For: Senate Special Committee on Illegal Drugs

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Public Health Framework- addressing drug use: 

Assumptions and Principles

or any population being protected.

Background

Addictions are chronic relapsing brain diseases
Drugs under consideration
Drugs of Use
Drugs of abuse
Drugs of dependency
Treatment and rehabilitation
Legalization of Drug Use
Public Health Framework

Public Health Goals

Individual
Social

A COMPARISON OF THE CURRENT PROHIBITION MODEL WITH THE PUBLIC HEALTH MODEL: 

With the Prohibition approach:

Benefits (intended and actual)
Harms

With the Public Health approach:

Benefits
Primary Prevention Strategies
Secondary Prevention Strategies
Treatment and Rehabilitation
Tertiary Prevention
Harms
Primary prevention

Strategies

Health Promotion
Reduction of Initiation of Use
Supply and Distribution regulation
Secondary Prevention
Treatment and rehabilitation
Tertiary Prevention

Production, Supply and Distribution

Agriculture

Advantages 

Disadvantages 

Executive Summary 

Prohibition adversely affects those who are users, abusers and dependents on drugs in addition to the harm being done to them as individuals from the direct toxic effects of the drugs and from the harm done to their communities from the social and economic costs of the drugs. Drugs are used because of the perceived benefits to the individual, whether due to physical or psychological effects. As the effects of the drugs occur at different areas of the brain, these benefits vary with the specific drug chosen by the individual. For some drugs and some users, the drug causes changes in the brain which result in dependency, either pharmacological and/or psychological. For those who become dependent, the need for the drug, when not available, will become the driving force in the persons activities, even when these activities are detrimental to health. There are also adverse effects which are directly due to the effect of the drug such as impaired ability to perform tasks, impaired judgement, and impaired interaction with individuals and society.

Bioethics gives an approach to the interactions of health service providers and patients. Similarly ethical considerations can guide a public health approach to drug use. The public health approach is based on a consideration of effects at the community as well as the individual level. It is based on the principle of maximizing the health of individuals, that is their ability to achieve their physical, mental and spiritual potential in their community, through beneficent, equitable and fair means and maximizing the benefits to their community while limiting the harm to the individual and the community.

A public health approach is based on the sound planning principles of developing the goals and objectives, implementing those objectives and evaluating the results. The public health goal is to maximize health at both the individual and community levels. While prohibition is one possible means to achieve the goal, it has failed to achieve individual or community health goals. Evidence based prevention, treatment and rehabilitation strategies have a much higher probability of achieving the goals and are much more flexible in responding to new needs indicated by ongoing evaluation of the attainment of the goals.

This framework is based on legalization. Legalization in this context is the removal of prohibition based criminal laws and their replacement with evidence based, individual and community health oriented regulations and where necessary civil and criminal law. The regulations would be designed to maximize the benefits of drug use, based on the individual’s informed consent for both desired and adverse effects, and the reduction of the harms to the individual and the community from use of the drugs.

Current drug policy as evidenced by Canada’s drug laws is responsible for many preventable illnesses and deaths of Canadians. 

Legalization and regulation using established public health methods will reduce the numbers of illnesses and deaths due to illicit and perhaps even licit drugs. It will reduce disease and disability among those who are users, abusers and dependents of drugs by a combination of prevention and treatment through evidence-based regulation.

Legalization of drugs will result in informed consensual use of drugs to prevent abuse and dependency and treat these conditions when they do occur 

Legalization will bring under community control the resources which currently are in the underground, illegal economy and greatly weaken the unregulated organized industry that supplies a variety of drugs. This will result in the protection of the consumer from wildly varying potency and adulteration of product. 

Legalization will return to civil society a group of people now at great risk to their health due to laws that impair their ability to reach their full potential as human beings. In the case of those who are dependent on drugs, legalization will assist the health care professions in the prevention and treatment of dependent people’s chronic relapsing brain disease. 

Public Health Framework- addressing drug use: 

 Assumptions and Principles

The framework is based on ethical considerations and principles.

