Category: Harm Reduction

Criminal activity and drug trafficking. Distressingly, those are dominant discussion points at this week’s annual UN drug policy conference – the Commission on Narcotic Drugs (CND).

As a result, public health considerations have been somewhat sidelined, but not, thankfully, among UN agencies, where a number of key representatives called for the removal of criminal sanctions associated with drug use, and the realignment of drug use as a public health issue.

Back in Canada, the federal government is considering changing Canada’s marijuana laws to allow ticketing by police instead of arrest, but Justice Minister Peter MacKay has insisted that even if that’s the case, “Criminal Code offences would still be available to police…. It’s not decriminalization. It’s not legalization.” What’s more, the move could be a step backwards if police begin issuing tickets, where in the past they might have turned a blind eye.

Regardless, under the current regime, simple cannabis possession charges in Canada numbered 61,406, a rate of 178 per 100,000 people as recently as 2011. This represented a 16% increase of such incidents since 2001. In BC alone, the arrest and prosecution of personal marijuana use costs taxpayers $10.5 million a year.

Contrast that criminalization framework with comments from UN agencies this week at the CND:

• UN Deputy Secretary Jan Eliasson tried to set a positive tone early by emphasizing the “public health imperative” in addressing drug use, and called for a “comprehensive and open-minded exchange” that included civil society input and that didn’t shy away from “discussing innovative ideas and perspectives.” He concluded by stressing that it is not enough to say no to drugs, “we are also saying yes… to human rights.”
• Gilberto Gerra, Chief of Drug Prevention and Health Branch for the UN’s drug control agency (UNODC) insisted that criminal sanctions are ineffective and counter-productive because they do nothing to address problematic drug use. He argued that drug policies should be based on health and not on punishment, and that nowhere do international drug conventions require that personal use should be criminalized.
•  Two Scientific Working groups convened by the UNODC to advise the CND criticized criminal sanctions and implored delegates to base their policy decisions on science.The first – headed by Nora Volkow (Director of the United States National Institute on Drug Abuse) – insisted that “substance use disorders should be treated as medical and public health issue rather than a criminal justice and/or moral issue.” Imprisonment does not equate with treatment, and the group discouraged the use of “criminal sanctions” given that they “are not beneficial in addressing substance use disorders.”
  The second group – headed by Michel Kazatchkine (UN Secretary General’s Special Envoy on HIV/AIDS for Eastern Europe and Central Asia) – concluded that “we need to stop incarceration of people who use drugs for minor drug related offenses.” Its members highlighted the legal and regulatory impediments to implementing harm reduction initiatives and noted that the “criminalization of drug use, restrictive drug policies and aggressive law enforcement practices are key drivers of HIV and hepatitis C epidemics among people who inject drugs.” Basically, people are dying because they are treated as criminals rather than patients.
• UNAIDS director Michel Sidibe echoed calls to understand drug use as a public health and human rights issue, stating: “The criminalization of millions of people for minor drug offences exacerbates vulnerability to HIV infection, and does little to protect society from the health and social harms caused by drug dependence.” He added, “We must work towards transforming laws and law enforcement officials to become bridges to connect people who use drugs to life saving health services.”
• The UN High Commissioner for Human Rights Navi Pillay’s statement drew attention to “the intense focus of law enforcement against drug use” which “has resulted in large numbers of persons being arrested and held in prolonged periods of pre-trial detention for minor drug offences.” She condemned the “so-called ‘treatment’ in such centres” which “is frequently not based on individualized assessment and evidence-based medical practice, but rather in mass treatment with a focus on disciplinary-type interventions.”

These comments represent a striking scientific consensus on the harm created by the criminalization of drugs and those who use them. Clearly the language of public health is beginning to inform the deliberations at this forum. The real challenge for countries to put teeth into these recommendations by implementing concrete and comprehensive public health approaches to drug related harm.

Zero New HIV Infections. Zero Discrimination and Zero AIDS-related deaths. That is the goal set by UNAIDS over the next two years. But when it comes to stopping HIV transmission associated injection drug use, we have a long way to go.

“An effective AIDS response among people who inject drugs is undermined by punitive policy frameworks and law enforcement practices” (UNAIDS 2013)

The 2013 UNAIDS Global report notes that HIV prevalence among people who inject drugs ranged from 5% in Eastern Europe to 28% in Asia.  Rates of HIV among drug injectors in Canadian cities range from approximately 5% to more than 30%. According to Canada’s own Public Health Agency, more than 50% of new HIV infections among Aboriginal people in Canada were caused by intravenous drug use. Rates of HIV and hepatitis C among people incarcerated behind the walls of Canada’s prisons are 10 to 30 times outside those same walls. Although Corrections Canada claims that injection drug use is strictly prohibited within its facilities, no prison system in the world is able to keep drug use out.  But only two of 32 reporting countries surveyed by UNAIDS provided adequate access to sterile syringes for persons who injects drugs in prison.

