to National Native Alcohol and this approach.148 Under nads, law enforcement Drug Abuse Program from initiatives continue to receive the overwhelming $36 to $45 million though it is majority of drug strategy funding (70%) while certainly too early to tell if this prevention (4%), treatment (17%) and harm reduc- funding will be used to create tion (2%) combined continue to receive less than diverse services and whether it a quarter of the overall funding.149 In 2012, the will address the scope of issues Department of Justice released the budget for the identified by Aboriginal people next five years of the National Anti-Drug Strategy in Canada. (2012/13 to 2016/17). Compared to the first five At the same time, components years (2008/2009 to 2011/12), the overall budget of nads related to the crimi- has decreased almost 12%.150 These figures do nal justice system received not account for the myriad of other enforcement increased funding including activities that go on at the municipal, provincial the rcmp, Correctional Service and federal levels. of Canada, Parole Board of Canada, and the Canada Border Despite decreases in overall spending, the pro- Security Agency. Overall the posed budget for 2012 - 2017 signals significant canadian drug policy coalition · cdpc 69

rcmp will receive an additional $16 million (for determinants of problematic a total of $112.5 million) between 2012 and 2017 substance use. The government for enforcement against cannabis growing opera- has abandoned the highly valu- tions and clandestine drug labs. able crime prevention through social development approach This strategy only accounts for a portion of federal of previous governments. There government spending on drug control. Common is little if any coordinated effort drug enforcement activities such as drug interdic- to address issues like poverty, tion, border services, use of military personnel homelessness, cultural dislo- in international drug control efforts and costs cation, and lack of economic of prison expansion are not fully included in the opportunity that tend to affect nads. Interdiction, for example, includes efforts rates of problematic substance to seize drugs, couriers or vessels, between source use. For example, the harms of countries and Canada, including as they enter drug use are often exacerbated the country. Accounting for expenditures on by homelessness with increased interdiction is complicated, since many interdic- harms associated with the twin tion efforts serve multiple functions, not just drug problems of substance use control. Nor can policing and corrections costs and lack of housing.156 Until related to drugs be easily determined. Like drug these issues are meaningfully interdiction, policing and corrections costs are incorporated into a broader not easily broken down in terms of amount of re- strategy to prevent problematic sources spent on drug enforcement and incarcera- substance use the strategy will tion due to drug crime. Clearly Canadians need remain narrowly focused and more transparency when it comes to the costs and have limited results. effectiveness of current policies.

The government’s own in-house policing and courts and the reviews of the nads suggest national anti-drug strategy other problems. An evaluation of the implementation of the Since 2007, the Conservative government has strategy conducted in 2008, ensured that law enforcement and criminal justice found that there were signifi- strategies are the main means of addressing drugs cant differences between the and crime. This government has increased the approach taken by the prov- range of mandatory minimum sentences for drug inces and the one espoused by and gun crimes; parole review criteria have been the federal government. As the abolished or tightened; and reduced credit for evaluators noted, the provinces time served in pre-trial custody and restricted use “focus on substance abuse in of conditional sentences has been eliminated.153 A general rather than abuse of wide variety of evidence suggests these approach- illegal drugs, support harm es have limited effects in deterring drug demand reduction, and take a more and supply or increasing overall public safety.154 holistic approach to substance And overall tough sentences do not deter people use issues (for example, many from committing crimes.155 provinces have integrated or are integrating mental health and The federal government’s current approach to addictions).”157 Evaluators also drug policy does not address the broad social noted other points of discord: getting to tomorrow: a report on canadian drug policy 70

Canada’s current approach does As part of its Prevention Action Plan, the federal not accord with international National Anti-Drug Strategy provided increased developments including recent funding to the rcmp’s Drugs and Organized calls by some Latin American Crime Awareness Service (docas). Programs countries to rethink prohibition developed under docas include the Aboriginal as the main means of prevent- Shield Program, Drug Abuse Resistance Program ing drug use.158 (dare), Drug Endangered Children (dec), Deal.org, Drugs and Sport: The Score, E-aware, drug prevention Organized Crime Awareness, Drug Awareness programs at the Officers Training (daot), the Community federal level Education Prevention Continuum (cepc), Racing Against Drugs (rad) Program. Other programs The National Anti-Drug receiving funding included the Prevent Alcohol Strategy has touted the impor- and Risk-related Trauma Youth Program (party), tance of prevention over harm Keep Straight, and Building Capacity for Positive reduction assuming that these Youth Development.162 Monies were also allocated two approaches to drug use are to prevention projects funded under the Drug mutually exclusive. Overall, Strategies Community Initiatives Fund, though a drug prevention programs are complete list of these projects and their outcomes plagued by a lack of success at was unavailable.163 curbing drug use. Evaluations of the programs like the To-date, no long-term assessment of these pro- rcmp’s Drug Abuse Resistance grams has been conducted. There is also no com- Programs (dare) indicate prehensive accounting for the content of these that there is a lack of evidence programs; nor has the federal government or demonstrating that these pro- the rcmp publicly released any information on grams have long-term positive their effectiveness. The mass media campaign, effects on levels of drug use.159 comprised of TV, radio, web and print materials, Adding to this is the fact that which received $13,889,000 between 2007 and few prevention programs have 2010, was not renewed in the second funding passed the scrutiny of rigorous period (2012-2017).164 This anti-drug mass media evaluation.160 Prevention ac- campaign was implemented without evidence to tivities have also been criticized support its efficacy and despite evidence that this for being piecemeal, lacking kind of campaign may even be harmful. Though comprehensiveness, oversight, participants in these programs initially report in- monitoring and accountability. creased knowledge about drugs, controlled trials In Canada it is also difficult to of similar antidrug media messages have suggest- track the effects of these pro- ed that they may result in harmful assumptions grams on drug use especially among youth about drug use and that they lack given that there are no overall demonstrated effectiveness over the long-term.165 strategies which identify goals against which effects could be Additionally, as part of nads the ccsa has pre- measured; and there is no way pared a document entitled “A Drug Prevention to know if the programs cur- Strategy for Canada’s Youth.” This strategy was rently in use are weak or poorly one of the recommendations for action in 2005 implemented or both.161 the National Framework for Action to Reduce the canadian drug policy coalition · cdpc 71

Harms Associated with Alcohol and Other Drugs health promotion activities and Substances in Canada. The goals of this strat- show promise particularly when egy includes reducing drug use by youth, delaying these programs support the onset of use, and reducing frequency of use, and development of young people’s identifies three activities it will use to reach these social and emotional learning goals including: development of a Media/Youth skills.169 These programs do not Consortium to help carry forward the anti-drug necessarily focus directly on messages in the nads; the development of na- substance use; rather, reduced tional standards for prevention; and creation of substance use is one of the “sustainable partnerships” including a number benefits of improved decision- of working groups to provide advice on the devel- making skills.170 opment of national standards and media-youth connections. This strategy promises an impact Successful programs also draw evaluation of these efforts that will draw on exist- on well-established principles of ing data on youth drug use. To date, this evalua- health promotion (health promotion has not been released by the ccsa.166 tion is the process of enabling people to increase control over, The methods used for this evaluation and its and to improve their health).171 results will be keenly important to assessing the Health promotion recognizes effectiveness of the National Anti-Drug Strategy. that good health and healthy Additionally the need for national standards for decision-making results from prevention programs is particularly acute given healthy environments. It focuses the number of community-based and other orga- on both universal and tailored nizations that offer drug prevention programs to strategies. Universal strategies young people. It is, however, beyond the scope of address large-scale inequi- this review to evaluate either the content or the ties in supports for health like effectiveness of the ccsa standards. There are, adequate income and housing, however, excellent resources that point to the best access to information, and sup- practices in prevention as described below. portive environments. Tailored strategies help to prevent in- promising practices in juries and other harm. In the prevention/health promotion light of these evidence-based findings, the approach to pre- A substantial research base points toward more vention supported by the nads effective models that have been proven to reduce is potentially quite limited. health-related and community concerns attrib- Though the ccsa has estab- utable to drug use, and reduce the unintended lished standards that could negative effects of drug policies.167 Problematic positively reorient prevention substance use does not simply arise from lack approaches, overall efforts are of knowledge about the dangers of drugs; thus it hampered by the vision of the is important to avoid programs that simply use nads that still conceptualizes scare tactics or simplistic messages about the prevention as a matter simply hazards of drug use. But there is no magic bullet of reduced drug use. The nads or one program that can eradicate the harms of does not look beyond to the substance use. Programs that mobilize community social determinants that shape wide efforts,168 and programs that are part of larger substance use; nor does the getting to tomorrow: a report on canadian drug policy 72 strategy measure effectiveness improve the health and well-being of Thunder of its programming in terms of Bay residents. The goals of the strategy reflect overall attitudes and behaviours a realistic approach to substance use and ac- toward all substances including knowledge the interrelated and complex nature alcohol. of this phenomenon. The Strategy leverages a wide range of policy options to meet its goals including: increasing the representation of CASE STUDY Aboriginal people in local agencies, increasing the availability of housing comprised of tran- Thunder Bay sitional, and supportive housing units, with a Drug Strategy special focus on women and youth; a commitment to supporting an evidence-based approach and urging the federal government to re-exam- By 2009, the community of ine its National Anti-Drug Strategy (see chapter Thunder Bay was experienc- 6). The Thunder Bay Drug Strategy also acknowl- ing increased harms from drug edges the importance of bolstering programs use including alcohol, concerns that support families and children in schools about community safety and and in communities, supporting a scale up of lack of services. Changes in harm reduction services including overdose pre- the industry base and the vention, improving methadone programs and economy had led to poor increasing access to and quality of treatment job options for many people programs.172 previously well-employed in sectors such as the pulp and paper industry. And poverty was clearly linked with substance use-related problems. These concerns drew community leaders and local politicians to convene a Steering Committee to examine the need for a local drug strategy. The Steering Committee held 26 focus groups and three strategy sessions to gather information about substance use in their city. Out of this process came the Thunder Bay Drug Strategy, a five- pillar approach encompassing prevention, treatment, harm reduction, enforcement and housing. Drawing on the international body of research, groups representing each of the pillars, created actions to canadian drug policy coalition · cdpc p.75 Does the ‘War on Drugs’ Work? 73 p.76 Overall Crime Rates Fall While Adult Drug Crime Increases p.77 Safe Streets and Communities Act—Are we any safer? p.80 Prison Overcrowding is Already a Reality p.81 Prison Sentences Are Inequitable p.82 The Failures of Prohibition p.84 Cannabis as a Case in Point p.86 Changes to Canada’s Medical Cannabis Access Program p.87 Alternatives to Prohibition—What are they? p.89 Case Study: Waterloo Crime Prevention Council getting to tomorrow: a report on canadian drug policy 74

SECTION SEVEN

The Criminalization of Drugs in Canada canadian drug policy coalition · cdpc 75 In Canada, drug crimes fall under the authority of the federal Controlled Drugs and Substances Act (cdsa) and include possession, trafficking, importing and exporting and production-related offences. The seriousness of penalties included in the cdsa is related to the perceived levels of harm caused by each drug. The cdsa does not recognize that drugs such as alcohol and tobacco are at least as harmful as some illegal drugs.

In general, drug law and policy promoted by one of Canada’s social reformers of in Canada has not been a the time, Emily Murphy.174 Over time, Canadian benign phenomenon linked lawmakers added more substances and harsher to health concerns, but a tool penalties for their use to drug laws. Alongside laws of social control directed un- that prevented the use, production and selling of evenly at some groups of people. some drugs, Canada developed a legal and lucra- Historically concerns about tive system for the regulation of prescribed medi- public safety have been linked to cations, and alcohol and tobacco. illegal drug use or drug dealing. In Canada the response to these does the ‘war on drugs’ work? concerns has been to increase the scope of laws, the severity Perhaps the most stunning display of unimagi- of punishments and the scale native thinking when it comes to solving current of policing. Drugs were first drug problems is the refusal by governments to prohibited in Canada in 1908 consider the failure of the overarching policy with the passing of the Opium framework that not only creates much of the drug Act. The prohibition of opium crime in Canada but also constrains our ability had more to do with anti-Asian to address many drug-related health harms. Far sentiments than with concerns from eliminating drug use and the illicit trade, about the health effects of this prohibition (making some drugs illegal) has in- substance. Prohibition of can- advertently fuelled the development of the world’s nabis in 1923 was likely related largest illegal commodities market, estimated by to a racist scare about the drug the un in 2005 at approximately $350 billion a getting to tomorrow: a report on canadian drug policy 76 233 TABLE 3: DRUG OFFENSES IN CANADA, 2010/11 police-reported drug offenses, canada 2010/2011 change in rate

2010 2011 POSSESSION Number Rate Number Rate 2010/2011 2001/2011

Cannabis 56,853 167 61,406 178 7% 16% Cocaine 7,325 21 7,392 21 23% Other Drugs 9,671 29 10,352 30 5% 97%

TRAFFICKING, PRODUCTION 2010 2011 OR DISTRIBUTION Number Rate Number Rate 2010/2011 2001/2011 Cannabis 18,363 54 16,548 48 -11% -26% Cocaine 9,873 29 10,251 30 3% 37% Other Drugs 7,047 21 7,215 21 1% 41% total 109,222 320 113,164 328 3 14

year. Just as with alcohol prohibition in the early In 2011, police reported more 20th century, the profits flow untaxed into the than 113,100 drug crimes, of hands of unregulated, often violent, criminal which more than half (54%) profiteers.175 Banning drugs and relying on en- were for the possession of can- forcement-based supply-side approaches to dis- nabis. Between 2010 and 2011, courage their use has not stemmed the increase the rate of drug crime increased in drug use or the increase in drug supply. Despite slightly following an increase Canada’s significant investment in drug control of 10% between 2009 and 2010. efforts, drugs are cheaper and more available than These increases continue a ever.176 There is a growing consensus among inter- general trend that began in the national experts that drug prohibition has failed early 1990s. The increase in to deliver its intended outcomes, and has been drug crime in 2011 was driven counter-productive.177 by a 7% rise in the rate of police reported cannabis possession overall crime rates fall while offences. However, the rate of adult drug crime increases police reported incidents of trafficking, production and dis- Compared to the u.s. where drug crime is a main tribution of cannabis declined driver of incarceration, Canada can seem like a 11%. Similar to previous years, more compassionate place when it comes to drugs. British Columbia reported the But Canada has a record of increasing numbers of highest rate of drug offences drug crimes and high levels of incarceration due among the provinces. While to drug convictions. British Columbia was highest canadian drug policy coalition · cdpc 77

for cannabis offences, Saskatchewan reported prohibition and increasingly the highest rate of cocaine offences, with a 73% punitive policies have been increase in 2011.178 demonstrated to create harms that undermine public safety The rising trend in the rate of drug crime coincides and human rights.184 with a decreasing trend in the overall crime rate. In 2011, there were declines in most police report- In 2012, Canada’s federal ed offenses with the exception of homicide, sexual government passed and offenses against children, child pornography, enacted the Safe Streets and criminal harassment, impaired driving and some Communities Act (ssca). The drug offences. The overall police reported crime ssca introduces a wide variety rate has decreased 21.8% since 1998, from 8,915 per of changes including mandato- 100,000 to 5,756 in 2011, while police reported inci- ry minimum sentences for some dents of drug crime increased by 14% between 2001 drug crimes including produc- and 2011.179 tion, trafficking, importing and exporting. These changes apply Increases in police reported drug crime do not to drugs listed in both Schedule necessarily represent real increases in these I (i.e. heroin, cocaine, meth- crimes. Policing priorities can influence crime amphetamine) and Schedule rates especially when time, resources and pri- II (cannabis) of the Controlled orities permit police to focus their efforts on other Drugs and Substances Act. crimes.180 It is alarming that drug crime continues These changes also increase to rise while other crime declines in Canada. the maximum penalty for the production of cannabis from 7 Youth crime also fell in 2011 continuing a down- to 14 years, and add more drugs ward trend that has been apparent for a number to Schedule I including amphet- of years.181 These declines are explained by the en- amine type substances, which actment of the Youth Criminal Justice Act in 2003 will result in higher maximum which provided clear guidelines for the use of penalties for activities involving extrajudicial measures (i.e. informal sanctions.)182 these drugs. Courts can delay Regardless, there were still 172.9 (per 100,000 youth) imposing a sentence while an police reported incidents of cannabis possession in offender undergoes a drug treat- 2011 among youth 12 to 17 years old, equalling a ment program approved by the total of 4,208 young people.183 province under the supervision of the court.185 These changes safe streets and communities act: were passed despite extensive are we any safer? opposition. In particular, criti- cism of this legislation focused With the introduction of the National Anti-Drug on the approach to crime high- Strategy in 2007, the Conservative government lighted by these changes—a signalled its intention to “get tough” on drugs. reactive approach that focuses This approach means more public spending on on punishment after the fact, law enforcement and more severe penalties—ap- instead of a proactive approach proaches that have been shown to be ineffective that focuses on key issues like at reducing drug use and promoting pubic safety early learning and develop- in other places around the world. In fact, drug ment, overall health promotion, getting to tomorrow: a report on canadian drug policy 78