If there is a single paper that describes the scientific basis for a public health ethics approach to managing illegal drug use and addictions, it may be the paper by Geoffrey Rose, Sick Individual and Sick Populations. Rose discusses looking at disease and prevention from the perspective of both the individual level characteristics and risk factors, and the community level distributions of illness. He states that the priority should always be the discovery of causes of illness in individuals and the application of this knowledge to populations as the basis of prevention or harm reduction. Weed, in a commentary on Rose’s thoughts, states that the ethics of public health is "an ethic of shared community responsibility; it is an ethic with beneficence and respect for population (and people) at its core; it is an ethic of human rights and social justice, of commitment to the ideal inquiry of objective science and to the careful application of technological knowledge". 

Jonathan Mann, former head of the World Health Organization AIDS programs, has explored the issue of the community application of medical ethics and states that individual ethics are to medicine, as human rights are to public health. The population-based approaches differ from the individual-based approaches of bioethics. They form an approach based on the health of communities and on the determinates of health in those communities. This approach dictates that public health seek to insure conditions in which people collectively and individually can be healthy. It dictates that the health of one group cannot be sacrificed because of perceived but not proven risks to another group. 

In clinical or one-to-one medical practice, the patient must give informed consent before any intervention is undertaken. This consent can only be given if the risks and benefits of the intervention are presented and understood. The public health ethics approach is based on populations, and it is not clear how a population can consent to a public health intervention. While the benefits and the risks need to be considered, who consents to the intervention is less clear. In the case of a law, such as drug prohibition, the elected lawmakers must assume the burden of consent on behalf of the population. They must ensure that the law does not unfairly discriminate against a population in the community. 

The displacement of risk from one group to another must be carefully considered. An example of this is the use of air bags. Although the risk of to adults was decreased, the risk to infants and children was increased. This increased risk was neither anticipated nor consented to and hence this risk displacement needed to be corrected as soon as possible, an action that has been done. In the original thoughts on drug use, it was the protection to the public from the availability of drugs increasing the number of drug users and from risks of the actions of drug users that was the basis for prohibition. The displacement of the perceived small risks to the public has dramatically increased the real risks and harms taken by drug users, and was not carefully considered in the light of current thinking on the ethics of public health. In my view, this balancing of potential small risks to the public with the actual huge costs/risks and harms to the user fails to meet a reasonable standard of public health ethical practice. 

Medicine in general is not morally judgmental and public health approaches are no exception. Thus while the prohibition of drugs remains one option for consideration, it is not a morally mandated pre-condition for a public health program.

Benefit outweighing harm is the basis for the public health framework 

One of the principles of public program planning is to include goals and objectives for the policy and specific criteria for the evaluation of those objectives. An intervention must be evaluated to ensure that the intended benefits of the program are achieved and that the harms, whether intended or unintended, are acceptable when compared to the benefits. The evaluation of laws using public health approaches is not common, although economic principles are being utilized more frequently. Evaluation requires that the outcome desired by the law be explicitly stated and quantified. Once this has been done then the outcomes achieved can be addressed and the effectiveness of the law in achieving its stated goal(s) can be assessed. Failure to achieve a goal mandates revision of that law. In most evaluations of the harms and benefits of current drug laws, the "fact" of the law being and remaining in place is assumed and hence the benefits and harms are measured from this viewpoint. The public health framework explicitly does not make that assumption. Rather it is based on an evaluation of whether the current prohibitionist approach results in the greatest benefit: harm ratio for the population.

The outcome measure for prohibition is not explicitly stated. It could be prevention of all use of the prohibited drugs, or a more modest goal of reduction in use, perhaps in specific populations or communities at risk. The former has failed. The latter has never been clearly stated but if it were, then there would need to be careful measurement to ensure that the outcome reduction in one population was not at the expense of worse outcomes in another population. The devastating adverse outcomes or harms are relatively easy to measure. The offsetting benefits in that user population or another populations are not easy to measure, if indeed there are any such benefits or any population being protected.

Individual benefit/harm

Individual benefits and harms include the pharmacological effects of the drugs, which are considered desirable to the person taking the drug. These can be, for example, the amelioration and relief of pain, reduction in nausea and other symptoms, increased alertness and a feeling of well being and euphoria. It also includes adverse effects, acute and chronic toxicity, and dependence on the drug.

