Highlights of this issue

CMAJ 2000;162:1657

Substance use is the interplay of 3 elements: the properties of the substance, the characteristics of the user and the environment where the use occurs. A person's ability to control use falls along a continuum, from compulsive to controlled. Similarly, society's approach to the problem falls along a continuum, from prohibitionist to extreme libertarian. Recently we have witnessed the emergence of a new approach — harm reduction — that shifts the drug use debate away from legal sanctions toward public health principles. Yuet Cheung describes these principles and outlines a model of harm reduction. In an accompanying commentary Catherine Hankins discusses the harm attributed to drug legislation and identifies the urgent need for drug law reform in Canada.

Marijuana is the most widely used illicit drug in many developed countries. Alan Ogborne and colleagues present the results of a telephone survey that included questions on cannabis use in a weighted sample of the general adult population in Ontario. Of the 2527 respondents 173 (6.8%, 95% confidence interval [CI] 5.7%–8.2%) reported using marijuana for nonmedical reasons in the year before the survey. An additional 49 (1.9%, 95% CI 1.3%–2.8%) reported using it for medical reasons, the most common being pain or nausea (41 [85%]). The authors conclude that about 2% of the population could claim the right to use marijuana for medical reasons, based on self-identified needs. In an accompanying commentary Wayne Hall argues that the dearth of evidence on the benefits and harms of cannabis has resulted in policy stasis and that investment in epidemiological research is the way forward.

Using pooled estimates Eric Single and colleagues calculate new estimates of the number and proportion of deaths and hospital admissions attributable to substance use in Canada. They estimate that, in 1995, 34 728 deaths and 194 072 admissions were attributable to tobacco, 6507 deaths and 82 014 admissions to alcohol, and 805 deaths and 6940 admissions to illicit drug use. According to previous estimates 62% of alcohol-related deaths in 1992 were due to chronic conditions; new estimates indicate that only 22% of such deaths in 1995 were due to chronic conditions. Accidents and other acute causes accounted for nearly half (47%) of all alcohol-related deaths and 62% of potential years of life lost in 1995.

The Ontario Student Drug Use Survey is a cross-sectional survey of high school students that has been conducted every 2 years since 1977. Using survey data on self-reported rates of drug use over the last 5 cycles (1991–1999), Edward Adlaf and colleagues noted an upward trend between 1993 and 1999 in the proportion of students reporting drug use. This increase was evident for tobacco (23.8% to 28.3%), alcohol (56.5% to 65.7%), cannabis (12.7% to 29.2%), glue (1.6% to 3.8%) and other solvents (2.3% to 7.3%), hallucinogens (3.1% to 13.6%), cocaine (1.5% to 4.1%), phencyclidine (PCP) (0.6% to 3.2%) and methylenedioxymethamphetamine ("ecstasy") (0.6 % to 4.8%). In addition to the rise in illicit drug use the authors flag cigarette smoking and binge drinking as priority public health issues.

Benedikt Fischer and colleagues have compared the morbidity and mortality rates among injection drug users in Canadian and Western European jurisdictions during 1988–1999 and explored their correlation with harm reduction programs. Whereas expanded harm reduction initiatives in the Netherlands, Switzerland and Germany correlated with a decrease in morbidity and mortality rates, the rates among drug users in Canada have increased. The authors attribute this increase to the limited range and penetration of harm reduction initiatives in Canada. According to John Anderson, who makes his case by examining specific jurisdictions, this conclusion is an oversimplification.

© 2000 Canadian Medical Association or its licensors