FIGURE 3: MANDATORY MINIMUM SENTENCES FOR SOME DRUG CRIMES

In 2012, the Conservative federal government • the production constituted a passed and enacted the Safe Streets and potential public safety hazard in Communities Act. This act amends the a residential area; Controlled Drugs and Substances Act (CDSA) to • the accused placed or set a trap apply mandatory minimum penalties for some drug offenses including production, trafficking, For example, mandatory possession for the purpose of trafficking, im- minimum sentences for porting and exporting; and possession for the cannabis would include: purpose of exporting. The mandatory minimum penalty applies where there is an “aggravating trafficking/possession factor”. According to information provided by for the purpose of traf- Canada’s Department of Justice, aggravating ficking—more than 3 kg factors are broken down into three categories: • 1 year, with Aggravating Factors List A 1. aggravating factors list a • 2 years, with Aggravating • for the benefit of organized crime; Factors List B • involving use or threat of violence; • involved use or threat of use of weapons; importing/exporting/ • by someone who was previously convicted of possession for the a designated drug offence or had served a term purpose of exporting of imprisonment for a designated substance —1 year offence in the previous 10 years; and, Production • through the abuse of authority or position or • 6–200 plants: 6 to 9 months; by abusing access to restricted area to commit maximum increased to 14 years the offence of importation/exportation and • 201–500 plants: 12 to 18 possession to export. months; maximum 14 years • More than 500 plants: 2 to 3 2. aggravating factors list b years; maximum 14 years • in a prison; • Oil or resin: 12 to 18 months • in or near a school, in or near an area normally frequented by youth or in the presence of youth; Adapted from: Canada. • in concert with a youth Department of Justice. 2011. • in relation to a youth (e.g. selling to a youth) Backgrounder: Safe Streets and Communities Act; In- 3. health and safety factors creased Penalties for Serious • the accused used real property that belongs to Drug Crimes. Available at: a third party to commit the offence; http://www.justice.gc.ca/ • the production constituted a potential security, eng/news-nouv/nr-cp/2011/ health or safety hazard to children who were in doc_32636.html the location where the offence was committed or in the immediate area; canadian drug policy coalition · cdpc 79

incarceration is costly ciples of proportionality and individualization and judges’ and the introduction of discretion to impose a just sen- mandatory minimum sentences tence after hearing all the facts in the individual case.189 A more only serves to increase these recent study warns that manda- costs. even very cautious tory minimum sentences have the potential to increase the estimates suggest that numbers of people in prison changes associated with the thus exposing more people for longer periods of time to in- Safe Streets and Communities creased potential for violence Act, including the imposition and an environment characterized by mental, emotional and of mandatory minimum physical degradation.190 sentences, will cost the The government’s own Depart- canadian federal government ment of Justice 2002 review of about $8 million and the the evidence concluded that mandatory minimum sentenc- provinces another es are “least effective in rela- $137 million. tion to drug offences” and that “drug consumption and drug related crime seem to be unaf- fected, in any measurable way, and community and economic development as a by severe mandatory minimum means to lower crime.186 sentences.”191 Putting people in prison does not reduce levels of Mandatory minimum sentences reduce the dis- harmful drug use or the supply cretion used by justice officials through the ap- of drugs. If it did, the United plication of predefined minimum sentences. The States—with the highest rates of imposition of mandatory minimum sentences incarceration in the world, the flies in the face of evidence of their ineffective- largest proportion of which is ness. Convicting people of drug-related offences attributable to drug offenses— does not reduce the problems associated with would have one of the lowest drug use nor do these sentences deter crime.187 levels of drug use and avail- The effects of mandatory minimum sentences ability. In fact, it has one of the include increases in the prison population in highest levels of use and a vast already overcrowded prisons, increases in the and increasing supply of illegal costs to the criminal justice system; the removal drugs.192 In the u.s. where man- of judicial discretion; failure to deter drug crimes; datory minimum sentences and a number of well-documented consequences have been instituted, the results on already marginalized populations.188 As the have been disastrous. Moreover, Canadian Bar Association notes, mandatory although rates of drug use and minimum sentences subvert important aspects selling are comparable across of Canada’s sentencing regime, including prin- racial and ethnic lines, blacks getting to tomorrow: a report on canadian drug policy 80 and Latinos are far more likely prison overcrowding is to be criminalized for drug law already a reality violations than whites.193 Canada’s federal prison system is already se- Incarceration is costly and the verely overcrowded, leading to increasing volatil- introduction of mandatory ity behind bars. In the two-year period between minimum sentences only serves March 2010 and March 2012, the federal in- to increase these costs. Even very custody population increased by almost 1,000 cautious estimates suggest that inmates or 6.8%, which is the equivalent of two changes associated with the large male medium security institutions. As of Safe Streets and Communities April 1, 2012 more than 17% of people in Canada’s Act including the imposition of prisons are double-bunked.198 This increase has mandatory minimum sentenc- occurred even before the imposition of mandatory es will cost the Canadian federal minimum sentences, which will stress Canada’s government about $8 million incarceration system even further.199 and the provinces another $137 million. These estimates fly in To accommodate increases in Canada’s prison the face of the federal govern- population, the federal government plans to add ment’s claim that these changes 2,700 cells to 30 existing facilities at a cost of would not cost anything.194 A $630 million. It also plans to close three federal study by the Quebec Institute for facilities as part of its budget reduction plan. These Socio-economic Research and closures will affect 1,000 people who will need to Information suggests that the be relocated including 140 residing at the Ontario costs for the provinces will be Regional Treatment Centre, a stand-alone facility much higher due to increases in at Kingston Penitentiary. the prison population—$1,676 million.195 Already expenditures As of April 2011, 21% of federal offenders were on federal corrections have serving a sentence for a drug crime. And 55% increased to $2.375 billion in of people incarcerated in federal prisons have 2010-11, a 43.9% increase since problems with substance use.200 Despite this 2005-06. The annual average clear need for in-prison treatment, prison-based cost of keeping a federal inmate substance use programming is also in decline; the behind bars has increased Correctional Service of Canada’s budget for these from $88,000 in 2005-06 to over programs fell from $11 million in 2008-09 to $9 $113,000 in 2009-10. In contrast, million in 2010-11.201 the daily average cost to keep an offender in the community is Programs and other services inside prison that $80.82 or $29,499 a year.196 Given help inmates transition to life after prison are also these soaring costs, Canada’s either in decline or plagued by lack of available Correctional Investigator, resources. For instance the government cancelled Howard Sapers has suggested the safer tattooing initiative in prisons in 2006 that, “at a time of wide-spread despite the effectiveness of such programs in budgetary restraint, it seems curbing the spread of hiv and hcv.202 The passage prudent to use prison sparingly, of the Safe Streets and Communities Act follows on and as the last resort it was in- these and other moves by the federal government tended to be.”197 that make prisons less safe and reduce the discre- canadian drug policy coalition · cdpc 81

tion of the judicial system in developing appropri- than 55% of the total prison ate sentences for individuals convicted of drug population at Saskatchewan crimes. This program recognized that tattooing Penitentiary and 60% at Stony takes place inside prison walls and that sharing Mountain Penitentiary in of used equipment could potentially result in hiv Manitoba. Provincial rates and hcv infections. The Canadian Correctional are even worse; 81% of people Service’s own evaluation of the program found in provincial custody in positive results including: infectious disease pre- Saskatchewan were Aboriginal vention practices; potential to reduce exposure in 2005.206 A 2004 study of in- to health risks and enhance the safety of staff carceration in Canada found members, inmates and the general public; addi- that visible minority offenders tional employment opportunities for inmates in are incarcerated more often for the institution; and work skills that are transfer- drug related offences than white able to the community.203 offenders despite having less extensive criminal histories than prison sentences are inequitable white offenders.207 The reasons for the overrepresentation of As the u.s. experience shows, the brunt of manda- Aboriginal people in Canada’s tory minimum sentences will be borne by people prisons are multifaceted and who are drug dependent, and not those involved have to do with root historical in the higher levels of drug selling and produc- causes discussed earlier in this tion. Indeed, individuals who sell drugs at the report. street level are more often than not involved in tasks such as carrying drugs and steering buyers A 2013 report by the bc Provincial towards dealers; real profiteers in the drug market Health Officer warns that recent distance themselves from visible drug-trafficking changes to sentencing and activities and are rarely captured by law-en- other justice practices brought forcement efforts.204 These findings undermine about by the enactment of the the ‘tough on crime’ approach touted by those Safe Streets and Communities in favour of mandatory minimum sentencing. Act will be extremely impact- In fact, recognizing the high financial and social ful on Aboriginal people. These costs of mandatory minimum sentences, as well changes will put Aboriginal as their widespread failure, the states of New York, people at greater risk for in- Michigan, Massachusetts and Connecticut, have carceration and the resulting repealed these sentences for non-violent drug consequences of incarceration, crimes, with other u.s. jurisdictions set to follow.205 including lack of access to cul- The overrepresentation of Aboriginal Canadians turally safe services that support in this country’s prison system is a national dis- healing and reintegration.208 grace, made all the more disturbing by its avoid- This report also notes that the ability. In 2011, approximately 4% of the Canadian ssca appears to conflict with population was Aboriginal, while 21.5% of the other federal programs aimed at federal incarcerated population were Aboriginal. reducing prison time, specifical- Since 2006-06, there has been a 43% increase in ly section 718.2(e) of the Criminal Aboriginal inmate population, and one in three Code which requires sentencing federally sentenced women are Aborignal. In judges to consider all options the Prairies, Aboriginal people comprise more other than incarceration.209 getting to tomorrow: a report on canadian drug policy 82

An October 2012 report by the offenders and greater access to more culturally- Correctional Investigator of appropriate services and programming were Canada entitled, Spirit Matters: original hopes when the ccra was proclaimed Aboriginal People and the in November 1992.”212 The report concludes by Corrections and Conditional calling on the csc to ensure that the provisions of Release Act (ccra, 1992) echoed the Act are implemented in good faith. these concerns.210 This report speaks to the lack of resolve The implications for Canadian drug policy are on the part of the Correctional clear: rising rates of incarceration of Aboriginal Service of Canada (csc) to meet people, higher rates of substance use problems the commitments set out in the combined with a lack of commitment to alterna- ccra. Sections 81 and 84 of this tive healing paths means more federally and Act were meant to help miti- provincially sentenced Aboriginal people will not gate the over-representation receive the services they need. of Aboriginal people in federal prison, and to provide a healing the failures of prohibition path based on cultural and spiritual practices. Included among Rather than reducing the supply of drugs, prohi- these requirements was the es- bition abdicates the responsibility for regulating tablishment of Healing Lodges drug markets to organized crime groups. Though that emphasize Aboriginal Canada’s rate of incarceration in 2011 was 117 beliefs and traditions and focus per 100,000 people, a moderate rate compared to on preparation for release.211 many other nations in the world (e.g. U.S at 730 and the Switzerland at 79)213 there are demon- The report found that in bc, strable ways in which public safety is undermined Ontario, Atlantic Canada and by a strictly prohibitionist approach to drugs: the North there were no Section 81 Healing Lodge spaces for Increases in Violence: Because of the lack of formal Aboriginal Women. In addition, regulation used in the legitimate economy, vio- because Healing Lodges limit lence can be the default regulatory mechanism in intake to minimum-security the illicit drug trade. It occurs through enforcing offenders 90% of Aboriginal payment of debts, through rival criminals and offenders were excluded from organizations fighting to protect or expand their being considered for a transfer market share and profits, and through conflict to a Healing Lodge. The report with drug law enforcers. In Canada, gang violence concludes with a critique sometimes results from turf wars over control of the lack of action by the of illegal drug markets. A “get tough” approach Correctional Service of Canada: to crime assumes that more enforcement will “Consistent with expressions of eliminate the problem of gang violence. But as a Aboriginal self–determination, comprehensive review by the International Center Sections 81 and 84 capture the for Science in Drug Policy states: “Contrary to the promise to redefine the relation- conventional wisdom that increasing drug law ship between Aboriginal people enforcement will reduce violence, the existing sci- and the federal government. entific evidence strongly suggests that drug prohi- Control over more aspects of bition likely contributes to drug market violence release planning for Aboriginal and higher homicide rates.”214 Indeed the demand canadian drug policy coalition · cdpc 83

for drugs means that as soon as one dealer is of medical cannabis programs removed others are there to take their place. in Canada has been repeatedly thwarted by the prohibited Creation of unregulated drug markets: Drug poli- status of this drug despite evi- cies that prohibit some substances actually elimi- dence that shows it has benefi- nate age restrictions by abandoning controls to cial effects for many patients.219 an unregulated market. In addition, when we prohibit rather than regulate substances, it becomes Punitive approaches do not limit impossible to control the purity and strength of use: Comparisons between drugs. Illegally produced and supplied drugs are states or regions show no clear of unknown strength and purity, increasing the correlation between levels of risk of overdose, poisoning and infection.215 drug use and the toughness of laws and penalties,220 nor do Substance displacement: As the United Nations studies tracking the effects of Office on Drugs and Crime reports, if the use of changes in policy show that drug one drug is controlled by reducing supply, suppli- use increases—for example if ers and users may move on to another drug with new laws decriminalising pos- similar psychoactive effects, but less stringent session are introduced.221 In controls.216 For example, studies of the effects of short, any deterrence is at best banning mephedrone (a cathinone analogue) marginal compared to the wider in the U.K. suggest that people who used this social, cultural and economic drug before the ban either continued their use, factors that drive up levels of or switched back to prohibited substances like drug use. ecstasy and cocaine, both of which are unregulated and thus of unknown purity and strength.217 Criminalization increases the Market displacement: Studies suggest that geo- negative effects of drug use: The graphically specific enforcement practices tend reality is that making some to displace drug markets to other locations rather drugs illegal does not stop than eliminate them.218 These findings raise people from using substances serious concerns about the capacity of law en- as is evident from the United forcement strategies to completely eliminate drug Nations data demonstrating supply. increasing levels of drug use over the past three decades.222 Medical applications: The complete prohibi- Criminalization of substance tion of some substances curtails their potential use further stigmatizes people medical uses and benefits, as well as research who use drugs, making it more into potential beneficial applications of controlled difficult to engage people in substances. An example is the use of pharmaceu- health care and other services. tical-grade heroin to treat individuals for whom Criminalization also increases other treatments have not worked. The findings of marginalization and encourag- a Canadian trial of heroin-assisted treatment—the es high-risk behaviours among North American Opiate Medication Initiative people who use drugs, such as (naomi) study conducted in Vancouver, bc and injecting in unhygienic envi- in Montreal, qc – were positive. Yet the continued ronments, poly-drug use and prohibition of heroin hinders the use of this drug binging. Evidence from other in treatment settings. Indeed the implementation countries suggests the stigma getting to tomorrow: a report on canadian drug policy 84