In 2012 the Global Commission on Drug Policy released a groundbreaking report titled “The War on Drugs and HIV/AIDS: How the Criminalization of Drugs Fuels THE Global Pandemic.” The report points to the inability of law enforcement to reduce global drug supply and raises the alarm about the role that repressive drug control policies play in driving the HIV epidemic in many regions of the world. The report also details how policies that prohibit needle distribution result in increased syringe sharing.  In fact the Global Commission confirms what others have been saying: the fear of arrest drives people underground and away from needed services. Together these repressive policies help to escalate HIV infections. The Commission urges countries to make available proven drug treatment and harm reduction services, to reduce HIV infection and protect community health and safety.

It’s clear that ending prohibition and scaling up harm reduction is an integral part of solving the complex global HIV problem. By drawing on the evidence of what works, British Columbia has made significant strides at reducing infection rates, but our federal government willingly refuses to acknowledge the role that harm reduction plays in protecting everyone’s health.

On September 30, 2013, the second anniversary of the Supreme Court of Canada decision that instructed the Canadian government to issue a permit for the supervised injection site, Insite in Vancouver, we worked with the Canadian HIV/AIDS Legal Network and PIVOT Legal Society to register our concerns to Health Minister Ambrose about attempts by the federal government to block the implementation of life-saving health services for people with addictions, in the face of extensive scientific evidence of their benefits in protecting public health and public safety. Our letter  to Ambrose, which garnered the support of more than 50 organizations in Canada, challenged her government to get going on life-saving harm reduction services. We are still waiting for a response.

Along with our commitment to World Aids Day, we will also continue to mark September 30 (9-30), the anniversary of the Supreme Court decision supporting Insite. We invite you to join us and help ensure that supervised consumption services become a part of the continuum of care for people who use drugs in Canada. And finally, please consider contributing to help our small but mighty team continue to work for evidence based and human rights focused drug policy reform in Canada.

By Connie Carter and Susan Boyd

On October 3, 2013, federal Health Minister Rona Ambrose announced new regulations that became effective immediately to prevent Health Canada’s Special Access Programme from approving the use of prescribed diacetylmorphine* as a treatment for addiction for a small number of patients finishing the clinical trial SALOME, in Vancouver, BC. Health Canada’s Special Access Programme (SAP) allows practitioners to request access to drugs that are unavailable for sale in Canada.

Ambrose’s comments at the October 3rd press conference misrepresented the extensive evidence supporting heroin-assisted treatment (HAT). She claimed HAT is unsafe and expensive and not in keeping with her government’s National Anti-Drug Strategy.  Her comments reflected the Harper government’s refusal to acknowledge the eight peer-reviewed research HAT trials worldwide that have found it to be a beneficial, safe, and cost-effective approach for patients where methadone and other conventional treatments have not worked.

Ambrose promoted the virtues of abstinence-based drug treatment failing to mention that Canada’s system of treatment programs is a patchwork of private and public providers. As the CDPC’s report on Canadian drug policy found, private treatment programs are expensive, and in the absence of national accreditation standards, these programs can vary in quality. Abstinence based treatment is also ineffective for many people with long-wait times for publicly-funded services.

Ambrose’s press conference included supporters who were called upon to back the federal government’s position. One speaker, Marshall Smith, a former political staffer with the BC Liberal Government, described his own struggles with drugs including crystal meth, and his recovery through abstinence-based treatment. Smith currently works for Cedars at Cobble Hill, a privately run drug treatment facility on Vancouver Island. Smith comes from a self-admitted well-to-do family, who can afford private treatment facilities that can cost upwards of $10,000 a month. Every person’s story of recovery and change is important, but with all due respect to Mr. Smith, it’s vital that no one person’s story stand in for the range of experiences with substance use.

Comments at the press conference reflected a narrow view of recovery from substance dependency and assumed that all people will benefit from conventional drug treatment approaches. In a turn about from previous calls for abstinence-only drug treatment, speakers’ called for expanded opiate-substitution programs like methadone. But HAT is only offered to patients who have failed repeatedly with methadone and abstinence-based programs.

Ambrose called Health Canada’s recent decision to approve the use of diacetylmorphine for 20 patients a “loophole” in the Special Access Program regulations. But the Special Access Program is supposed to provide patients with serious or life-threatening conditions, access to drugs on a compassionate or emergency basis and especially when conventional therapies have failed. Under these conditions, many of the seriously ill patients who enter HAT would certainly qualify for access.

No one knows better the concerns of patients in these research trials than SNAP, an independent Vancouver based group comprised of former and current members of Vancouver based HAT research trials (former NPA). SNAP advocates for human rights and access to appropriate health care for its members and has been working since January 2011 to establish permanent HAT programs. SNAP members also have first hand experience with the use of diacetylmorphine. Their experiences confirm the findings of other research studies that this drug is a proven safe and effective treatment for opiate dependency. Patients’ physical and psychological health improved, accompanied by decreased criminal activity and illegal drug use. Given the positive results from studies around the world and here in Canada, the federal government’s refusal to recognize the best treatment for this small groups of patients is an egregious violation of their rights to access to health care.

