Key Points
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The catastrophic effects set in motion by the Canadian opioid epidemic will continue to disproportionately hurt those negatively affected by social determinants of health in many forms, such as addiction, untreated chronic pain, poverty, incarceration, decreased quality of life, early death, and so on. The lack of appropriate response, especially on a federal level, has only exacerbated this public health issue.
The War on Drugs
To understand why decriminalization is necessary, we need to understand how drug law and policy were initially shaped in both the United States and Canada due to our historical ties, as well as the contributing factors to the opioid crisis. So, here’s a short history lesson.
Although a step in the right direction, barriers to mental health treatment didn't end with the deinstitutionalization of mental asylums in Canada in the 1960s (Ontario Human Rights Commission, 2014). There was still a great deal of stigma surrounding addiction, viewed by the public as dangerous, a perception often fueled by racism (Ontario Human Rights Commission, 2014). Drug use cannot be discussed without acknowledging the role that systemic racism has had on this crisis in the form of the creation and alterations of drug laws (Virani & Haines-Saah, 2020). It was never about public safety, but about control.
Although drug prohibition laws began as early as the 19th century in the United States, the “war on drugs” is said to have started either with the Harrison Narcotics Act in 1914, which applied a tax on opiates and cocaine for medical purposes, with an outright ban for nonmedical purposes, or with President Richard Nixon’s official declaration in 1971. It wasn’t until decades later that Nixon’s domestic policy advisor John Ehrlichman told a journalist in 1994, not revealed until 2016, about their motivations.
"The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people…We knew we couldn't make it illegal to be either against the war or blacks, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities” (Baum, 2016).
The truth to this is debated as Ehrlichman may have harbored resentment for Nixon after Watergate, but the Reagan, Bush, and Clinton administrations would continue to implement anti-drug policies (Baum, 2016; Nunn, 2002). Reagan in particular increased law enforcement spending and approved mandatory minimum penalties for drug offences (Canadian Drug Policy Coalition, 2020). The prison population began to grow significantly in the 1970s with disproportionate rates of racial minorities, with Reagan doubling it by the time he left office (Cullen, 2018). Black people have also been disproportionately investigated, detained, searched, arrested, and charged with drug-related offences (Nunn, 2002).
Canada’s version of the war on drugs is said to have officially begun in 1982 by Prime Minister Brian Mulroney, resulting in a 5-year national drug strategy (Khenti, 2014). However, racism also contributed to the origins of drug prohibition in Canada, starting with the Indian Act in 1876, shaped by the 1844 Bagot Report (Joseph, 2018). An 1884 amendment made it a felony for Indians to purchase or consume alcohol. Furthermore, the notion of moral purity in Protestantism significantly influenced the perception of Chinese immigrants, many of whom used opium (Canadian Drug Policy Coalition, 2020). This racism shaped the law and policy to come surrounding drug use including The Opium Act in 1908 and The Opium and Narcotic Control Drug Act in 1911 and strengthened in 1922 (Canadian Drug Policy Coalition, 2020; Toronto Public Health, 2018). These all disproportionately harmed racialized Canadians.
Drug propaganda only became more prevalent after fears of immigrants rose in a post-world war Canada (Canadian Drug Policy Coalition, 2020). With drug use shifting in the 40s and 50s public figures began to advocate for treatment of substance use from a public health perspective (Canadian Drug Policy Coalition, 2020). Despite this, in 1961, The Narcotic Control Act was implemented to continue to focus on criminalizing drug use (Toronto Public Health, 2018). Canada followed in the footsteps of the US and continues to fail those negatively impacted by the social determinants of health to this day. Racialized groups are overrepresented in Canada’s prison system, related to drug laws and over-policing of these communities (Chan et al, 2017). Decriminalization is an important step in the dismantling of systemic racism in this country.