Societal benefit/harm

Society benefits from drug use in so far as drug use allows individuals to continue to meet their aspirations, satisfy their needs and cope with change in their environment. Society also benefits from the overall economic activity as far as that activity supports the collective needs. Harms to society include those which result in an individual no longer participating, the effects and costs of illness and disease due to the use of drugs, and the actions of drug use that are antithetical to societal goals and objectives.

Balance between these ratios where they are in conflict

The balance between personal and societal actions is a source of ethical debates. The libertarian arguments of Mills and the Kantian views are individual centered. There are communitarian views however that stress the need to consider the effects of actions on the community as well as the individual. By virtue of public health activities being a community’s response to protecting its collective health, the communitarian view is more relevant to the public health ethical framework.

Addictions are chronic relapsing brain diseases

This principle has been accepted for alcohol. The basic pathway for the dependency to alcohol is similar to other addicting or dependency producing drugs. Therefore the medical and public health approaches to drugs are based on the designation of dependency as a brain disease, however induced. Among the characteristics of the dependency is that it is a chronic and relapsing disease. These observations have clear implications in both treatment and prevention. The pathway for the dependency component of drug use is via the reinforcement and reward center of the brain.

Drug use

The terminology of drug use adopted for this paper is that of the Institute of Medicine Report Pathways of Addiction. They have adopted a terminology that most clearly allows the differing aspects of drug use to be described. Their terminology is used throughout this paper.

User

Any individual who has tried the drug under discussion. A current user is one who has used the drug within the specified time period.

Abuser

A person who uses the drug to excess, such as with binge use. The drug has caused either illness, personal or social difficulty.

Dependent

A person who uses regularly and at a frequency that is determined by the need to maintain a level of balance in the brain reward system. If drug is not available, this person will seek out drug in spite of the personal, social and financial costs of obtaining the drug.

Compensated

A dependent person who is able to function at or nearly at a normal level

Tobacco dependent person may be the clearest example of this group

Decompensated

A dependent person whose drive for drugs has resulted in major personal and social dysfunction, for example, an individual who has lost his or her social support systems and financial status. This sub-group is associated with but not limited to the addict in skid row depictions.

The ratio of users to abusers to dependents varies with the drug in question and the social context in which the drug is used. There are persons who are users of all the drugs under consideration. As can be seen in this reference, there are varying user: dependency ratios, from 32% for tobacco, 23% for heroin, 17% for cocaine, 15% for alcohol, and 9% each for tranquilizers and other prescription drugs of this class and marijuana. Other surveys (same reference) have found dependency rates for marijuana of 5% versus 14% for alcohol and 36% for tobacco at some time in the surveyed person’s life. While many discussions of drug use revolve around drug dependency or addiction, there are more drug users than drug dependents and hence the benefit: harm ratio must include those who are users as well individuals who are dependent.

Drugs of Use

These drugs are under varying levels of legal control but in the usual mode the effects of the drug are those intended by the users. All of these drugs have properties that are considered desirable and beneficial by the user, either due to the direct effect of the drug or due to the reduction of some noxious symptom. These effects, while they may involve the brain’s reward system, may include other centers in the central and peripheral nervous systems or other organ systems. Even when the user is dependent on the drugs, there may still be a desirable and beneficial effect of the drug quite separate from the brain reward system and dependency.

Drugs may be available in relatively pure form (i.e. cocaine) or be available in a much more "raw" form in association with other substances (i.e. nicotine in tobacco). It is often the associated substances; impurities ,adulterants and additives that cause the harm from the drug taking.

Drug concentration is also ad important factor in causing harm. The increase in concentration of street heroin resulted in many deaths of users that were used to using a more dilute form of the drug. These are the inadvertent drug overdose deaths that have been an epidemic in BC

Caffeine
Tobacco (nicotine)
Alcohol
Prescription drugs
Sedatives (i.e. Valium)
Painkillers (i.e. Codeine)
Stimulants (Appetite suppressants)
Steroids

Illicit drugs

Opiates
Cocaine
Marijuana (THC)
Khat

Drugs of abuse

The effects of the drugs are such that the usual controls by the user are changed by the action of the drug itself. An example is the removal of inhibitions by alcohol that result in increasing use until the central nervous system depression caused by the alcohol results in discontinuing the ingestion. The loss of inhibitions can result in actions that the individual may not carry out except under the influence of alcohol. Cocaine is similar but the mechanism is one of excitement rather than depression of CNS function. Binge use is the usual mode of cocaine use.