FIGURE 4: CANNABIS INCIDENTS REPORTED BY THE POLICE IN 2011

380 import & export

5,280 production

10,898 trafficking

61,406 possession

Source: Statistics Canada. Table 252-0051—Incident-based crime statistics, by detailed violations.

and fear of arrest deter people Despite the well-documented failures of prohibi- from seeking treatment, and it tion, Canada still pursues a strictly prohibitionist is more effective to divert users approach to many drugs and has in fact, scaled-up into treatment without harming this approach in recent years. their future prospects with a criminal record for drug use.223 cannabis as a case in point

Trying to manage drug use Numerous drug use surveys in Canada report that through incarceration diverts next to alcohol and tobacco, cannabis is the most law enforcement away from often used substance. Cannabis control policies, efforts to improve community whether harsh or liberal, appear to have little or safety with crime prevention no impact on the prevalence of its consumption.225 programs. Funding prisons and Though heavy use of cannabis can have negative police also takes away precious health impacts, the overall public health impacts resources from services like of cannabis use are low compared with other illicit adequate housing and family drugs such as opioids or with alcohol, especially income, and robust educational given that risk of overdose is very low, as is the risk programs, all of which have from cannabis-related accidents.226 A review of the potential to address the the harms of various substances published in the root causes of crime.224 None highly respected medical journal The Lancet found of these strategies is at the that alcohol was the most potentially harmful drug forefront of the approach taken over even heroin and cocaine. Of the 20 drugs as- by Canada’s current federal sessed by this study cannabis was ranked at eight government. in terms of harmfulness behind most major illegal substances.227 canadian drug policy coalition · cdpc 85 FIGURE 5: CANNABIS POSSESSION, INCIDENT AND CHARGE RATE, 2001 - 2011

200 possession incident 180 rate per 100,000 160 population 140 120 rate, total persons 100 charged per 100,000 80 population aged 12 years and over 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Source: Statistics Canada, Table 252-0051 —Incident-based crime statistics, by detailed violations, annual.

In addition, police reports suggest that Canada possession of cannabis, a rate has a robust underground cannabis industry. For of 178 per 100,000 population example, the rcmp reported that in 2009, police for the whole of Canada. Police agencies seized a total of 34,391 kilograms of can- reported incidents of cannabis nabis and 1,845,734 cannabis plants. Police drug possession are far higher than seizures only tell us part of the story. The most any other illegal drug (21 for recent estimates of the size of the underground cocaine possession and a rate cannabis economy in Quebec peg it at 300 tonnes of 30 for all other illegal drugs in 2002; in bc estimates of the size of the economy combined). Indeed, police re- suggest it could reach as high as $7 billion annu- ported incidents of cannabis ally.228 A recent study estimated that annual retail possession have increased 16% expenditures on cannabis by British Columbians between 2001 and 2011. Of was $407 million and daily users accounted for these police reported incidents, the bulk of the cannabis revenue, with a median 28,183 were charged for posses- estimated expenditure of approximately $357 sion of cannabis in 2011.231 million.229 A recent study in British These data suggest that cannabis remains a Columbia suggests that charges popular drug, but the potential financial benefits for possession of cannabis in bc of a regulated and taxable product like cannabis have doubled between 2005 and are completely lost to the federal and provincial 2011 despite low public support treasuries.230 In addition, the costs of criminal- for the imposition of a criminal izing cannabis including policing, courts and conviction for this conduct. This corrections are borne by governments and study also found that charges Canadian taxpayers. In 2011 for example, there for cannabis possession vary were 61,406 incidents reported to police involving considerably between police getting to tomorrow: a report on canadian drug policy 86 departments and between applying for an Authorization to Possess through municipal police and rcmp Health Canada. The elimination of the very cum- detachments. The rcmp are bersome application process and the addition responsible for an overwhelm- of nurse practitioners as authorized health care ing majority of the charges in practitioners prescribers are welcome moves. bc. The study’s author conser- But in Canada too few physicians currently know vatively estimates that it costs enough about the benefits and risks of cannabis about $10 million annually in for medical purposes to make sound medical bc alone to enforce criminal judgments and recommend it to their patients, prohibition against cannabis nor are enough physicians sufficiently aware of possession. Given the relatively the appropriate use of cannabis for medical pur- low impact cannabis has on poses.236 More education of physicians is needed public health compared to other to ensure that patients will have adequate access drugs, and the significant limi- to the program. In the meantime, Health Canada tations placed on people with must take proactive steps to establish fair and criminal convictions (employ- timely access to the program. ment and travel restrictions), the study’s author suggests The proposed mmpr will also eliminate the that our current policies likely Personal Use Production Licenses (pupl) and do more to undermine collec- thus the ability of people to grow their own can- tive respect for the law and law nabis. This is of concern for several reasons. enforcement, than they do to Many people choose to produce their own supply protect public health.232 because current prices of available cannabis are prohibitive.237 Producing their own also enables changes to canada’s them to select the strain(s) that work best for medical cannabis them. Health Canada’s proposal to centralize access program the cultivation of cannabis for medical purposes in the hands of licensed commercial producers The federal government has will increase the costs substantially as stated in operated a Medical Marihuana the Regulatory Impact Analysis Statement which (Sic) Access Program since 2001 accompanies the proposed mmpr.238 The elimina- prompted by court rulings that tion of the pupl responds to concerns expressed upheld the right to access can- by law enforcement and others about the cultiva- nabis for serious and chronic tion of medical cannabis in residential homes.239 medical conditions.234 That Rather than eliminating this option, the mmpr program is currently undergo- could address these concerns through routine in- ing a major overhaul and in spections and certification of home gardens. December 2012, the federal government released a set of pro- The proposed regulations also exclude currently posed new regulations for the existing medical cannabis dispensaries in the supply program.235 The Marihuana for and distribution system. These dispensaries play a Medical Purposes Regulations key role in disseminating information about can- (mmpr) will require patients nabis, and they offer a range of cannabis strains, to obtain a prescription-like products and services such as peer counseling and document from a physician or referrals to other services. Including medical can- nurse practitioner, rather than nabis dispensaries in the distribution system would canadian drug policy coalition · cdpc 87

address some of the barriers to Motion Passed at the 2012 access to cannabis for medical Conference of the Union of British purposes that Canadians currently experience. Columbia Municipalities

If the goals of our current laws WHEREAS marijuana prohibition is a failed policy are to reduce cannabis produc- which has cost millions of dollars in police, court, jail tion and consumption clearly and social costs; AND WHEREAS the decriminaliza- these laws are not effective. tion and regulation of marijuana would provide tax Young people in Canada use revenues: THEREFORE BE IT RESOLVED that UBCM cannabis extensively (depend- call on the appropriate government to decriminalize ing upon the province, 30% to marijuana and research the regulation and taxation 53% of grade 12 students report- of marijuana. ed using cannabis during their lifetime).240 In fact, a recent Recent polls also suggest that a majority of report from unicef suggests Canadians are prepared to legalize and regulate that Canada has the highest rate cannabis (57%). In British Columbia, 77% of re- of youth cannabis use among spondents to a poll indicated support for cannabis developed countries, but one law reform.243 They are not alone. In an effort to of the lowest rates of tobacco stem the damage that underground drug markets use.241 Yet there are no regula- create, leaders in Central and South America have tory controls such as age restric- called for changes to the way cannabis is regulated. tions on cannabis as there are In 2011, the Global Commission on Drug Policy on tobacco. Nor can purchasers encouraged governments to experiment with the reliably determine the dose (i.e. regulation of cannabis with the goals of safeguard- level of thc) or the origin of this ing health and safety of all citizens.244 substance. When it comes to tobacco use, a regulatory system alternatives to prohibition: that includes age restrictions on what are they? purchase, prohibiting lifestyle marketing, and focusing on It is time to consider an approach that helps to clean air initiatives has been ef- contain the negative effects of drug use, provides fective in making Canada safer a variety of treatment modalities and harm reduc- and healthier. Recognizing the tion services, and avoids criminalizing those who unique challenges presented by choose to use drugs. cannabis policies, and the potential of a public health regula- New models for addressing drug related prob- tory framework to control the lems are also emerging across the globe. In fact, use and availability of this drug, in 2012 and 2013 the international consensus on the Union of British Columbia prohibition seems to be coming apart. Countries municipalities recently en- are beginning to experiment with approaches dorsed a motion to encourage that show more promise for achieving the health the BC provincial government and safety goals for their communities. At least 25 to support the decriminaliza- jurisdictions around the world are currently de- tion and regulation of cannabis. ploying some form decriminalization of drugs.245 Portugal, Uruguay, Guatemala, Colombia, the getting to tomorrow: a report on canadian drug policy 88

one of the key priorities of legislation to do the same has been introduced in eight other the cdpc is to eliminate the state legislatures. These events criminalization of drug use. follow on a long history of decriminalization of cannabis drug use is a health, not a including the Dutch coffee shop criminal matter, and should model, and the decriminalization of cannabis in several be treated as such. prohibition Australian and u.s. states. One does not deliver on its of the key priorities of the cdpc is to eliminate the criminaliza- intended goals, but it does tion of drug use. Drug use is a result in the marginalization health not a criminal matter and should be treated as such. of whole groups of people Prohibition does not deliver on and, in some cases, its intended goals, but it does result in the marginalization of their deaths. whole groups of people and in some cases their deaths.

Czech Republic, as well as some U.S. states, are Canada has contributed some among the jurisdictions experimenting with either of the best thinking in the decriminalization or legal regulation of some world when it comes to offer- drugs. Portugal decriminalized all illegal drugs ing alternatives to prohibition. in 2001. The Czech Republic has ventured down Since 1998, the Health Officers this same road. The Czech Republic decided to Council of British Columbia has decriminalize all drugs in 2010 after undertaking created a series of discussion a cost-benefit analysis of their policies that found papers that recommend an end that despite drug prohibition, 1. Penalization of to prohibition and its replace- drug use had not affected the availability of illegal ment with a regulated market drugs; 2. Increases in the levels of drug use had for all substances based on the occurred; 3. The social costs of illicit drugs had in- principles of public health.247 creased considerably. After decriminalization and The latest of these papers pub- similar to Portugal, drug use has not increased lished in 2011 describes how significantly but the social harms of drug use have public health-oriented regula- declined. In Portugal decriminalization has had tion of alcohol, tobacco, pre- the effect of decreasing the numbers of people scription and illegal substances injecting drugs, decreasing the number of people can better reduce the harms that using drugs problematically, and decreasing trends result both from substance use of drug use among 15 to 24 year olds.246 and substance regulation, compared to current approaches. In Uruguay legislators are considering a proposal A model for legalizing and to create a legally regulated and state controlled regulating cannabis draws on a regime for cannabis. In November 2012, the u.s. public health approach which states of Washington and Colorado voted to create includes price controls through regulated markets for cannabis for adults, and taxation, restriction of advertis- canadian drug policy coalition · cdpc 89

FIGURE 6: THE PARADOX OF PROHIBITION

illegal market legalize/ gangsterism promote Supply & Demand Social & Health Problems

Prohibition Public Health Legalize & Promote Defacto Regulation Legalize Decriminalization with Many Restrictions Decriminalization Preescription

Adapted from: Health Officer’s Council of BC, 2011

ing and promotion, controls on age of purchaser, the point where a substance is driving restrictions, limited hours of sale, labeling available in a regulated market that contains information on potency and health with appropriate age and other effects, plain packaging and licensing guidelines controls and appropriate pro- for producers of cannabis. Taxation has been grams that address the harms shown to decrease levels of alcohol and tobacco and benefits of substance use. use; similar approaches could be taken to cannabis to balance the need to limit use but avoid re- This discussion paper draws creating an illegal market for contraband.248 The U on a strong evidence base and curve depicted (Figure 6) illustrates the relation- focuses on the prevention of ship between how we control or regulate drugs illness, injury, and mortality. As and what happens to supply and demand. The left the image above illustrates, this hand of the curve shows what happens when a paper recognizes that careful substance is fully prohibited and thus controlled thought must be put into all by an underground market. The right side of the aspects of a regulatory model curve similarly depicts what happens when a sub- for drugs. It also recognizes that stance is legalized and promoted without regard changing how we control sub- for public health impacts. From the perspective of stances requires a robust gov- public health, the ideal mode of regulation sits in ernmental response to provide the middle of the curve at its lowest point. This is adequate health care and other getting to tomorrow: a report on canadian drug policy 90 supports. In particular, a public The wrcpc facilitated the Waterloo Region health approach proposes that Harm Reduction Network in 2005 and later, the supply chain for drugs the Ontario Network of Municipal Drug Strat- would be under comprehen- egy Coordinators. The wrcpc established the sive societal control in order to “KW Drug Users Group” as a safe place for maximize control over avail- people who use illicit drugs to meet and talk ability and accessibility and with each other about important issues. At any reduce consumer demand. 249 level, change always starts with dialogue. In the absence of interest from any sector, the wrcpc undertook primary research on the extent and typology of accidental drug overdoses, the third cause of accidental death in Ontario. They sub- CASE STUDY sequently facilitated the establishment of Waterloo Crime Preventing Overdose Waterloo Wellington (poww), a unique peer and service provider Prevention Council effort to train citizens and providers in overdose prevention and intervention. In 2012, the wrcpc published “Between Life and Death: Barriers to The Waterloo Region Crime Calling 9-1-1 During an Overdose Emergency”, Prevention Council (wrcpc) a report unique in Canada which demonstrates has been a Canadian model a clear reluctance of od witnesses to call 9-1-1, for crime prevention through primarily out of fear of police attendance. social development since 1995. The Council’s mission is to prevent and reduce crime, fear of crime and victimization— and always in partnership with community, including those most affected by program/ policy design and delivery.