Increasing incarceration rates meant that those experiencing addiction were and continue to be punished, rather than viewed as a person and provided treatment and rehabilitation. This frames drug users and dealers as an enemy that must be fought instead of fellow community members with a problem, caused by societal failures (Szalavitzm, 2021). However, punishment does not address addiction. It ignores the source of the problem, and it ignores the evidence that exists for different approaches. It also presents further barriers to rehabilitation in the future, allowing this cycle to continue. As a result, individuals often don’t receive the help they need unless in imminent danger and require a transfer to a regional treatment center (WHO, 2005). It is not unsurprising that the prison population consists of a disproportionate number of people with a history of serious mental illness, not because they are more likely to commit crimes, but because systems in place make them more susceptible to engage in substance abuse (Collier, 2014).
Contributing Factors to the Development of the Canadian Opioid Epidemic
The power that pharmaceutical companies hold could be considered a public health concern. The misleading advertisements pushed in the late 20th century created false hope and distorted understandings of appropriate opioid analgesic use in the treatment of patients with chronic non-cancer pain. Purdue Pharma played a noteworthy role in the progression of this crisis through their promotion of OxyContin in the United States, likely influencing Canadians as well due to the high exposure to our media (Hirsch, 2017).
The healthcare provider community was assured that addiction was not something to worry about when prescribing opioids, and they trusted this (Deweerdt, 2019). It is worth noting that with physicians receiving insufficient training on adequate pain management practices at that time, it is not difficult to understand why.
Prescriptions for opioid analgesics increased drastically. Since the early 1980s, the volume of opioids sold to hospitals and pharmacies for prescriptions in Canada has increased by more than 3000%; Canada is the second-largest consumer of prescription opioids in the world, after the US (Belzak & Halverson, 2018). Physicians became much more hesitant to prescribe these opioids when the negative effects became apparent in the form of overdose and addiction. This was not due to addiction in those being treated with opioids for pain, as the majority do not develop addiction, but because of the excess of drugs provided in prescriptions that allowed for others in the household to experiment; 80% of people that misuse prescription opioids do not have a prescription for them (Szalavitz, 2021).
Unfortunately, this resulted in those with chronic pain to be left behind. These were patients who had finally found a drug that made a difference in their quality of life thanks to these prescriptions were now cut off with no alternatives provided because doctors were afraid of the legal consequences. Many individuals also developed tolerance to these drugs, requiring more of the same drug to have similar effects. This led to the exploration of more dangerous drugs to match previous “highs” and thus resulted in higher risks.
As individuals were left with few options to manage their pain, some turned to street drugs. However, the increasingly toxic drug supply (often tainted with benzodiazepines, fentanyl, and fentanyl analogues) has resulted in proportionally increasing rates of deaths by overdose (Government of Canada, 2021). “87% of accidental apparent opioid toxicity deaths from January to March 2021 involved fentanyl” (Government of Canada, 2021). Criminalizing drug use and drug-related behaviors is partially to blame for the tainted street drug supply, and decriminalization and safe supply could provide more hopeful futures for those who currently experience addiction.
3 Main Approaches to Responding to Drug Use
Criminalization refers to illegal personal use, possession, production, and sales of drugs.
In contrast, decriminalization refers to the lessening or elimination of criminal penalties for personal use and possession, but not for production or redistribution.
Finally, legalization refers to legal possession, with production and sales being regulated by the government, like alcohol and cannabis.
Current Literature on Drug Decriminalization and Legalization
Eliminating criminal penalties is necessary to make treatment more accessible and tackle the stigma that persists surrounding drug users today. Decriminalization and legalization have been implemented in various countries as a harm reduction approach, which contrasts with the abstinence-only approach, as it is often not realistic (Jaffe, 2011).
Current literature demonstrates that drug use generally doesn’t change with decriminalization, but it does allow for increased access to treatment and thus should be more closely considered. The results in Portugal, after they became the first country to decriminalize all drugs in 2001, are promising (Bajekal, 2018). It is noteworthy that this refers to consumption and possession under a 10-day supply only, not production or intent to distribute. This was in response to over half of their prison population being sentenced for drug-related reasons, as well as a high prevalence of deaths by overdose.