Alcohol
Cocaine

Drugs of dependency

These drugs act on the brain’s reward system and set up a physiological need to use the drug to maintain homeostasis. The other effects of the drug are still present but the stimulus for use is the need to maintain the balance of the reward system. If the drug is not immediately available, the dependent person will attempt to obtain the drug irrespective of personal, social and economic cost. As well as the physiologic dependency, there may develop a psychological dependency that is not based on the reward system needs but rather on the other effects of the drugs considered desirable by the user. This form of dependency does not result in physical withdrawal symptoms if the drug is not available.

Physical Dependency

Tobacco
Alcohol
Opiates

Psychological Dependency

Marijuana
Cocaine

Treatment and rehabilitation

Treatment and rehabilitation are not the usual responsibility of public health services other than assuring that treatment and rehabilitation options are available to those that need them. This framework will assume that treatment and rehabilitation facilities are available or will advocate for greater availability within the resource constraints of the health service system. Treatment and rehabilitation are necessary services but the public health focus is on prevention.

Legalization of Drug Use

In the context of this paper, legalization refers to the removal of criminal sanctions from the production, manufacture and distribution of drugs as currently covered by the Controlled Drugs and Substances Act ( 1996, c. 19 ). What legalization is not is decriminalization which maintains the statutes currently in place but has an administrative program to not enforce the law. Legalization however does not require that law not be a part of the regulation of drugs. Such statutes as the Natural Products Act can apply. Similarly regulations for the manufacture of drugs should apply as they are needed for the protection of the user. The major difference is that the acts and regulations in place are for the protection of the user rather than the prohibition of use. Regulations at the provincial and municipal level can also be in place in terms of place of use, prohibitions of activities while impaired, protection of others from harms and nuisances such as second hand smoke. Legalization would require that Canada withdraw from those treaties which treat some drugs as prohibited substances. As noted above, it is clearly unethical, from a public health perspective to have laws which are responsible for the illness and death of Canadians when those illnesses and deaths are attributable to the law.

Public Health Framework

A public health framework is one based on individual and community ethical considerations which strives for the maximization of health for individuals and communities with the minimal harm to either. The framework is grounded in public health practice based on primary, secondary and tertiary prevention plus treatment and rehabilitation. As with medical practice in general it makes no moral judgments. The public health policies that derive from the evidence based review of the issues meet the overall goal of respect for autonomy, non-maleficence, beneficence and justice as applied to the individual and to the community. 

Public Health Goals

The overall goal of this framework is to allow people to make informed choices as free from undue influence as possible. Decompensated dependency is an outcome to be reduced or prevented. The toxic effects of the drugs must be balanced by the individual and by the community against the desirable effects of the drugs. All cultures use drugs in some form for relief of noxious symptoms however those symptoms arise. This includes relief of pain but also includes the management of various stressors. These stressors may be individually chosen or may be imposed by society. However the stressor is imposed, assisting the individual in their choices of managing health needs to minimize risks while achieving the individual’s goals for their health is both an individual and a public health goal. In addition the public health goal must take the community benefits and risks from a population health perspective into account. This framework is proposed as an attempt to achieve a reasonable, acceptable balance of individual choices and community resources.

Reduction in stress to manageable levels
Social group functioning
Productive work
Pleasure

Reduction in overall mortalit:y as with low doses of alcohol (a J or U shaped health effect with moderate doses being beneficial. No alcohol or high doses being associated with higher mortality)

This includes the cancer and heart disease effects of tobacco and the liver damage caused by alcohol. The effects on the heart of cocaine fall into this category. The prevention of effects on the fetus is also a direct toxic effect.

There have been over 2400 inadvertent overdose deaths in BC since 1992. They have been in all areas of the province. The Chief Coroner,. Vince Caine, produced a report on these deaths in 1996. At that time he advocated strongly for legalization of drugs to prevent these needless deaths.