* Diacetylmorphine is the active ingredient in heroin. It is pharmaceutical-grade product manufactured by a company outside Canada. For the purposes of research trials, it is purchased and imported with permission of the Government of Canada.

Book review:

The Evidence Enigma: Correctional Boot Camps and Other Failures in Evidence-Based Policymaking, Tiffany Bergin, (Ashgate, 2013), 213 pages.

Why do policy makers adopt policies for which there is no evidence that they will work or for which the evidence is clear that they will not work? Why do they continue to defend policies which have demonstrably failed or for which the unintended consequences are so costly as to undermine their rationale? Why do policy makers ignore evidence that policies are failing thereby squandering resources that could be diverted to policies with a better track record? The Evidence Enigma does not answer all of theses questions, but it does shed some light on the complexity of policy making in one highly contested policy domain.

Bergin begins with a question: What explains the rapid diffusion of boot camps – correctional facilities inspired by military drills, physical exertion and rigid discipline – to almost every U.S. state during the 1980s and 1990s when it was clear that these facilities were not reducing either recidivism rates, prison overcrowding or justice system costs? Their failure to achieve any of these objectives did not reduce their appeal to policy makers – indeed their popularity grew with evidence of their failure to deliver on their promises. The same questions can be posed for Drug Abuse Resistance Education (DARE), which survives in many jurisdictions despite numerous well-designed meta-analyses and evaluations demonstrating little to no deterrent effect on participants. The granddaddy of all failed policies to which policy makers are still committed, of course, is the war on drugs. The example of boot camps, however, is particularly interesting because so much was known about them so early in their diffusion across the United States.

Bergin employs a multi-method approach to unravel her problem, involving extensive quantitative, qualitative and event history analysis of the diffusion and then contraction of the boot camp model, the racial composition of jurisdictions in which boot camps were located, the economic conditions for which boot camps were supposed to be a partial remedy, the geographic proximity of one boot camp jurisdiction to another, the prevalence of military veterans among policy makers in a given jurisdiction, the pervasiveness of media articles about boot camps, the influence of federal funding programs, the percentage of Evangelical Christians in a given jurisdiction, the north-south geographic location of boot-camp jurisdictions, the nature of local electoral competition and numerous other variables.

She finds that boot camps were more likely to be adopted in jurisdictions with higher adult incarceration rates and conservative populations; more popular in jurisdictions with higher percentages of African Americans and Evangelical Christians and higher levels of income inequality. In fact, these three variables correlate reliably with early adoption of boot camp regimes. Furthermore, state governors who were military veterans – and jurisdictions with a high percentage of military veterans in their populations – were less likely to abolish boot camps once the contraction set in.

Of the contending theoretical streams, Bergin finds that Windlesham’s populist theory – a conservative political climate in a racially charged environment – was the strongest predictor of the adoption of boot camps. By contrast, Kingdon’s theory that boot camps found their way onto legislative agenda in response to “problems” – i.e., high rates of crime, incarceration and levels of prison overcrowding – found little support in the analysis. Boot camps, in other words, were not so much a solution to a problem but a predilection arising out of the particular ideological needs of specific populations and their political leadership.

Bergin’s analysis concludes that the diffusion of boot camps is easier to explain than their contraction. Jurisdictions with higher levels of military veterans, higher levels of Black and Hispanic populations and greater numbers of Evangelical Christians proved more resistant to the evidence that boot camps were not delivering savings, lower rates of re-offending or reduced rates of prison overcrowding.

So what light does this study – of one policy model in the United States – tell us about the general problem of policy makers’ adherence to failed policies, or to policies for which there is no support in evidence or for which the evidence contradicts the policy preference? No single theory of policy diffusion seems adequate: all explain some aspect but leave other issues unaddressed. Missing from Bergin’s account is a discussion of power – specifically the power to frame a particular problem area as responsive to a preferred policy response. What we have, in the boot camp example, are indicators of kinds of power without an articulate account of how power frames and circumscribes the limits of the possible – making some options live and rendering others out of order.

Policy makers do not simply do what they want, particularly in a realm like criminal justice, which is costly and involves deprivation of liberty. They must fashion responses according to the menu of available and acceptable options and within the requirements of electoral survival – which involves a shrewd estimation of what their constituents will endorse or at least tolerate. When populations are largely passive in their preferences, of course, policy makers can exercise discretion – but when policy makers are constrained by electoral competition, the need to be seen to be doing something can overwhelm even the most honourable political instincts. The need to be seen to be doing something – which is distinct from the reality of actually doing something – looms large in domains like criminal justice where policy makers know, or rapidly learn, that they can do little of long-term substance in the short mandates available to them. This is how we come to see – particularly in criminal justice – the triumph of symbol over substance and the willingness to subordinate principle to electoral opportunity.

Bergin’s study of boot camps offers valuable insights into the diffusion and contraction of a discredited policy – but the book provokes as many questions as it answers. And that is often the mark of a good book.

– Craig Jones, PhD

Craig Jones is the former Executive Director of The John Howard Society of Canada.