The wrcpc addresses the root causes of crime, fear of crime and victimization by acting as a catalyst, educator, connec- tor, resource and supporter through evidence-informed practice and the wisdom of local community. For several years the Council has been involved with community and systems-wide issues related to alcohol, prescription and currently illicit substance use. canadian drug policy coalition · cdpc p.93 The International Drug Control System p.93 Change is in the Wind p.94 The Global Drug Policy Commission and the Vienna Declaration p.95 Canada is Falling Behind on an International Stage getting to tomorrow: a report on canadian drug policy 92

SECTION EIGHT

Canada On An International Stage canadian drug policy coalition · cdpc 93

the international states for policy developments it considers to be drug control system inconsistent with the international treaties.

As in Canada, policies and Recently the Board voiced its concern about laws that prohibit and punish the outcome of referenda in Washington and the use of certain substances Colorado that effectively legalized simple posses- have been the mainstay of the sion of cannabis by adults.251 And in its most recent international approach.250 The report, the incb chastised the Canadian Supreme current United Nations drug Court for ruling in favour of the Insite, Vancouver’s control system is based on in- Supervised Injection facility. The incb takes the ternational treaties including position that supervised injection facilities con- the 1961 Single Convention on travene the international drug control conven- Narcotic Drugs, the 1971 un tions, despite their excellent record of preventing Convention on Psychotropic the harms of drug use.252 Drugs and the 1988 Convention Against Illicit Traffic in Narcotic These comments by the incb reflect its support for Drugs and Psychotropic harsh policing and its tendency to use its reports Substances. This drug control as a mechanism to criticize states that deviate system requires member states from repressive and supply-oriented international to take measures to prevent the drug policies. While criticizing innovative and ef- non-medical use of a wide range fective public health programs, the incb overlooks of drugs through restrictions on the most heinous and repressive of drug policy production and supply and by developments around the globe including human suppressing demand for drugs. rights abuses. Drug control cannot operate in Canada participates in inter- isolation from international law including human national forums and agencies rights law; nor can it be unconnected from the that monitor the implementa- concerns of public health or medical ethics.253 tion of these treaties including the Commission on Narcotics change is in the wind Drugs and the International Narcotics Control Board (incb). But despite these international bodies, the current One of the key problems with system of drug control is under considerable pres- international drug control is sure to change. Some national governments have that bodies involved in shaping begun to chart their own paths when it comes to drug policy like the incb have drug control. Some countries do not suppress historically emphasized law socially and culturally embedded uses of con- enforcement and operate in iso- trolled drugs like cannabis, opium and coca leaf lation from the un agencies that chewing. Other governments have introduced deal with the health and social pragmatic measures based on public health that consequences of drug markets focus on reducing the harms associated with (who, World Bank, unaids, drugs (i.e. needle exchanges, etc.) And a number undp) and the un bodies that of governments have introduced de-penalization focus on human rights issues. or decriminalization of some or all drugs to move The incb for example, operates away from the mass incarceration of people who as a guardian of drug prohibi- use drugs.254 tion and chastises member getting to tomorrow: a report on canadian drug policy 94

2012 was a monumental year for on countries to end the criminalization, margin- drug policy reform around the alization and stigmatization of people who use world. Cannabis legalization drugs but who do no harm to others and called for is now a reality in the U.S. with wide-ranging changes in drug policies. Some of the passing of voter initiatives in these recommendations include: experiment with Colorado and Washington State. models of legal regulation of drugs to undermine Sitting politicians are beginning the power of organized crime; make available a to speak out and call for dia- variety of approaches to health, harm reduction logue on alternative approach- and treatment services; abolish abusive practices es. Leaders throughout Latin associated with treatment such as forced deten- America have begun to openly tion; invest in effective prevention activities that denounce the war on drugs and avoid simplistic ‘just say no’ messages and ‘zero table reforms. The Organization tolerance’ policies in favour of educational efforts of American States has begun grounded in credible information and programs a formal review process of the that focus on social skills and peer influences; hemisphere’s drug policies. focus repressive actions on violent criminal or- There is an emerging consensus ganizations, to undermine their power and reach that the global war on drugs while prioritizing the reduction of violence and has been a catastrophic failure. intimidation; and replace drug policies and strate- Nowhere has this been made gies driven by ideology and political convenience more evident than with the with fiscally responsible policies and strategies situation in Mexico, where the grounded in science, health, security and human drug war has claimed the lives rights. 256 of 40,000 people over the past six years.255 In 2010 the International aids Conference endorsed the Vienna Declaration. The Declaration the global commis- affirms the body of research that demonstrates sion on drug policy that the criminalization of drugs and enforcement and the vienna efforts at the international and national level are declaration costly and ineffective when it comes to curbing substance use. The Declaration also outlined the One of the key events that helped unintended consequences of drug law enforce- turn the tide was the release of ment and the criminalization of people who use the Global Commission on Drug drugs including rising rates of hiv, the under- Policy’s first report in June 2011. mining of public health approaches to substance The 19-member panel, includ- use, and human rights abuses among others. ing current and former heads of The Vienna Declaration has been endorsed by state and former United Nations thousands of people and organizations including Secretary General Kofi Annan the Canadian Public Health Association and the among others, and Canada’s Urban Public Health Association, which repre- Louise Arbour, criticized global sents the medical health officers of Canada’s 18 prohibition and recommended largest cities.257 that policies be based on evidence of what works to protect the health and safety of citizens. The Global Commission called canadian drug policy coalition · cdpc 95

canada is falling canada also opposed the recent behind on an international stage un resolution to hold a special session on drug policy globally, Meanwhile, Canada’s federal now scheduled for 2016. the government, once a leader in the field of drug policy, has fallen resolution was co-sponsored by behind and embraced punitive 95 countries including countries policies, such as mandatory minimums for drug offences, in latin america and the which have already proven to caribbean and in the european be ineffective in curbing drug use and detrimental to society union, as well as japan, china, at large. Despite evidence to the australia, and the united states. contrary, Canada is continuing to address the harms of its large underground drug economy by expanding a war on drugs approach that other countries are Three federally funded reports, the 1973 Le Dain beginning to question. Commission, the Report of the Senate Special Committee on Illegal Drugs and the House of Canada possesses a wealth of Commons Special Committee on Illegal Drugs public health expertise, drug report, have all recommended various versions of researchers, scientists and ac- drug policy reform.258 But since 2006, Canada has tivists to help lead the country ceased to be a leader in innovative drug policies toward a more humane and just on an international stage. drug policy. Unfortunately this expertise has not translated into Canada on the International Stage: On an international policy. Despite signs national stage, Canada recently expressed its op- of progress in other countries, position to Bolivia’s reservation to the 1961 Single Canada’s approach to drug Convention on Narcotic Drugs. In 2011, Bolivia policy has taken significant proposed an amendment to article 49, deleting steps backwards since 2006. the obligation that “coca leaf chewing must be Before that time, the Canadian abolished.” The coca leaf has been chewed and government participated in the brewed for tea for centuries in the Andean region growing movement towards re- and produces a mild stimulant effect similar to forming drug policy to incorpo- caffeine. Without any objections, Bolivia’s request rate a public health approach. In would have been approved automatically. When the past, Canada attempted to its attempt to amend the Single Convention failed decriminalize minor cannabis in 2011, Bolivia left the Convention with the intent possession and supported some to rejoin with a new reservation designed to align innovative harm reduction and its international obligations with its constitution, treatment programs for injec- which protects indigenous rights including the tion drug users, including su- right to chew coca leaves.259 Coca chewing is part pervised consumption services of traditional and Indigenous practice in Bolivia and heroin-assisted treatment. and has many important social and health ben- getting to tomorrow: a report on canadian drug policy 96 efits. With the support of 169 Canada’s increasing involvement in the war on countries Bolivia re-entered drugs: Canada, has also scaled up its involvement the Convention in 2013 with in drug enforcement around the world. the reservation in place, though the exportation of coca inter- Since 2006, the Canadian Forces have joined with nationally remains prohibited. other countries in an unprecedented increase Only 15 countries objected to in military involvement in drug interdiction in Bolivia’s reservation, including Latin America. Canada, for example, participates Canada.260 Bolivia’s actions are in ongoing counter-narcotics missions in the part of a rising tide of efforts to Caribbean Sea and the eastern Pacific. Canadian assert unique national perspec- warships and aircraft have acted as eyes and ears tives on the regulation of drugs for the U.S.-led Joint Interagency Task Force— and to affirm respect for tradi- South (jiatf-s) to prevent transport of drugs and tional Indigenous use of these money by air and sea between South America, substances. Central America, the Caribbean islands and North America.262 Canadian military aircraft and war- Canada also opposed the recent ships have been involved in interdiction efforts un resolution to hold a special in the Caribbean Sea including assisting the u.s. session on drug policy glob- Coastguard to board vessels and seize illegal ally, now scheduled for 2016. The drugs. Canadian military aircraft have been in- resolution was co-sponsored by volved in surveillance sorties in the region.263 95 countries including countries in Latin America and the These moves signal a renewed emphasis on a re- Caribbean and in the European pressive approach both at home and internation- Union, as well as Japan, China, ally.264 The rationale for the Canadian military’s Australia, and the United involvement in the war on drugs is built on a series States.261 This resolution was of faulty premises. Firstly—that military might initially brought forward by the and securitization can defeat drug cartels. One leaders of Mexico, Colombia need only look to Mexico, which saw an explosion and Guatemala, three countries in violence after President Calderón declared war suffering some of the worst on the drug cartels in 2006, to see how woefully harms of global drug policies dangerous an idea this is. Secondly, regardless of that focus on enforcement to the the Canadian military’s interdiction efforts, the exclusion of human rights and supply of illegal drugs to Canadian consumers has health concerns. Support for remained the same. As with all attempts over the this resolution was an acknowl- last forty-plus years to control the flow of narcot- edgement of a deepening crisis ics into Canada, as long as a demand exists, the in the hemisphere. Canada’s supply will continue. No counter-narcotic activity, refusal to support this resolu- no matter how costly or logistically sophisticated, tion signals its approach: to keep has ever managed to halt the flow of drugs across to the status quo and to refuse Canadian borders. to acknowledge that a vigorous discussion about the harms of Given Canada’s unique geopolitical position, it is drug prohibition is taking place time for Canada to again become a global leader around the globe. in drug policy reform. canadian drug policy coalition · cdpc 97 list of acronyms

· BBV Blood-borne virus · CADUMS Canadian Alcohol and Drug Use Monitoring Survey · CCRA Corrections and Conditional Release Act · CDSA Controlled Drugs and Substances Act · CND UN Commission on Narcotic Drugs · CSC Correctional Service of Canada · CCSA Canadian Centre on Substance Abuse · DOCAS Drugs and Organized Crime Awareness Service (RCMP) · DTC Drug Treatment Court · HCV Hepatitis C virus · HAT Heroin-Assisted Treatment · HIV Human Immunodeficiency Virus · INCB International Narcotics Control Board · MDMA Methylenedioxymethamphetamine (sometimes known as ecstasy though ecstasy does not necessarily contain MDMA) · MMT Methadone Maintenance Therapy · NADS National Anti-Drug Strategy · NNDAP National Native Alcohol and Drug Abuse Program · RCMP Royal Canadian Mounted Police · SSCA Safe Streets and Communities Act · TDS Toronto Drug Strategy · UNODC United Nations Office on Drugs and Crime · VANDU Vancouver Area Network of Drug Users · WRCPC Waterloo Region Crime Prevention Council · WHO World Health Organization getting to tomorrow: a report on canadian drug policy 98 notes

1 National Treatment Strategy Working Group. 2008. A 10 Loppie, C, and Wien, F. 2009. Health Inequities and Social Systems Approach to Substance Use in Canada: Recommenda- Determinants of Aboriginal Peoples Health. Victoria: National tions for a National Treatment Strategy. Available at: http:// Collaborating Centre for Aboriginal Health. Available at: www.nationalframework-cadrenational.ca/uploads/files/ http://www.nccah-ccnsa.ca/docs/nccah%20reports/Lop- TWS_Treatment/nts-report-eng.pdf, p. 9. pieWien-2.pdf

2 For examples of this work see: Canadian Centre on Sub- 11 cadums, 2011. Table 2: Main 2011 cadums Indicators by stance Abuse (ccsa), 2012. National Alcohol Strategy: Reduc- Province—Drugs. Available at: http://www.hc-sc.gc.ca/ ing Alcohol-Related Harm in Canada. Available at: http://www. hc-ps/drugs-drogues/stat/_2011/tables-tableaux-eng.php#t2 ccsa.ca/Eng/Priorities/Alcohol/Pages/default.aspx cadums, 2011. Table 1: Main 2011 cadums Indicators by Sex and Age. – Drugs. Available at: http://www.hc-sc.gc.ca/hc-ps/ 3 Statistics Canada reports that in 2010, 13% of Canadian drugs-drogues/stat/_2011/tables-tableaux-eng.php#t1 households used a cell phone exclusively and 50% of house- 12 holds in the 18-to-34 age bracket were using only cell phones, Ibid. Table 2. up from 34% two years earlier. See: http://www.statcan. 13 Fischer, B, Bibby, M. Argento, M., Kerr, T., Wood, E. 2012. gc.ca/daily-quotidien/110405/dq110405a-eng.htm; Shield, “Drug Law and Policy in Canada: Torn Between Criminal K.D., Rehm, J. 2012. “Problems with Telephone-Based Surveys Justice and Public Health.” In Canadian Criminal Justice Policy: on Alcohol Consumption in High-Income Countries: the Contemporary Perspectives, Ismaili, Sprott and Varma, Eds. Canadian Example.” International Journal of Methods in Psychi- Toronto: Oxford University Press, p. 192; Werb, D. et al., 2010. atric Research, 21(1), 17-28. “Modeling crack cocaine use trends over 10 years in a Cana- 4 This issue was a finding in Drug Treatment Funding Project dian setting.” Drug and Alcohol Review, 19, 271-277. (National Anti-Drug Strategy) funding project located at the 14 Centre for Addiction and Mental Health, Toronto, Develop- The Surveillance and Risk Assessment Division, Centre for ment of a Needs-Based Planning Models for Substance Use Infectious Disease Prevention and Control, has established Services and Supports in Canada. See: http://needsbased- I-Track, which is an enhanced surveillance system to track risk planningmodels.wordpress.com/ behaviours associated with HIV and hepatitis C virus (hcv) in people who inject drugs (idu) in urban and semi-urban 5 Boyd, S., 2004. From Witches to Crack Moms: Women, Drug centres across Canada. Public Health Agency of Canada. Law and Policy. Durham: Carolina Academic Press, p. 27. 2006. Enhanced Surveillance of Risk Behaviours Among Injec- tion Drug Users in Canada. Phase 1 Report. Surveillance and 6 Wood, E. McKinnon, M., Strang, R., Kendall, P.R. 2012. Risk Assessment Division, Centre for Infectious Disease Pre- “Improving Community Health and Safety in Canada Through vention and Control, Public Health Agency of Canada, 2006. Evidence-Based Policies on Illegal Drugs.” Open Medicine, 6(1), p. 37. 15 Werb, et al., 2010. ccendu reports on Ottawa also suggest increasing crack use. See: Pocock, J. 2011. Drug and Alcohol 7 MacPherson, D., Mulla, Z. 2005. Preventing the Harms from Trends in Ottawa: Ottawa Site Report for the Canadian Commu- Psychoactive Substance Use. Vancouver: City of Vancouver nity Epidemiology Network on Drug Use (ccendu). Available at: Drug Policy Program, p. 16. Available at: www.cfdp.ca/van05. http://cgso.ca/upload/2011%20Ottawa%20Drug%20and%20 pdf Alcohol%20Use%20REPORT.pdf

8 Alexander, B. 1990. Peaceful Measures: Canada’s ‘Way out 16 Fischer, B., & Argento, E. 2012. “Prescription Opioid Related the War on Drugs’. Toronto: University of Toronto Press, Misuse, Harms, Diversion and Interventions in Canada: A p. 103-105. Review.” Pain Physician, 15, E193.