HIV 16% of HIV positive, over 25% for the past 6 years

Hepatitis C 85% of users in Vancouver’s Downtown east side are positive

Hepatitis B Immunization has reduced risk but was at one time very common (similar to HC rates currently

Bacterial endocarditis due to injecting organisms

Fungal Candida albican infections including heart valves

The reduction of driving while intoxicated is an example of reduction of harm to bystanders. Reduction of theft of personal property, etc.

Abuse and dependency can have marked effects on social functioning. The violence associated with the loss of inhibitions with alcohol is an example. Although not a drug effect, one of the "purest" addictions is to gambling, particularly video lottery terminals as they are designed to have reinforcing effects on the brain’s reward system. The effects of the dependency of gambling on families is dramatic and are an example of social harm even though there are no direct toxic effects to the user of this dependency.

One of the dramatic results of the Swiss program to supply heroin was the assumption of a productive life by many of the addicts enrolled in the program. It is estimated that 80% of the users in Vancouver hold down full time jobs. One of the problems of dependency when the supply of drug is both expensive and irregular is that the dependent person spends time and resources on the acquisition of drugs. When the drug is available, as with tobacco, most dependent people can continue with a productive life style. Assisting individuals to achieve their potential is a goal of public health, regardless of disability or dependency.

As a sometimes-bitter experience has shown, there is another player in the goals of drug use and that is the industrial goal. The tobacco and alcohol industries have worked very hard and invested large amounts of money in maximizing their profits even when the adverse effects of their products were clearly known. There will be equally powerful industrial efforts in maintaining the status quo as the illicit drug trade is a major international industry, or if legalization occurs in developing a legal industry that maximizes profits. The estimated value of the BC production of marijuana is a six billion dollars a year industry and the largest primary producer in BC.

However, the huge industrial complex behind illegal drugs will fight with all of the means in its power to maintain its profits, and there will be large resources behind these efforts. This corrupting influence will not necessarily be easy to detect except that the underlying strategy will be to maintain the business of prohibition, whether for the producers, the manufacturers, or the distributors.

Currently the alcohol and tobacco industries use sophisticated methods of marketing to create and maintain their markets. These include developing a product for a specific, target audience, promoting the product to that audience, pricing the product based on the resources of the target group and making the product easily and widely available. The public health framework, while it recognizes the infrastructure that will be needed for legal drugs, should be very wary of creating or supporting an industry that will ultimately exist to maximize drug use rather than having the goal of maximizing the benefit: harm ratio for users.

 

Benefits (intended and actual)

Reductions in availability of drugs by preventing access. The actual situation is that use is widespread and access is easy. This system has generated and supported a major illegal infrastructure for the supply and distribution of drugs, without regulation of quality and without regulation of sales

Growth, distribution and supply and use are now criminal activities, uncontrolled and unregulated

Prohibition limits the range of responses that can be made to drug use. The criminal justice system is the tool used by this system. This has several effects. An underlying principle is that for great rewards, great risks will be taken, whether the risks are legal or illegal. The individuals who are taking the risks will perform their own benefit: risk analysis and act accordingly. They will also protect their rewards as best they can. All of this system is based on the observation that when people are offered these drugs, some will take them. There are sufficient users to offer great rewards to the system that supplies the drugs, without any controls being applied except prohibition. This is a very limited response system. This system puts the users at maximum risk as it rewards the distribution of product that is most easily supplied, often the most concentrated product. It also rewards the mode of use that is most rapid, even though it has the highest risk, so that the drug will not be confiscated. The criminal justice system cannot meet the underlying principles of maximizing health by putting people in jail. The distributors have no reason, other than personal resources, not to try to have as wide a market as possible, including recruiting all age groups to use. This approach maximizes personal and social harms.

Reduction in use

Initiation of use. There is now considerable experience with both alcohol and tobacco in methods of reducing the initiation of drug use. Although experimentation may occur, regular use can be discouraged by several means including pricing, availability, use restriction, and educational materials that are accurate and true. Reductions in abuse can occur in regulations that require the provider of the product to discontinue service when the patron has reached a pre-determined stage of impairement.

Reduction in moving from use to abuse to dependency

Giving users point of use education, making sure that experimentation does not result in disease or death due to lack of knowledge. Use of single use sterile syringes. Availability of counseling and other service to assist users in remaining users only and in helping them limit adverse and toxic effects over both short term and long term use.

Reduction in relapse occurrences.