Some outcomes of this historic decision included significant decreases in drug-induced death rates, HIV infections, and drug use among young adults aged 15-24 (Bajekal, 2018; Hughes & Stevens, 2012). Additionally, hospital costs based on the most common pathologies for drug users being admitted (ex. Hepatitis, HIV) dropped significantly (Goncalves et al, 2015). In areas in Portugal with syringe access programs, the Centers for Disease Control and Prevention (2019) found that the incidence of HIV in those that inject drugs dropped by 50%. I have already outlined the power of supervised injection sites in a previous article that you can find in the 'harm reduction' tab under 'content'.
Switzerland has seen similar results. “Their 2008 revision of the Narcotics Act outlines the four pillars of prevention, therapy, harm reduction, and repression (law enforcement) as their approach to reducing drug use and negative consequences for users and society” (Switzerland Federal Office of Public Health, 2021). “Knopf (2019) spoke with the secretary-general of the Romand Group of Addiction Studies in Geneva about this, who emphasized the importance of taking care of the problems that can result from those experiencing addiction.” Since their change in approach, opioid-related deaths have reduced by 64%, with HIV infections decreasing as well.
Although more evidence is necessary, legalization should be considered as well, as it would allow for a regulated safe supply.
If you still can't wrap your head around the misconception that decriminalization encourages drug use, I have a question for you: If we eliminated criminal penalties tomorrow, would you go out and try heroin? No? Almost as if the law isn't what's stopping you. Similarly, consider times when alcohol was illegal – it didn’t stop people from drinking. We must eliminate the law as a barrier to treatment.
Opioid Overdose Death During the COVID-19 Pandemic by the Numbers There has been an overall steady increase in opioid overdose deaths in Canada since the early 2000s (Canadian Institute for Health Information, 2019).
Action cannot come soon enough. |
Current Decriminalization Model
With multiple jurisdictions calling for decriminalization, the models still can’t seem to get it right. Vancouver sought to be the first Canadian jurisdiction to decriminalize possession of low levels of drugs (City of Vancouver, 2021; Ibrahim, 2022; Larson, 2021). This means seeking a federal exemption under the Controlled Drugs and Substances Act (CBC News, 2021). On May 31, 2022, British Columbia became the first province to decriminalize drugs such as opioids, cocaine, and methamphetamines, although the plan will not go into effect until 2023 (Lindsay, 2022; Paterson, 2022; Woo & Gee, 2022). However, their model for decriminalization has been criticized a great deal for not being enough and could set a dangerous precedent if other cities follow, like Toronto or Kingston, also calling for decriminalization in the name of public health (Jones, 2021; Soucy, 2022). Some critiques of the model include:
Too low of a threshold. 2.5 grams is half the requested exemption, already deemed too low to make a difference.
Decriminalization without safe supply does not address the reasons for increasing overdose deaths. We need safe supply implementation simultaneously to save lives.
Potential for discrimination regarding who is stopped to check if drug amounts are above the threshold.
Society has failed those suffering from substance use disorders throughout history and the present, but this can be addressed in part through decriminalization and a shift in our approach to mental health issues towards a public health perspective to both correct injustice and improve health outcomes.
If you are interested in learning more, I would highly recommend checking out the following documents addressing approaches to decriminalization:
Drug Policy Alliance: https://www.unodc.org/documents/ungass2016/Contributions/Civil/DrugPolicyAlliance/DPA_Fact_Sheet_Approaches_to_Decriminalization_Feb2015_1.pdf
Canadian Centre on Substance Use and Addiction: https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Decriminalization-Controlled-Substances-Policy-Brief-2018-en.pdf
Please stay informed friends,
Raquel
References
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