9 Csete, J., Pearshouse, R. 2007. Dependent on Rights: Assess- 17 Fischer, et al., 2005. “Illicit opioid use in Canada: comparing ing Treatment of Drug Dependence from a Human Rights Per- social, health, and drug use characteristics of untreated users spective. Toronto: Canadian HIV/AIDS Legal Network, n. 7. in five cities.” Journal of Urban Health, 82, 250-266. canadian drug policy coalition · cdpc 99

18 Popova, S, Patra, J., Mohapatra, S., Fischer, B., and Rehm, J. motion Framework.” Substance Abuse: Research and Treatment, 2009. “How many people in Canada use prescription opioids 2012(6), 23–31. non-medically in general and street-drug using populations?” Canadian Journal of Public Health, 100(2), 104-8. 30 BC Centre of Excellence for Women’s Health. ND. Manufac- turing Addiction: The Over-Prescription of Benzodiazepines and 19 Nosyk, B, Marhsalla, D.L. Fischer, B, J.S.G. Montaner, J.S.G, Sleeping Pills to Women in Canada. Vancouver: BC Centre for Wood, E. Wood, Kerr, T. 2012. “Increases in the availability of Excellence for Women. prescribed opioids in a Canadian setting.” Drug and Alcohol Dependence, 126, 7-12. 31 Spittal, Patricia, et al. 2002. “Risk factors for elevated HIV incidence rates among female injection drug users in 20 National Advisory Council on Prescription Drug Misuse. Vancouver.” Canadian Medical Association Journal, 166(7), 2013. First Do No Harm: Responding to Canada’s Prescription pp. 894-898. Drug Crisis. Ottawa: ccsa, p. 23. Available at: http://www. ccsa.ca/2013%20CCSA%20Documents/Canada-Strategy-Pre- 32 Tupper, K. W. 2008. “The Globalization of Ayahuasca: Harm scription-Drug-Misuse-Report-en.pdf?utm_source=NR&utm_ Reduction or Benefit Maximization?” International Journal of medium=NewsRelease&utm_campaign=Rx2013 Drug Policy, 19(4), 297-303; Alexander, B. 2006. Globalization of Addiction: A Study in the Poverty of Spirit. Oxford: Oxford 21 Canadian Alcohol and Drug Use Survey (cadums), 2011. University Press. Available at: http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/ stat/_2011/tables-tableaux-eng.php#t1 33 Fischer et al., 2012. 22 Hadland, S., Kerr, T., Li, K., Montaner, J.S., Wood, E. 2009. 34 Csete and Pearshouse, 2007, p. 1. “Access to Drug and Alcohol Treatment Among a Cohort of Street-Involved Youth.” Drug and Alcohol Dependency, 1(101), 1-7. 35 Health Systems and Health Equity Research Group, Centre 23 Pocock, J. 2011. Drug and Alcohol Trends in Ottawa: Ottawa for Addiction and Mental Health. 2011a. Development of Needs Site Report for the Canadian Community Epidemiology Network Based Planning Models for Substance Use Services and Sup- on Drug Use (ccendu). Available at: http://www.ccsa.ca/Eng/ ports in Canada – Current Practices, p. 28. Available at: http:// Priorities/Research/CCENDU/pages/2010-report-summaries. needsbasedplanningmodels.wordpress.com/about/ aspx#ottawa. See also: Toronto Public Health. 2011. Alcohol 36 and Other Drug Use: A Research Summary. Available at: http:// A tiered model of service provisions recognizes that not www.ccsa.ca/Eng/Priorities/Research/CCENDU/pages/2010- everyone requires the same level of services. Each tier rep- report-summaries.aspx#toronto resents a cluster of services and supports that offer similar levels of access and address problems of similar severity. 24 Public Health Agency of Canada. 2010. Population Specific Lower tiers usually meet the needs of the greatest number HIV/AIDS Report: Aboriginal People’s. Ottawa: PHAC. Avail- of people. They may include a broad range of services do not able at: http://www.phac-aspc.gc.ca/aids-sida/publication/ necessarily focus directly on substance use. The higher up ps-pd/index-eng.php levels of a tiered model include increasingly specialized and intensive the services likely accessed by fewer people. For 25 CADUMS, 2011. Table 2: Main 2011 CADUMS Indicators by more information see National Treatment Strategy Working Province – Drugs. Available at: http://www.hc-sc.gc.ca/hc-ps/ Group, 2008. drugs-drogues/stat/_2011/tables-tableaux-eng.php#t2 37 National Treatment Strategy Working Group, 2008. 26 Bell, M., Dell, C., Duncan. 2011. Alcohol and Substance Use in Saskatoon: Emerging Trends. A Canadian Community Epidemiol- 38 BC Mental Health and Substance Use Project. 2007. Cross- ogy on Drug Use Inaugural Site Report. Saskatoon: CCENDU. Jurisdictional Review: Mental Health and Substance Use Poli- cies. Available at: http://www.nshrf.ca/sites/default/files/ 27 Beasley, E., Jesseman, R., Patton, D., & National Treatment bc_report_referenced_in_rfps_05.01.12.pdf; Health Systems Indicators Working Group. 2012. National Treatment Indica- and Health Equity Research Group, Centre for Addiction and tors Report, 2012. Ottawa: Canadian Centre on Substance Mental Health, 2011a, p. vi. Abuse, p. 11. 39 Ibid. 28 CMAJ News. 2012. “Prescription Drug Abuse Rising Among Aboriginal Youths.” CMAJ, Sept. 4, 184(12). Available at: 40 National Treatment Strategy Working Group, 2008, p. 6. http://www.cmaj.ca/content/184/12/E647.full 41 See for example: BC, Ontario, Nova Scotia. 29 Dell, Roberts, G., Kilty, J., Taylor, K., Daschuk, M., Hopkins, C. and Dell, D. 2012. “Researching Prescription Drug Misuse 42 Rush, B. 2012. “Development and Pilot Testing a Model Among First Nations in Canada: Starting from a Health Pro- to Estimate the Required Capacity of Substance Abuse getting to tomorrow: a report on canadian drug policy 100

Treatment Systems in Canada.” Presentation to the Health publications-resources/documents/GenderingNatFrame- Systems and Equity Research Group, December 19, 2012. workWomencentredHarmReduction.pdf

43 For more information on the structure of treatment 51 Hadland et al., 2009. services in Canada see CCSA. National Picture of Treatment in 52 Canada. Available at: http://www.nts-snt.ca/Eng/National- For more information on integration across the provinces Picture/Pages/default.aspx and territories see: CCSA. A Systems Approach—National Picture of Treatment in Canada. Available at: http://www. 44 Bungay, V., Johnson, J., et al. (2010). “Women’s Health and nts-snt.ca/Eng/National-Picture/Pages/default.aspx Use of Crack Cocaine In Context: Structural and ‘Everyday’ 53 Violence.” International Journal of Drug Policy, 21, 4, 321-329; Rush, B., Fogg, B., Nadeau, L., Furlong, A. 2008. On the Henderson, S., Stacey, C., Dohan, D. 2008. “Social Stigma and Integration of Mental Health and Substance Use Services and the Dilemmas of Providing Care to Substance Users in a Safe- Systems: Main Report. Ottawa: Canadian Executive Council on ty-Net Emergency Department.” Journal of Health Care for Addictions; Evidence Exchange Network for Mental Health the Poor and Underserved, 19, 1336-1349; Pauly, B., MacKinnon, Addictions. 2010. Literature on Mental Health and Addictions K. & Varcoe, C. 2009. “Revisiting ‘Who Gets Care?’: Health Systems Research, with a Focus on Integration. Available at: Equity as an Arena for Nursing Action.” Advances in Nursing http://eenet.ca/products-tools/eenet-literature-reviews/ Science, 32(2), 119-127. 54 Rush, et al., 2008, Summary, p. 12. 45 See: Ontario Human Rights Commission. 2012. Minds That 55 Rush, B., Nadeau, L. 2011. “Integrated Service and System Matter: Report on the Consultation on Human Rights, Mental Planning Debate.” In Responding in Mental Health—Substance Health and Addictions. Available at: http://www.ohrc.on.ca/ Use, Ed., D. Cooper. Milton Keynes, UK: Radcliffe Health. en/minds-matter-report-consultation-human-rights-mentalhealth-and-addictions 56 The Canadian Network of Substance Abuse and Allied Professionals. ND. Essentials of…Trauma Informed Care. Avail- 46 Consistent data on the availability and quality of treat- able at: http://www.bccewh.bc.ca/news-events/documents/ ment services is difficult to obtain, but see the following PT-Trauma-informed-Care-2012-01-en.pdf See also: Poole, N., for comments on gaps in the system of services: College of Greaves, L., eds. 2012. Becoming Trauma Informed. Toronto: Physicians and Surgeons of Ontario. (2010). Avoiding Abuse, CAMH. Achieving a Balance: Tackling the Opioid Public Health Crisis. 57 Toronto: Author, and British Columbia Medical Association. For a good discussion of the social determinants of health 2009. Stepping Forward: Improving Addiction Care in British at the provincial level, see Nova Scotia, 2012. Together We Columbia. Available at: https://www.bcma.org/files/Addic- Can. P. 17. tion_Stepping_Forward.pdf 58 For a fuller discussion of this issue, see the National Treat- 47 Pocock, J. 2011. Drug and Alcohol Trends in Ottawa: Ottawa ment Strategy, 2008, p. 11. Site Report for the Canadian Community Epidemiology Network 59 on Drug Use (CCENDU). Available at: http://www.ccsa.ca/ Centre for Addictions Research. 2011. Housing and Harm Eng/Priorities/Research/CCENDU/pages/2010-report-sum- Reduction: A Policy Framework for Greater Victoria. Available maries.aspx#ottawa at: http://carbc.ca/Portals/0/PropertyAgent/558/Files/13/ Housing&HR_Vic.pdf See also Nova Scotia. 2012. Together We 48 National Treatment Strategy Working Group, 2008; Rush Can: The Plan to Improve Mental Health and Addictions Care in et al., 2012b. Development of a Needs-Based Planning Model Nova Scotia. Available at: http://www.gov.ns.ca/health/mhs/ for Substance Use Services and Supports in Canada (Draft). reports/together_we_can.pdf, p. 17. Toronto: Centre for Addictions and Mental Health, Health 60 Beasley, E., Jesseman, R., Patton, D., & National Treatment Systems and Health Equity Research Group, p. 23. Indicators Working Group, 2012. 49 Rush, et al., 2012b. 61 Canadian Centre on Substance Abuse (CCSA). 2012. 50 Health Canada and the Canadian Centre on Substance National Treatment Indicators Report, 2012. Available at: Abuse. 2007. Answering the Call: National Framework for 62 Action To Reduction the Harms Associated with Alcohol and Canadian HIV/AIDS Legal Network. 2012. Impaired Judg- Other Drugs and Substances in Canada. Available at: http:// ment: Assessing the Appropriateness of Drug Treatment Courts www.nationalframework-cadrenational.ca/detail_e.php?id_ as a Response to Drug Use in Canada. Available at: http://www. top=1 See also: BC Centre for Excellence in Women’s Health. aidslaw.ca/publications/publicationsdocEN.php?ref=1302 2010. Gendering the National Framework: Women Centred 63 Health Canada and the National Native Addictions Part- Harm Reduction. Available at: http://www.bccewh.bc.ca/ canadian drug policy coalition · cdpc 101

nership Foundation, 2011, p. 8; Redding, C. Wien, F. 2009. tives of Addictions and Poor Mental Health to Intervene into Health Inequities and Social Determinants of Aboriginal Peoples’ the Lives of Indigenous Children and Families in Canada.” Health. National Collaborating Centre on Aboriginal Health. International Journal of Mental Health and Addictions, 8(2), Available at: http://www.nccah-ccnsa.ca/docs/social%20de- 282-295. terminates/NCCAH-loppie-Wien_report.pdf 72 International Harm Reduction Association. What is Harm 64 Royal Commission on Aboriginal Peoples. 1996. High- Reduction? A Position Statement from the International Harm lights from the Report of the Royal Commission on Aborigi- Reduction Association. Available at: http://www.ihra.net/ nal Peoples. Available at: http://www.aadnc-aandc.gc.ca/ files/2010/08/10/Briefing_What_is_HR_English.pdf (Now eng/1100100014597/1100100014637 See also: Trevethan, S., called Harm Reduction International) Rastin, C. J. 2004. A Profile of Visible Minority Offenders in the Federal Canadian Correctional System. Research Branch, 73 For evidence on the effectiveness of harm reduction see: Correctional Service of Canada. Available at: www.csc-scc. The WHO/UNODC Evidence for Action series and policy briefs. gc.ca/text/rsrch/reports/r144/r144_e.pdf Available at: http://www.who.int/hiv/pub/idu/idupolicy- briefs/en/index.html. See also Canadian Nurses Association. 65 National Collaborating Centre for Aboriginal Health. 2011. 2011. Harm Reduction and Currently Illegal Drugs: Implications The Aboriginal Health Legislation and Policy Framework in for Nursing Policy, Practice, Education and Research, p. 28-29. Canada, p. 2. Available at: http://www.nccah-ccnsa.ca/en/ Available at: http://www2.cna-aiic.ca/CNA/documents/pdf/ publications.aspx?sortcode=2.8.10&searchCat=5 publications/Harm_Reduction_2011_e.pdf; Marlatt, G. A., 66 Health Canada and the National Native Addictions Part- Larimer, M. E., Witkiewitz, K. 2012. Harm Reduction: Prag- nership Foundation. 2011. Honouring our Strengths: A Renewed matic Strategies for Managing High-Risk Behaviours (2nd Framework to Address Substance Use Issues Among First Nations edition). New York: Guilford Press People in Canada. Available at: http://nnadaprenewal.ca/ 74 Marlatt et al., 2012, p. 25; Friedman, S. R., et al. 2007. “Harm 67 First Nations Health Authority, BC Ministry of Health, Reduction Theory: Users’ Culture, Micro-social Indigenous Health Canada. 2013. A Path Forward: BC First Nations and Harm Reduction, and the Self-Organization and Outside- Aboriginal People’s Mental Wellness and Substance Use – 10 Organizing of Users’ Groups.” International Journal of Drug Year Plan: A Provincial Approach to Facilitate Regional and Local Policy, 18(2), 107-117. Planning and Action, p. 6. Available at: http://www.health.gov. bc.ca/library/publications/year/2013/First_Nations_Aborigi- 75 Rachlis, B.S., Kerr, T., et al. 2009. “Harm Reduction in nal_MWSU_plan_final.pdf Hospitals: is it Time?” Harm Reduction Journal, 6(19). 68 Ibid. 76 Marlatt, G. A., et al., 2012; see also Canadian Nurses 69 Health Council of Canada. 2012. Empathy, Dignity and Association, 2011, p. 29. Respect: Creating Cultural Safety for Aboriginal People in Urban 77 Health Care Settings. Toronto: Health Council of Canada. For more about this social movement see: Boyd, S., Available at: http://www.healthcouncilcanada.ca/rpt_det_ MacPherson, C., Osborn, B. 2009. Raise Shit: Social Action gen.php?id=437&rf=2; see also Browne, A. J. 2007. “Clinical Saving Lives. Halifax: Fernwood Publishing. Encounters Between Nurses and First Nations Women in a 78 MacPherson, D., Mulla, Z., Richardson, L. 2006. “The Western Canadian hospital.” Social Science & Medicine, 64(10), Evolution of Drug Policy in Vancouver, Canada: Strategies for 2165-2176. Preventing Harm from Psychoactive Substance Use.” International Journal of Drug Policy, 17, 127-132. 70 Health Canada and the National Native Addictions Part- nership Foundation, 2011. p. 54. 79 Csete, Pearshouse, 2007.

