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CMAJ
CMAJ - June 13, 2000JAMC - le 13 juin 2000

Substance use: time for drug law reform

Catherine Hankins

CMAJ 2000;162:1693-4

See also:
In the article "Substance abuse and developments in harm reduction" (page 1697 of this issue1) Dr. Yuet Cheung concludes that in the 21st century harm reduction should be welcomed as an important player in addressing the use of currently illicit drugs, alongside prohibition and legalization. Other strategies that have become part of the discourse on how to resolve the drug problem include medicalization, which recognizes addiction as an illness to be treated rather than as a crime to be punished, and decriminalization, which even a recent editorial in the Economist argued should be considered as an alternative policy.2 In Canada decriminalization is advocated in many quarters for cannabis, a drug for which it is estimated 1 in 50 adult Canadians has a criminal record for possession.3 Although much of the harm reduction literature to date has focused on the harms associated with drug use, increasingly attention is being focused on the harms attributed to drug legislation itself and its enforcement in the war on drugs led by the United States. Prohibition has fostered violent crime both in consuming and producing countries, corruption at many levels, sex work to finance drug consumption, overdose-related deaths from drugs of unknown purity, reluctance to educate drug users about safe injection practices and to provide needle exchange services, a culture of marginalization that drives drug users away from their traditional social support networks of nonusing family, friends and coworkers,4 high levels of incarceration with resultant weakening of the social fabric of communities, and high direct and indirect costs for the public purse.

Following a dramatic increase in the number of deaths due to drug overdose, the chief coroner in British Columbia recommended in 1996 that the government examine the feasibility of decriminalizing possession of certain drugs and diverting funds destined for drug law enforcement to prevention and treatment.5 Whereas more than $400 million was spent in Canada in 1992 for drug law enforcement, only $42 million was spent on prevention and research and $88 million on direct health costs.6 To address this imbalance the National Task Force on HIV and Injection Drug Use recommended that a portion of the considerable proceeds obtained through drug-related fines and confiscation of assets be directed to prevention and treatment rather than remaining in law-enforcement coffers.7

Drug laws and their enforcement affect drug choice, cost and method of consumption, with refined drug products being easier to conceal than precursors and the efficacy of injecting being greater than that of inhaling as drug costs increase in response to prohibition and repression. Enforcement practices have thus influenced the decision of drug users around the world to inject rather than inhale or ingest drugs, even though these latter delivery modes carry far less risk of overdose and exposure to serious infectious disease. The transition from opium smoking to heroin injection in traditional opium smoking areas such as Thailand, Laos and Hong Kong was shown to be strongly correlated with the introduction of laws aimed at controlling the supply and consumption of narcotic substances.8 Drug refinement now occurs closer to production areas in order to facilitate transportation and distribution. This has led to dramatic changes in consumption patterns among local populations, with the result that HIV prevalence has soared to levels of 61% to 84% among injection drug users (IDUs) in the Golden Triangle countries of Myanmar (Burma) and Thailand.9

Transmission of HIV among IDUs, their noninjecting sexual partners and children has heightened concern and emphasized the urgency of addressing drug law reform. Injection drug use has now been reported from 129 countries, 103 of which also report HIV infection among their injecting populations.10 HIV infection swept through an entire cohort of IDUs in the United States and Europe during the late 1980s and subsequently has spread rapidly among IDUs in many countries, becoming the predominant mode of transmission in many areas of North Africa, the Middle East, Asia and South America.11 New and explosive epidemics are now being described among IDUs in the newly independent states of Eastern Europe and in Russia, where official estimates in 1996 suggested that 66% of new cases of HIV were associated with injection drug use.12 Unacceptably high incidence rates have been documented among IDUs in established epidemics in major Canadian cities such as Vancouver13 and Montreal.14

The link between injection drug use and bloodborne infections such as HIV, hepatitis B and hepatitis C is forged both by personal behaviour and by environmental context. Although IDUs in many settings have adopted clean needle practices and safer forms of drug consumption, the ongoing spread of HIV and other bloodborne infections among IDUs is being facilitated by lack of access to sterile injecting equipment and by law enforcement that encourages users to inject rather than to smoke or ingest drugs. Current Canadian drug policy views the health consequences of drug use as a moral issue requiring a moral and punitive response rather than as a health issue requiring comprehensive public health policies and interventions to address the social, economic and political conditions underlying drug problems and to mitigate the consequences.15 The direct and indirect costs of this choice made by society are being borne by us all.6,16–18 With an estimated 51% of all new cases of HIV infection in 1996 in Canada attributed to injection drug use,19 there is an urgent need for strategic alliances among physicians, public health professionals, politicians, lawmakers, community representatives, IDU advocates and the public at large to address the expanding epidemic of bloodborne infections among Canadians who inject drugs and the evident and urgent need for drug law reform in Canada. Decriminalization of possession of small amounts of drugs for personal use would disgorge the criminal justice system and refocus discourse and action toward pragmatic prevention programs, risk reduction strategies for those who consume drugs, and accessible detoxification and rehabilitation treatment services for those who wish to reduce or stop their drug consumption.

Competing interests: None declared.

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Dr. Hankins is with the Montreal Regional Public Health Department, the McGill University AIDS Centre and the Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Que.

Correspondence to: Dr. Catherine Hankins, Direction de la santé publique de Montréal-Centre, 1301 rue Sherbrooke E, Montréal QC H2L 1M3; fax 514 528-2452 or 514 528-2441; chankins@santepub-mtl.qc.ca or md77@musica.mcgill.ca

References
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  2. A muddle in the jungle [editorial]. Economist 2000;Mar 4:17-28.
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  14. Hankins CA. Syringe exchange in Canada: good but not enough to stem the HIV tide. Subst Use Misuse 1998;33:1129-46. [MEDLINE]
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