Now we need to regulate the most dangerous drugs and destigmatize their use as we begin to see the upside of cannabis legalization.
Of the many things we have learned from almost 100 years of drug prohibition, it is obvious to all but the most ideological that public health education and the cultivation of norms for responsible use of potentially toxic substances are more effective tools for the management of complex policy problems — particularly those that involve human appetites — than the hammer of law enforcement, courts and prisons.
The legalization of cannabis has shown Canadians that public policy can trade a big problem — the mass criminalization of racialized and inner-city youth — for the slightly smaller, more manageable ones that concern safe and responsible consumption of a regulated substance.
Cannabis criminalization imposed harsh and unjustifiable harm on millions of people and did little to deter use. Its legalization is an example of how public policy, done properly, can lead to a more humane society by setting out to minimize those harms to individuals and the community, including by reducing the number of people burdened with criminal records for using a mild intoxicant for pleasure or to alleviate discomfort.
That’s a big deal because scholars of drug policy have long argued that the “war on drugs” is really a war on poor people; that it enriches and empowers drug trafficking organizations and the state security apparatus tasked with combating them; that the “iron law of prohibition” incentivizes traffickers to handle more potent — hence dangerous — substances; that attacking the supply side does nothing to address demand; and that prohibition’s business model makes the drugs themselves more toxic and life-endangering than they would be in a regulated environment.
The catastrophe of alcohol prohibition was an example of all that.
Canada legalized cannabis this time last year and the sky did not fall. There has been no explosion of use or sudden spike in highway fatalities — which begs the question: When will Canada take the bull by the horns and launch a concerted public health and education strategy to combat our opioid crisis?
Canadian carnage: 11 lives lost to opioid overdose per day in 2017
The iron law of prohibition holds that as enforcement increases, traffickers migrate to the drugs with the highest potency and toxicity. And that is what has happened. The death rate per 100,000 from opioids like fentanyl has increased to 11.6 in the first three months of 2019 from 8.4 in 2016, with the percentage involving fentanyl or fentanyl analogues climbing to 79 percent from 50 percent over the same period. British Columbia, Alberta and Ontario are the hot zones.
It does not have to be this way. These deaths are the unintended consequence of a policy zombie called the “war on drugs,” initiated during a racist moral panic in the late 19th century; it mandated punishment and stigmatization rather than treatment and rehabilitation. Subsequent iterations of the 1908 Opium Act have only exacerbated the foundational intent of the legislation while — coincidentally — growing the power and resources of Canada’s enforcement agencies. Today, we have the worst of all worlds: powerful and violent drug trafficking organizations benefiting from police enforcement, which has led to high prices, enriching these criminal organizations.
If you doubt this, review the last 20 years of drug-market-related violence tearing Mexico apart.
A policy zombie is “a belief that seemingly can’t be killed by evidence” but is able to wreak havoc because it is still useful to certain interests. Drug prohibition is the ultimate policy zombie. And this is among the worst kept secrets in the corridors of power. So how do we kill it once and for all?
The first step is to embrace the fact we are experiencing “the largest health crisis of our generation,” according to Gillian Kolla at the University of Toronto’s Dalla Lana School of Public Health. It’s those in the prime of their lives — 25 to 44 years — who are most deeply affected, accounting for upwards of 11,500 deaths over the past three years, or roughly one person every two hours. “Canadian life expectancy at birth has stopped rising for the first time in over four decades,” according to a Statistics Canada finding. By contrast, the 2003 SARS public health emergency killed fewer than 50 people but provoked an outpouring of money and sympathetic media attention.
One important difference: SARS was not shrouded in the stigmatization that surrounds drug use and users because of 100 years of prohibition propaganda.
What is to be done?
Portugal decriminalized — not depenalized, not legalized — all drug possession. Use of drugs fell, rates of death by overdose fell, and HIV/hep C transmission by needle sharing fell. What has spiked upward, according to independent analyses, is demand for treatment. How did they do it?
In 2016, I spoke with João Castel-Branco Goulão, a medical doctor and the architect of Portugal’s breakthrough public health policy. He told me that Portugal’s politicians turned to the country’s public health experts and essentially said, “Save us.”
In the late 1990s, Portugal had a public health crisis of addiction, with 1 percent of the population addicted to heroin. Crucially, however, that 1 percent included people from every socio-economic class, from richest to poorest. “There was not a family in Portugal who did not have a member with a heroin problem,” he told me when we spoke in Ottawa, and that is what mitigated the impact of the stigma faced by drug users. The public health experts returned to the politicians with one clear finding: people were afraid to seek treatment because they feared they would be criminalized. When they did seek treatment, they were put on a waiting list for weeks or months. The solution was to decriminalize all drug use, aggressively pursue evidence-based harm reduction and public education strategies, create “dissuasion commissions” and expand treatment options while cutting wait times.
Today, Portugal — a small and extremely Catholic country — is leading the world on treating drug-use-related problems.
The challenge of new thinking
We urgently need to aggressively destigmatize drugs and drug users. That’s not a small ask in the face of unrelenting propaganda and misinformation, of which the “just say no” approach was an example, along with political hostility to evidence-based safe injection strategies.
Regulating potentially toxic drugs and making them available in a tightly controlled environment where their worst side effects can be mitigated or reversed is not an endorsement of drug use. It’s a policy that seeks to moderate its worst consequences and minimize the social and individual harm that arises from it. It seeks to meet drug users “where they are” and create an environment conducive to their safe and healthy reintegration — including eventual cessation of use.
You can’t rehabilitate people if you can’t keep them alive. Nor can you reintegrate them if you stigmatize their personal health issues.
Safe injection sites in every community would go a long way toward arresting the death rate, reducing expensive emergency room admissions and rehabilitating those who seek treatment. We should not leave our response to this crisis to the small and under-resourced community-based organizations that — in the vacuum created by political indifference — have risen to the task. Canadians need to vigorously push our public officials to take the evidence seriously, put the programs in place, fund them for the long term and aggressively expand treatment and rehabilitation options and programs.
We need, in other words, to trade the big problem of escalating opioid deaths for the smaller, more manageable public health problems associated with a regulated supply that prioritizes safe use and opens doors for treatment. We need to give ourselves permission to think anew so that we can say this time next year that we prevented the needless deaths of thousands of opioid users. The sky won’t fall this time, either.
This article is part of the The Making of a Cannabis Industry: Year One special feature.
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