71 See for example: Canada. 1996. The Royal Commission on 80 WHO, UNODC & UNAIDS. 2009. WHO, UNODC & Aboriginal Peoples. Excerpts available at: http://www.aadnc- UNAIDS, Technical Guide for Countries to Set Targets for aandc.gc.ca/eng/1100100014597/1100100014637#chp6. For Universal Access to HIV Prevention, Treatment and Care for an excellent analysis of the intersections of sexism and racism Injecting Drug Users. Available at: www.unodc.org/docu- in the representations violence against Indigenous women ments/eastasiaandpacific//Publications/DrugsAndHIV/ in Canadian media see: Culhane, D. 2003. “Their Spirits Live WHO_UNODC_UNAIDS__IDU_Universal_Access_Target_ Within Us: Aboriginal Women in Downtown Eastside Van- Setting_Guide_-_FINAL_-_Feb_09.pdf couver Emerging into Visibility.” American Indian Quarterly, 81 27(3/4), 593-606. For more discussion of this issue see, de National Advisory Council on Prescription Drug Misuse. Leeuw, S., M. Greenwood and E. Cameron. 2010. “Deviant 2013, p. 32. Constructions: How Governments Preserve Colonial Narra- getting to tomorrow: a report on canadian drug policy 102

82 National Advisory Council on Prescription Drug Misuse. 2013. 89 See for example: Robson, G. 2013, March 26. “Harm Reduc- tion Doesn’t Fit All Sizes.” Maple Ridge Pitt Meadows Times, 83 Saskatchewan Ministry of Health. 2010. Saskatchewan’s HIV p. 10; Woo, A. 2013, Jan. 30. “Debate Over Harm Reduction Strategy, 2010 – 2014. Available at: www.health.gov.sk.ca/hiv- Simmers in Abbotsford.” The Globe and Mail. Available at: strategy-2010-2014 http://www.theglobeandmail.com/news/british-columbia/ debate-over-harm-reduction-simmers-in-abbotsford/ 84 Alberta Health. 2011. Creating Connections: Alberta’s Mental article8029819/ Health and Addictions Strategy, 2011. Available at: http:// www.health.alberta.ca/documents/Creating-Connections- 90 Urban Health Research Institute. ND. Insight into Insite. 2011-Strategy.pdf; BC Ministry of Health. 2010. Healthy Vancouver: BC Centre for Excellence in HIV/AIDS. For more Minds, Healthy People: A Ten-Year Plan to Address Mental information about the research into Insite visit: http://uhri. Health and Substance Use in British Columbia. Available at: cfenet.ubc.ca/content/view/57/92/ http://www.health.gov.bc.ca/library/publications/year/2010/ healthy_minds_healthy_people.pdf; Nova Scotia. 2012. To- 91 Wood, A., Zettel, P. and Stewart, W. 2003. “Dr. Peter gether We Can: The Plan to Improve Mental Health and Addic- Centre: Harm Reduction in Nursing.” Canadian Nurse, 99(5), tions Care in Nova Scotia. Available at: http://www.gov.ns.ca/ 20-24. health/mhs/reports/together_we_can.pdf; Nova Scotia. 2011. 92 See BC Ministry of Health, 2012. Guidance Document for Nova Scotia Public Health Standards 2011-2016. Available at: Supervised Injection Services. Available at: http://www.health. http://www.gov.ns.ca/hpp/yourmove/Public_Health_Stan- gov.bc.ca/cdms/pdf/guidance-document-for-sis-in-bc.pdf dards_EN.pdf; Ontario. 2011. Open Minds Healthy Minds: Ontario’s Comprehensive Mental Health and Addictions Strat- 93 Canadian HIV/AIDS Legal Network. 2012. Lawsuit Filed egy, 2011. Available at: http://www.health.gov.on.ca/en/ Against Government of Canada for Failing to Protect the Health common/ministry/publications/reports/mental_health2011/ of Federal Prisoners. Available at: http://www.aidslaw.ca/pub- mentalhealth.aspx; Ontario Expert Group on Narcotic Addic- lications/interfaces/downloadDocumentFile.php?ref=1316 tion. 2012. The Way Forward: Stewardship for Prescription Nar- See also the website for Prison Health Now for more informa- cotics in Ontario. Available at: http://www.health.gov.on.ca/ tion: http://www.prisonhealthnow.ca/ en/public/publications/mental/docs/way_forward_2012. pdf; Quebec. 2011. Plan d’action interministerielle toxicomanie, 94 Correctional Service of Canada. 2010. Summary of Emerg- 2016-2011. Available at: http://publications.msss.gouv.qc.ca/ ing Findings from the 2007 National Inmate Infectious Diseases acrobat/f/documentation/2005/05-804-01.pdf and Risk-Behaviours Survey. Available at: http://www.csc-scc. gc.ca/text/rsrch/reports/r211/r211-eng.shtml#Toc253473348 85 MacKinnon, S. 2011. CCPA Review: Poverty Reduction and the Politics of Setting Social Assistance Rates. Manitoba Office: 95 Canadian HIV/AIDS Legal Network. 2012. Women in Prison, Canadian Centre for Policy Alternatives. Available at: http:// HIV and Hepatitis C. Available at http://www.aidslaw.ca/pub- www.policyalternatives.ca/publications/commentary/ lications/publicationsdocEN.php?ref=1281 ccpa-review-poverty-reduction-and-politics-setting-social- 96 assistance-rates HIV/AIDS Legal Network. 2006.

86 Natural helpers include unpaid individuals who visit harm 97 See: UNODC, WHO, UNAIDS. 2009. reduction programs and take away supplies to be distrib- 98 uted to others. See: Sharp Advice Needle Exchange. ND. The Lines, R., Jürgens, R., Betteridge, Gl, Stöver, H., Laticevshi, Natural Helper Model: A Rural Remedy: A Guide to Reaching D, Nelles, J. 2006. Prison Needle Exchange: Lessons From a Rural Injection Drug Users. AIDS Coalition of Cape Breton. Comprehensive Review of International Evidence and Experience. Available at: http://www.catie.ca/en/resources/natural- Available at: http://www.aidslaw.ca/publications/interfaces/ helper-model-rural-remedy-guide-reaching-rural-injection- downloadFile.php?ref=1173 drug-users 99 BC Centre for Disease Control. 2012. Toward the Heart: 87 Chandler, R. 2008. Best Practices for British Columbia’s Study—Crack Cocaine Users. Available at: http://towardthe- Harm Reduction Supply Distribution Program. Vancouver: heart.com/news/perceptions-of-people-who-smoke-crack- BC Centre for Disease Control, p. 3. Available at: http://www. cocaine-in-vancouver health.gov.bc.ca/cdms/harmreduction.html 100 Bracke, H., Bailey, K., et al. 2012. Safer Crack Use Kit Dis- 88 Buxton, J.A., Preston, E.C., et al. 2008. “More than just tribution in the Winnipeg Health Region. Winnipeg: Popula- needles: An Evidence-Informed Approach to Enhancing Harm tion and Public Health Program, Winnipeg Regional Health Reduction Supply Distribution in British Columbia.” Harm Authority, p. 9. Reduction Journal, 5(37). 101 Leonard, L., 2010. Ottawa’s Safe Inhalation Program: Final canadian drug policy coalition · cdpc 103

Evaluation Report. Ottawa: Somerset West Community Health mance Measures, 2011/12. Available at: http://www.health. Centre. Available at: http://www.medecine.uottawa.ca/epi- gov.bc.ca/pho/pdf/methadone-2011-12.pdf; Ontario figures demiologie/assets/ documents/Improving%20 Services%20 were updated using statistics on the website for the Ontario for%20People%20in%20Ottawa%20who%20smoke%20 College of Physicians and Surgeons. See: College of Physi- crack.pdf; Leonard, L., et al. 2007. “’I inject less as I have cians and Surgeons of Ontario. Methadone Maintenance easier access to pipes’: Injecting and Sharing of Crack-Smok- Treatment Program: Answers to Frequently Asked Questions. ing Materials Decline as Safer-Crack Smoking Resources are Available at: http://www.cpso.on.ca/uploadedFiles/homep- Distributed.” International Journal of Drug Policy, 19(3), 255- age/homepageheadlines/MethadoneFactSheet%281%29.pdf. 264; Isvins, A., Roth, E., et al. “Uptake, Benefits of and Barri- ers to Safer Crack Use Kit (SCUK) Distribution Programmes 110Reist, D. 2011, p. 16. in Victoria, Canada – A Qualitative Exploration.” Interna- 111 tional Journal of Drug Policy, 22(4), 292-300; Johnson, J., et al. Luce, J., Strike, C., 2011; See also: Cavacuiti, C, Selby, P. 2008. Lessons Learned from the SCORE Project: A Document 2003. “Managing Opioid Dependence: Comparing Buprenor- to Support Outreach and Education Related to Safer Crack Use; phine with Methadone.” Canadian Family Physician, 49, 876- Boyd, S., Johnson, J., & Moffat, B. 2008. “Opportunities to 877; Mattick, R., Kimber, J., Breen, C., & Davoli, M. 2007. learn and barriers to change: Crack-cocaine use and harm “Buprenorphine Maintenance Versus Placebo or Methadone reduction in the Downtown Eastside of Vancouver.” Harm Maintenance for Opioid Dependence.” Cochrane Database of Reduction Journal, 5(34), 1-12. Systematic Reviews, Issue 4. Art. No.: CD002207.

102 Fischer, et al., 2012. 112 Blanken, P. et al. 2010. “Heroin-Assisted Treatment in the Netherlands: History, Findings, and International Context.” 103 Bracke, H., Bailey, K., Marshall, S., Plourde, P. 2012. Safer European Neuropsychopharmacology, 20 (Suppl 2), S105-S158. Crack Use Kit Distribution in the Winnipeg Health Region. 113 Winnipeg: Population and Public Health Program, Winnipeg The NAOMI Study Team, 2008. Reaching the Hardest to Regional Health Authority. Reach – Treating the Hardest-to-Treat: Summary of the Primary Outcomes of the North American Opiate Medication Initiative 104 Ti L, Buxton J, Wood E, Shannon K, Zhang R, Montaner J, (NAOMI), p. 18. Available at: http://www.naomistudy.ca/ Kerr T. 2012. “Factors Associated with Difficulty Accessing documents.html. Crack Cocaine Pipes in a Canadian setting.” Drug and Alcohol Review, 31, 890-896. 114 To read their report, see: NAOMI Patients Association & Boyd, S. NAOMI Research Survivors: Experiences and Recom- 105 See Vancouver Coastal Health, http://www.vch.ca/about_ mendations. Available at: http://drugpolicy.ca/2012/03/nao- us/news/safer-smoking-kits-pilot-study-to-prevent-disease- mi-research-survivors-experiences-andrecommendations. transmission. 115 See District of Mission. Zoning Bylaw 505-2009. Available at: 106 CBC. “Calgary Addicts No Longer Given Crack Pipes.” http://www.mission.ca/municipal-hall/bylaws/. August 19, 2011. Available at: http://www.cbc.ca/news/ canada/calgary/story/2011/08/19/calgary-crack-pipes-street- 116 See for example: Coquitlam. Schedule K to Bylaw 3000, 1996: health.html. Methadone Dispensary Limiting Distances. Available at: http:// www.coquitlam.ca/city-hall/bylaws/frequently-requested/ 107 Luce, J., Strike, C. 2011. A Cross-Canada Scan of Methadone zoning-bylaw.aspx. Maintenance Treatment Policy Developments. Ottawa: Canadi- an Executive Council on Addictions. Available at: http://www. 117 See: City of Windsor: Bylaw 8600, see INDEX OF BY-LAWS ccsa.ca/ceca/activities.asp; Reist, D. 2011. Methadone Main- AMENDING BY-LAW 8600, p. 21.12. Available at: http://www. tenance Treatment in British Columbia, 1996-2008. Victoria: citywindsor.ca/cityhall/by-laws-online/documents/8600. Centre for Addictions Research of BC. Available at: http:// pdf; City of Pembroke, see: Zoning Bylaw: http://www.pem- www.health.gov.bc.ca/cdms/methadone.html. brokeontario.com/download.php?dl=YToyOntzOjI6ImlkIjtzO jM6IjU3MiI7czozOiJrZXkiO2k6MTt9; City of Oshawa: Zoning 108 Christie, T., Murugesan, A., Manzer, D., O’Shaughnessy, By-law Number 60-94 as Amended: http://www.oshawa.ca/ Webster, D. 2012. “Evaluation of a Low-Threshold/High Toler- documents/ZoningBylawNo.6094.pdf. ance Methadone Maintenance Treatment Clinic in Saint John, New Brunswick, Canada: One Year Retention Rate and Illicit 118 Leonard, 2010, p. 95. Drug Use.” Journal of Addiction, doi.org/10.1155/2013/753409. 119 Toronto Drug Strategy. 2010. Stigma, Discrimination and 109 These figures were compiled using the statistics provided Substance Use: Experiences of People Who Use Alcohol and in Strike, Luce, 2011, and supplemented by Provincial Health Other Drugs in Toronto. Available at: http://www.toronto.ca/ Officers, 2013. BC Methadone Maintenance Systems: Perfor- health/drugstrategy/pdf/stigma_discrim_summ.pdf. getting to tomorrow: a report on canadian drug policy 104

120 BC Coroner’s Service. 2012. Coroners Service Con- 132 National Advisory Council on Prescription Drug Misuse, firms Chemical Linked to Ecstasy Deaths. Available at: 2013, p. 26. http://www2.news.gov.bc.ca/news_releases_2009- 2013/2012PSSG0004-000029.htm 133 Fischer, B., Keates, A. 2012.

121 See for example Dancesafe in Seattle, Washington: http:// 134 National Advisory Council on Prescription Drug Misuse, dancesafe.org/products/testing-kits/complete-adulterant- 2013. screening-kit-0. 135 Ibid., see p. 33, Recommendation 8. 122 Benschop, A., Rabes, M., & Korf, D.J. 2002. Pill Testing, Ecstasy and Prevention: A Scientific Evaluation in three 136 Walley, et al., 2013. “Opioid Overdose Rates and Imple- European Cities. Amsterdam: Rozenberg Publishers. mentation of Overdose Education and Nasal Naloxone Distri- bution in Massachusetts: Interrupted Time Series Analysis.” 123 Ibid. British Medical Journal, 346, f174. DOI: 10.1136/bmj.f174 124 Milloy, M.J.S. et al. 2008. ”Estimated Drug Overdose 137 See Project Lazarus. Available at: http://projectlazarus. Deaths Averted by North America’s First Medically-Super- org/doctors/nc-medical-board. vised Safer Injection Facility.” PLoS One, 3(10), e3351.

125 Vallance, et al., 2012. Overdose Events in British Columbia: 138 Personal Communication with Susan Shepherd, Toronto Trends in Substances Involved, Contexts and Responses. Victoria: Drug Strategy. Centre for Addiction Research of BC. Available at: http://www. carbc.ca/Portals/0/propertyagent/558/files/180/carbc_bul- 139 Ibid. See also: Ontario Harm Reduction Distribution letin8.pdf Program for materials on overdose prevention and response: http://www.ohrdp.ca/; Dong et al. 2012. “Community Based 126 Fischer, B. and Keates, A. 2012. “’Opioid Drought’, Cana- Naloxone: A Canadian Pilot Program.” Canadian Journal of dian Style? Potential Implications of the ‘Natural Experiment’ Addiction Medicine, 3(2), 4-9. of Delisting Oxycontin in Canada.” International Journal of Drug Policy, 23, 495-497. 140 BC Provincial Harm Reduction Program. 2012. Take-Home Naloxone: Backgrounder. Available at: http://towardtheheart. 127 BC Interior Health. Alert for Physicians/Pharmacists: com/naloxone/. Prescription Opioid Overdose Deaths of Persons with Chronic 141 Pain in the Interior Health Region. Available at: http://www. Fisher, B. et al. 2006. ”Drug-related Overdose Deaths in interiorhealth.ca/AboutUs/MediaCentre/PublicationsNews- British Columbia and Ontario 1992-2004” Canadian Journal of letters/Documents/MHO Update October 9, 2012.pdf Public Health 97(5); Dhalla, et al., 2009. 142 See Toronto Drug Strategy Implementation Panel. 2012. 128 Corneil, T., Elefante, J., May-Hadford, J., Goodison, K., The Toronto Drug Strategy Report 2012, p. 19-20. Available at: Harris, B. 2012. Non-Illicit, Non-Methadone Prescription Opiate www.toronto.ca/health/drugstrategy. Overdose Deaths in BC’s Interior Region: Findings From a Retrospective Case Series, 2006-2011. British Columbia Interior 143 Health Canada and the Canadian Centre for Substance Health Region Alert. Abuse, 2007.

129 Ontario Public Drug Programs Division, Ministry of Health 144 CBC News. 2007. “Tories Plan Get-Tough National Drug and Long Term Care. Notice from the Executive Officer. Feb- Strategy.” Sept. 29. Available at: http://www.cbc.ca/news/ ruary 17, 2012. Available at: http://www.health.gov.on.ca/ canada/story/2007/09/29/drug-strategy.html english/providers/program/drugs/opdp_eo/notices/exec_ 145 WHO, UNODC & UNAIDS. 2009. office_odb_20120217.pdf 146 Canadian Association of Nurses. 2011; Centre for Addiction 130 Dhalla, I. A. et al. 2009 “Prescribing of Opioid Analgesics and Mental Health. 2008. The National Anti-Drug Strategy: A and Related Mortality Before and After the Introduction CAMH Response. Available at: http://canadianharmreduction. of Long Acting Oxycodone.” Canadian Medical Association com/node/1799. See also: Webster, C. 2012. “The Redlining of Journal, 181(12). Harm Reduction Programs.” CMAJ, 10(184), E21-E22. 131 Sproule, B., Brands, B., Li, S., Catz-Biro, L. 2009. “Chang- 147 Treasury Board of Canada, Department of Justice Sup- ing Patterns of Opioid Addiction.” Canadian Family Physician, plementary Tables, Horizontal Initiatives, 2007/08 and 55(1), 68-69. See also: National Advisory Council on Prescrip- 2012/13. Data on budgets for the 2007-12 period can be tion Drug Misuse. 2013. found at: http://www.tbs-sct.gc.ca/hidb-bdih/plan-eng. canadian drug policy coalition · cdpc 105

aspx?Org=37&Hi=28&Pl=164. Data for the 2012-2017 period 160 Cuijers, P. 2003. “Three Decades of Drug Prevention Re- can be found here: http://www.tbs-sct.gc.ca/hidb-bdih/plan- search.” Drugs Education Prevention and Policy, 10(1), 7-20; eng.aspx?Org=37&Hi=28&Pl=447. Kilmer et al., 2012, p. 23 148 DeBeck, K., Wood, E., et al. 2006. “Canada’s 2003 Renewed 161 See Kilmer et al., 2012, p. 45 Drug Strategy: An Evidence Based Review.” HIV/AIDS Policy and Law Review, 11(2/3), p. 5-12. 162 Ference Weicker and Company. ND. Evaluation of the 149 DeBeck, K., Wood. E., et al. 2009. “Canada’s New Federal National Anti-Drug Strategy. Obtained under the Access to “National Anti-Drug Strategy”: An informal Audit of Reported Information Act, p. 23 Funding Allocation.” International Journal of Drug Policy, 20(2), 163 Ibid., p. 24. For more information about this program see: 188-191. Health Canada. The Drug Strategy Community Initiatives Fund at a Glance. Available at: http://www.hc-sc.gc.ca/hc-ps/drugs- 150 Data on budgets for the National Anti-Drug Strategy drogues/dscif-ficsa/index-eng.php#af 2007-12 period can be found at: http://www.tbs-sct.gc.ca/ hidb-bdih/plan-eng.aspx?Org=37&Hi=28&Pl=164. 164 Ference Weicker and Company. ND. p. 9. 151 For more information about the funding priorities of the 165 Wood et al., 2012, see note 19. DCIF, see http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/dscif- ficsa/index-eng.php#fproj. 166 CCSA. 2007. A Drug Prevention Strategy for Canada’s 152 Ontario Drug Treatment Funding Program, Ontario Youth. Ottawa: CCSA. Available at: www.ccsa.ca/2007%20 Systems Projects. What is the DTFP? Available at: http://ontari- CCSA%20Documents/ccsa-011522-2007-e.pdf odtfp.wordpress.com/. See also Development of Needs-Based 167 Wood, et al., 2012, p. 19. Planning Models for Substance Use Services and Supports in Canada. Available at: http://needsbasedplanningmodels. 168 Kilmer, et al., 2012. wordpress.com/. 169 Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor, R. 153 Correctional Investigator of Canada (CIC). 2012. Annual D., Schellinger, K. B. 2011. “The Impact of Enhancing Stu- Report of the Office of Correctional Investigator, 2011/12, p. 3. dents’ Social and Emotional Learning: A Meta-Analysis of Available at: http://www.oci-bec.gc.ca/rpt/index-eng.aspx. School-Based Universal Interventions,” Child Development, 154 Degenhardt, L., Chiu, W.T., et al. “Toward a Global View 82, 405–432. of Alcohol, Tobacco, Cannabis, and Cocaine Use: Findings 170 From THE WHO World Mental Health Surveys.” PLoS Med, Kilmer et al., 2012, p. 23. 5(7), e141. Available at: http://www.plosmedicine.org/article/ 171 World Health Organization. 1986. The Ottawa Charter for info:doi/10.1371/journal.pmed.0050141. Health Promotion. Available at: http://www.who.int/health- promotion/conferences/previous/ottawa/en/index.html 155 Siren, A.H. and Applegate, B.K. 2006. “Intentions to Offend: Examining the Effects of Personal and Vicarious -Ex 172 More information about the Thunder Bay Drug Strategy periences with Punishment Avoidance. Journal of Crime and can be found at: http://www.thunderbay.ca/City_Govern- Justice, 29(20), 25-50. ment/News_and_Strategic_Initiatives/Thunder_Bay_Drug_ Strategy/Roadmap_for_Change.htm. 156 Johnson, T. P., Fendrich, M. 2007. “Homelessness and Drug Use: Evidence From a Community Sample.” American Journal 173 Fischer et al., 2003, p. 267; see also, Carter, C. I. 2009. of Preventive Medicine, 32(6, Supplement 1), S211-S218. “Making Residential Cannabis Growing Operations Action- able: A Critical Policy Analysis. International Journal of Drug 157 131 Evaluation Division Office of Strategic Planning and Per- Policy 20, 371-376. formance Measurement. 2010. National Anti-Drug Strategy: Implementation Evaluation, p. 11. Available at: 174 Carstairs, C. 2006. Jailed for Possession: Illegal Drug Use, http://canada.justice.gc.ca/eng/pi/eval/rep-rap/10/nasie- Regulation and Power in Canada, 1920-1961. Toronto: Univer- snaef/index.html sity of Toronto Press; Fischer, B., Ala-Leppilampi, K., Single, E., & Robins, A. (2003). “Cannabis Law Reform in Canada: Is 158 See for example, The Global Commission on Drug Policy, 2012. the “Saga of Promise, Hesitations and Retreat” Coming to an End?” Canadian Journal of Criminology and Criminal Justice, 159 Kilmer, B., Caulkins, J.P., Pacula, R.L., Reuter, P. 2012. The 45(3), 265–297; Grayson, K. 2008. Chasing Dragons: Security, U.S. Drug Policy Landscape: Insights and Opportunities for Im- Identity, and Illicit Drugs in Canada. Toronto: University of proving the View. Santa Monica: RAND Drug Policy and Re- Toronto Press; Solomon, R. and M. Green. 1988. “The First search Centre. p. 13. getting to tomorrow: a report on canadian drug policy 106

Century: The History of Nonmedical Opiate Use and Control ments. Available at: http://www.cba.org/CBA/submissions/ Policies in Canada: 1870-1970.” Pp. 88-116 in Illicit Drugs in pdf/09-27-eng.pdf; Mallea, P. 2010. The Fear Factor: Stephen Canada: A Risky Business, edited by J. Blackwell and P. Erick- Harper’s “Tough on Crime” Agenda. Ottawa: Canadian Centre son. Scarborough: Nelson Canada. for Policy Alternatives. Available at: http://www.policyalternatives.ca/sites/default/files/uploads/publications/ 175 Count the Costs. 2012a. Creating Crime, Enriching Criminals. National%20Office/2010/11/Tough%20on%20Crime.pdf. Available at: http://www.countthecosts.org/seven-costs/ 189 creating-crime-enriching-criminals. Canadian Bar Association Favours Judge’s Discretion over Mandatory Minimums for Drug-Related Offenses. Available 176 Werb, D. et al, 2010. Effect of Drug Law Enforcement on at: http://www.cba.org/cba/news/2010_releases/2010- Drug Related Violence: Evidence From a Scientific Review. 10-27-MandatoryMin.aspx Vancouver: International Centre for Science in Drug Policy. Available at: http://www.icsdp.org/docs/ICSDP-1%20-%20 190 Iftene, A., Manson, A. 2012. “Recent Crime Legislation and FINAL.pdf. the Challenge for Prison Health Care.” CMAJ, 2012, Nov. 5.

177 The Global Commission on Drug Policy. War on Drugs: 191 Gabor, T. Crutcher, N. 2002. Mandatory Minimum Penalties: Report of the Global Commission on Drug Policy. Accessed Their Effects on Crime, Sentencing Disparities and Justice System here: http://www.globalcommissionondrugs.org/reports/. Expenditures. Ottawa: Research and Statistics Branch.

178 Brennan, S. 2012. Police Reported Crime Statistics in 192 Substance Abuse and Mental Health Services Adminis- Canada, 2011. Ottawa: Statistics Canada, p. 31. Available tration (SAMHSA), Office of Applied Studies. (2012), Results at: http://www.statcan.gc.ca/pub/85-002-x/2012001/ from the 2011 National Survey on Drug Use and Health: National article/11692-eng.htm, p. 19. Findings; and United Nations, Office on Drugs and Crime (UNODC), World Drug Report 2012. 179 Ibid., p. 31. 193 U.S. Department of Health and Human Services, Sub- 180 Ibid., p. 11. stance Abuse & Mental Health Services Administration. 2012. National Survey on Drug Use & Health 2011. Washington: U.S. 181 Ibid., p. 22. Department of Health and Human Services; Human Rights 182 Ibid., p. 21. Watch. 2008. Targeting Blacks: Drug Law Enforcement and Race in the United States. New York: Human Rights Watch, 183 Statistics Canada. Table 252-0051 - Incident-based crime 2008. statistics, by detailed violations, annual (number unless oth- 194 erwise noted). Yalkin, T.R., Kirk, M. 2012. The Fiscal Impact of Changes to Eligibility for Conditional Sentences of Imprisonment in Canada, 184 Count the Costs. 2012a; see also: Verma, Al. 2008. This is see p. 2. Available at: http://www.pbo-dpb.gc.ca/files/get/pu Your Bill of Rights… on Drugs. American Civil Liberties Union. blications/23?path=%2Ffiles%2Ffiles%2FPublications%2FCon Available at: http://www.aclu.org/blog/criminal-law-reform- ditional_sentencing_EN.pdf. religion-belief/your-bill-rightson-drugs. 195 See: Institute de recherché et d’informations socio- 185 Department of Justice, Canada. 2012. Backgrounder – Safe economiques. 2011. Coûts et efficacité des politiques correction- Streets and Communities Act: Targeting Serious Drug Crime. nelles fédérales. Available at: http://www.iris-recherche.qc.ca/ Available at: http://www.justice.gc.ca/eng/news-nouv/nr- wp-content/uploads/2011/12 /Note-Crime-web2.pdf. cp/2012/doc_32809.html. 196 Correctional Investigator of Canada (CIC). 2012a. Annual 186 See for example: Canadian Bar Association; Collaborat- Report of the Office of Correctional Investigator, 2011/12, p. 3. ing Centre for Prison Health and Education, Vancouver; As- Available at: http://www.oci-bec.gc.ca/rpt/index-eng.aspx. sembly of First Nations; BC Representative for Children and Youth; St. Leonard’s Society of Canada; John Howard Society; 197 Ibid. Elizabeth Fry Society. 198 Ibid., p. 3 187 Tonry, M. 2009. “The Mostly Unintended Effects of Man- 199 Correctional Service of Canada. 2010. Statistics: Key Facts datory Penalties: Two Centuries of Consistent Findings.” In and Figures. Ottawa: Correctional Service of Canada. Avail- Crime and Justice: A Review of Research, Tonry, M., Ed. Volume able at: http://www.csc-scc.gc.ca/text/pblct/qf/41-eng.shtml. 38. Chicago: University of Chicago Press. 200 Ibid. 188 Canadian Bar Association, National Criminal Law Section. 2009. Bill C-15 – Controlled Drugs and Substances Act Amend- 201 CIC, 2012a, p. 16. canadian drug policy coalition · cdpc 107

(UNGASS): Assessing Drug Problems, Policies and Reform 202 Harris. K. 2009. “Prison Tattoo Program Cut Risk of HIV: Proposals.” Addiction, 104, 510–17. Report.” Sudbury Star, April 15. Available at: http://www. thesudburystar.com/2009/04/15/prison-tattoo-program-cut- 216 Count the Costs. 2012b. The Alternative World Drug Report: risk-of-hiv-report-7. Counting the Costs of the War on Drugs. Available from: http:// www.countthecosts.org/; Van Hout, M.C., Brennan, R. 2012. 203 Evaluation Branch, Performance Assurance Sector. 2009. “Curiosity Killed the M-Cat: A Post Legislative Study on Me- Evaluation Report: Correctional Service Canada’s Safer phedrone Use in Ireland.” Drugs: Education, Prevention and Tattooing Practices Pilot Initiative. Available at: http://www. Policy, 19(2), 156-162. csc-scc.gc.ca/text/pa/ev-tattooing-394-2-39/ev-tattooing- 394-2-39_e.pdf. 217 Van Hout & Brennan, 2012; Winstock, A., Mitcheson, L, & Marsden, J. 2010. “Mephedrone: Still Available and Twice the 204 Chu, Sandra. 2012. Thrown Under the Omnibus: Implica- Price.” Lancet, 376, 1537. tions of the Safe Streets and Communities Act. Presentation to 218 OHRDP 2012 The Current Political Environment: Implications Kerr, T., Small, W. & Wood, E. 2005. “The Public Health and for Harm Reduction and Supervised Consumption. January Social Impacts of Drug Market Enforcement: A Review of the 30, 2012. Available at: http://www.ohrdp.ca/conference/2012- Evidence.” International Journal of Drug Policy, 16(4), 210-220. conference/. 219 Grindspoon, L. 1998. “Medical Marihuana in a Time of 205 Wood, et al., 2012, p. 37. Prohibition.” International Journal of Drug Policy, 10(2), 145-156.

206 Office of the Correctional Investigator. 2012b. Spirit 220 Count the Costs, 2012a; Degenhardt, et al. 2008. Matters: Aboriginal People and the Corrections and Conditional 221 Release Act, p.11. Available at: http://www.oci-bec.gc.ca/rpt/ Hughes, C. and Stevens, A. 2010.”What Can We Learn pdf/oth-aut/oth-aut20121022-eng.pdf. From the Portuguese Decriminalization of Illicit Drugs?” British Journal of Criminology, 50(6), 999-1022. 207 Trevethan, S., Rastin, C. J. 2004. A Profile of Visible 222 United Nations Office on Drugs and Crime. 2013. World Minority Offenders in the Federal Canadian Correctional System. Drug Report, 2012. Available at: http://www.unodc.org/docu- Research Branch, Correctional Service of Canada. Available ments/data-and-analysis/WDR2012/WDR_2012_web_small. at: www.csc-scc.gc.ca/text/rsrch/reports/r144/r144_e.pdf. pdf. 208 Office of the Provincial Health Officer (BC). 2013. Health, 223 Ibid. Crime and Doing Time: Potential Impacts of the Safe Streets and Communities Act (Former bill C10) on the Health and Well-being 224 Canadian Council on Social Development. Children and of Aboriginal People in BC. Available at: http://www.health. Youth: Crime Prevention Through Social Development. gov.bc.ca/pho/pdf/health-crime-2013.pdf. International Centre for the Prevention of Crime. Available at: http://www.ccsd.ca/cpsd/ccsd/sd.htm. 209 Ibid., p. 43. 225 Room, R., Fischer, B., et al. 2008. Cannabis Policy: Moving 210 CIC, 2012b. Beyond Stalemate. Oxford: Oxford University Press, p. 8. 211 Office of the Provincial Health Officer (BC), 2013. 226 Fischer, B., Rehm, J., Hall, W. 2009. “Cannabis Use in 212 Ibid., p. 33. Canada: The Need for a ‘Public Health’ Approach.” Canadian Journal of Public Health, 100(2), 101-103; Room, et al., 2008. 213 International Centre for Prison Studies. World Prison 227 Nutt, D., King, L.A., Phillips, L.D. 2010. “Drug Harms in the Population List, Ninth Edition. For more comparative informa- U.K.: A Multicriteria Decision Analysis.” The Lancet, 376(9752), tion globally, see: http://www.prisonstudies.org/images/ 1158-1565. news_events/wppl9.pdf. 228 Easton, S. T. 2004. Marijuana Growth in British Colum- 214 Werb, D. et al, 2010. bia. Public Policy Sources: A Fraser Institute Occasional Paper. Vancouver: The Fraser Institute, p. 15; Bouchard, M. 2008. 215 Health Officers Council of British Columbia. 2011. Public “Towards A Realistic Method to Estimate Cannabis Produc- Health Perspectives for Regulating Psychoactive Substances: tion in Industrialized Countries.” Contemporary Drug What We Can About Alcohol, Tobacco and Other Drugs. Problems, 35, 291-320. Available at: http://drugpolicy.ca/solutions/research-and-statistics/hocreport/ p. 49; See also Reuter P. 2009. “Ten Years 229 Werb, D., Nosyk, B., Kerr, T., Fischer, B., Montaner, J., After the United Nations General Assembly Special Session Wood, E. 2012. “Estimating the Economic Value of the British getting to tomorrow: a report on canadian drug policy 108

Columbia’s domestic cannabis market: Implications for 243 Angus Reid. 2012. “Most Americans and Canadians are Provincial Cannabis Policy.” International Journal of Drug Ready to Legalize Marijuana.” Angus Reid Public Opinion, Policy, http://dx.doi.org/10.1016/j.drugpo.2012.05.00. Nov. 29, 2012. Available at: http://www.angus-reid.com/ 230 Werb, D. Nosyk, B., et al. 2012. “Estimating the Value of polls/47901/most-americans-and-canadians-are-ready-to-le- British Columbia’s Domestic Cannabis Market: Implications galize-marijuana/. Angus Reid poll, commissioned by Stop The for Provincial Cannabis Policy.” International Journal of Drug Violence BC British Columbians link gang violence to illegal Policy, 23(6), 436-441. cannabis market. September 2011. http://stoptheviolencebc. org/2011/10/26/poll-britishcolumbians-link-gang-violence-to- 231 Statistics Canada, Table 252-0051. Available at: http:// illegal-cannabis-market/. www5.statcan.gc.ca/subject-sujet/result-resultat.action?pi 244 d=2693&id=2102&lang=eng&type=ARRAY&pageNum=1&m Global Commission on Drug Policy. 2011. War on Drugs: ore=0 Report of the Global Commission on Drug Policy. Available at: http://www.globalcommissionondrugs.org/reports/. 232 Boyd, N. 2013. The Enforcement of Marijuana Possession 245 Rosmarin, A., Eastwood, N. 2012. A Quiet Revolution: Offenses in British Columbia: A Blueprint for Change. Drug Decriminalization Policies in Practice Across the Globe. Available at: http://sensiblebc.ca/wp-content/ London: Release. Available at: http://www.release.org.uk/ uploads/2013/02/Blueprint-for-Change.pdf. publications/drug-decriminalisation-policies-in-practice- 233 Brennan, S. 2012, p. 31. across-the-globe.

234 Belle-Isle, L., Hathaway, A. 2007. “Barriers to Access to 246 Ibid. Medical Cannabis for Canadians Living with HIV/AIDS.” AIDS 247 Care, 19(4), 500-506. Health Officers Council of British Columbia. 2011. Public Health Perspectives for Regulating Psychoactive Substances: 235 “Marihuana for Medical Purposes Regulations.” Canada What we can do about Alcohol, Tobacco and Other Drugs. Gazette, 146(5), December 15, 2012. Available at: http:// Available at: http://drugpolicy.ca/solutions/research-and- gazette.gc.ca/rp-pr/p1/2012/2012-12-15/html/reg4-eng.html. statistics/hocreport/. 236 Canadian Medical Association. 2012. “MD Role in the Use 248 Emont, S.L., Choi, W.S., et al. 1993. “Clean Indoor Air of Medical Marijuana Baffles Many Doctors: Survey.” October Legislation, Taxation, and Smoking Behaviour In The United 11, 2012. Available at: http://www.cma.ca/md-role-medical- States: an Ecological Analysis.” Tobacco Control, 2(1), 13; Levy, marijuana-baffles. D.T., Chaloupka, F., Gitchell, J. 2004. “The Effects of Tobacco 237 Lucas, P. (2012). “It Can’t Hurt to Ask; A Patient-Centred Control Policies on Smoking Rates: A Tobacco Control Score- Quality of Service Assessment of Health Canada’s Medical card.” Journal of Public Health Management and Practice, 10(4), Cannabis Policy and Program.” Harm Reduction Journal, 9(2). 338. Lewit, E.M., Hyland A., Kerrebrock, N., Cummings, K.M. 1997. “Price, Public Policy and Smoking in Young People.” 238 “Marihuana for Medical Purposes Regulations,” 2012. British Medical Journal, 6(Suppl 2), S17; Room, R., Babor, T., Rehm, J. 2005. “Alcohol and Public Health.” The Lancet, 239 See for example: Garis, L., Plecas, D., Cohen, I.M., McCor- 365(9458), 519. mick, A. 2009. Community Response to Marijuana Grow Operations: A Guide to Promising Practices. Available from: 249 Health Officers Council of British Columbia, 2011. http://www.surrey.ca/city-services/8224.aspx. 250 Barrett, D., Lines, R., Scheifer, R., Elliot, R., Bewley-Taylor, 240 Canadian Centre of Substance Abuse. 2011. Cross Canada D. Recalibrating the Regime: The Need for a Human Rights- Report on Student Alcohol and Drug Use, Technical Report. Based Approach to International Drug Policy. Beckley Founda- Ottawa: CCSA, p. Available at: http://www.ccsa.ca/Eng/Pri- tion Drug Policy Programme. Available at: http://www.ihra. orities/Research/StudentDrugUse/Pages/default.aspx. net/contents/552. 241 UNICEF. 2013. Child Well-Being in Rich Countries: A 251 November 15, 2012 - INCB President Voices Concern About Comparative Overview. See p. 25. Available at: http://www. the Outcome of Recent Referenda About Non-Medical Use of unicef.org.uk/Images/Campaigns/FINAL_RC11-ENG-LORES- Cannabis in the United States in a number of states. Available fnl2.pdf. at: http://www.incb.org/documents/Press_Releases/press_ 242 Union of BC Municipalities. 2012. Member Release – 2012 release_151112.pdf Resolutions Disposition. Available at: http://www.ubcm.ca/EN/ 252 main/resolutions/resolutions/resolutions-responses.html. International Narcotics Control Board. 2012. Report of the International Narcotics Control Board, 2011, p. Available at: canadian drug policy coalition · cdpc 109

http://www.incb.org/incb/en/publications/annual-reports/ un-general-assembly-approves-resolution-presented-mexico- annual-report.html. international-cooperation-against-.

253 Csete, J. 2012. Overhauling Oversight: Human Rights at 262 Forget, P. 2011. “Law Enforcement Detachments and the the INCB. London: LSE Ideas. Available at: http://www2.lse. Canadian Navy: A New Counter-Drug Capability.” Canadian ac.uk/IDEAS/publications/reports/SR014.aspx. Naval Review, 7,2, 6-11.

254 International Drug Policy Consortium. 2012. IDPC Ad- 263 Government of Canada. 2012. National Defense and the vocacy Note: The United Nations Drug Control System: A Canadian Forces: Operation Caribe. Available at: http://www. Time for Carefully Planned Reform. Available at: http:// cjoc.forces.gc.ca/cont/caribbe/index-eng.asp. americansforcannabis.com/drugpolicynews/2012/12/20/ 264 Hyshka, E., Butler-McPhee, et al. 2012. “Canada Moving idpc-advocacy-note-the-un-drug-control-system-a-time-for- Backwards on Illegal Drugs.” Canadian Journal of Public carefully-planned-reform/. Health, 103(2), 125-127. 255 Count the Costs. 2011a. The War on Drugs: Creating Crime, Enriching Criminals, p. 9. Available at: http://www.countthecosts.org/seven-costs/creating-crime-enriching-criminals.

256 Global Commission on Drug Policy, 2011. War on Drugs: Report of the Global Commission on Drug Policy. Available at: www.globalcommissionondrugs.org.

257 Vienna Declaration. Available at: http://www.viennadecla- ration.com/; see also Wood et al., 2012, p. e36.

258 Le Dain, Gerald. 1973. Final report of the Commission of Inquiry into the Non-medical Use of Drugs. Ottawa: Informa- tion Canada; Nolin, Pierre Claude and Colin Kenny. 2002. Cannabis: Our Position for Canadian Public Policy: Report of the Senate Special Committee on Illegal Drugs. Ottawa: Canadian Senate. Available at: http://www.parl.gc.ca/Content/SEN/ Committee/371/ille/rep/repfinalvol2-e.pdf; Tornsey, P. (House of Commons, Canada). 2002. Working Together to Redefine Canada’s Drug Strategy: Report of the Special Committee on the Non-Medical use of Drugs. Available at: http://www.parl.gc.ca/ HousePublications/Publication.aspx?Language=E&Mode=1& Parl=37&Ses=2&DocId=1032297&File=0.

259 Blickman, T. 2013. Objections to Bolivia’s Reservation to Allow Coca Chewing in the UN Conventions. TNI: Drug Law Reform in Latin America. Available at: http://druglawreform. info/en/weblog/item/4245-objections-to-bolivias-reservation-to-allow-coca-chewing-in-the-un-conventions.

260 Transnational Institute, Drug Law Reform. 2012. Objections to Bolivia’s reservation to allow coca chewing in the UN conventions: The United States, United Kingdom, Sweden, Italy and Canada notified their objections. Available at: http://druglawreform.info/en/weblog/item/4245-objections- to-bolivias-reservation-to-allow-coca-chewing-in-the-un- conventions

261 “The UN General Assembly Approves Resolution Pre- sented by Mexico on International Cooperation Against Drugs.” Available at: http://www.drugpolicy.org/resource/ getting to tomorrow: a report on canadian drug policy 110