Dependency is a chronic relapsing disease. As with other chronic diseases, treatment and rehabilitation cannot be predicted on abstinence without adequate provisions for the nature of the disease. Successful strategies for the treatment of dependency

Primary prevention

The public health strategy recognizes that there are powerful determinants of use and that primary prevention will not be completely successful. This recognizes that for some individuals the strategy is to reduce the amount of harm that is generated by the individual’s choice to reduce the individual’s stress. The individual’s right to choose stress reduction and their method of reward satisfaction is recognized. The choice must be made on the basis of informed consent and when made be as safe as possible given the drug chosen. For example, tobacco with its very high dependency ratio, and its very high rate of toxicity is a poor choice. Alcohol is a better choice if abuse can be prevented, such as driving after drinking. Alcohol in moderation is associated with few if any toxic effects and has now been associated with an overall reduction in mortality, i.e. a beneficial effect. It has been associated with an effect on the fetus however and is not a good choice for women who are or may become pregnant. Alcohol when abused however is associated with violence due to the loss of inhibitions and is not a good choice. Marijuana is a better choice than tobacco as the toxicity is mild and limited to long term lung function reductions. The dependency ratio is low. It does not affect pregnancy. Opiates have a risk of dependency but have very low toxicity and good reward/ stress reduction properties. Cocaine has a risk of abuse but also is a potent stimulant that enhances performance. Among the harms of opiates and cocaine is the method of use. Intravenous use is extremely risky in terms of the need for a precise dosage and sterile equipment for use. Smoking opium or nasal ingestion of cocaine are much safer.

Education and Advertising

Education includes delivering information about using the least harmful means of managing the stresses of life. With legal drugs however the contrary issue is that advertising is one of the ways that sellers use to promote use. This has been well demonstrated with tobacco.

Alternative methods of rewards

As the reward system in the brain is present to encourage certain activities, such as eating and sex, the assumption that with these activities there are not potential and actual harms is incorrect. At least some overeating is due to the need to stimulate the reward system and over-ride other mechanisms that indicate more food is not needed. At this time research is needed in finding ways to bypass this system to reduce the dependency on this system.

Peer pressure experimentation

Probably not much to be done except information on the pros and cons via school, media etc. Not likely to be very successful

Casual or spur of the moment use

Regulations that reduce the ability to acquire the drugs except as a planned act

Products for oral ingestion or smoking, not concentrated

Examples are khat, coca, marijuana and tobacco. Existing and proposed legislation for natural products in terms of purity, concentration and claims can be applied to this group. Material must be present at point of sale on effects and side effects. Such regulations as age-restriction on sale

needs to be examined for the evidence for effectiveness. If this evidence supports age restrictions and refutes less controlled use, they can be applied on a product by product basis. If the evidence does not support age restrictions at point of sale or point of use, then there would be no regulation.

Processed or concentrated products

Examples are hashish, opium, cocaine, and alcohol. There can be point of use regulating the establishment of licensed premises as are used with alcohol. The providers will have similar rules about use to the point of abuse. Licensed premises would be able to elect to able to offer a wide or limited range of products for on site use.

There would be no advertising of specific products except at the licensed establishment. Regulations would include educational requirements for staff on the use of specific products

Off Site Sales

Similar to alcohol, these could be regulated by specific licensure or government controlled agents. One requirement would be the provision of information materials on methods of use, adverse effects and prevention of abuse and dependency at the site.

Such distribution as with establishment sales would be controlled by regulations to prevent commercial advertising beyond that found for the point of use establishments. Restrictions on age, as with all of the regulations would be evidence based, with the goal of maximizing the public health goals, not the commercial goals.

Injectables

Examples are heroin and cocaine. Product intended for use at home would be supplied by pharmacist or equivalently trained and licensed person under conditions suitable for intravenous injection. The provision of information on safe use would be supplied. The decision to use such a product would be made by the individual however, not a physician or other health professional. It would be the responsibility of the pharmacist to determine that the user was as informed as possible. Safe site use would also be an option as long as the availability met the needs of those who are dependent on the drug. The criteria, especially age criteria need be carefully considered with respect to the danger of injection noted below. The purpose of the regulations would be to discourage experimentation, but when it is done, it is done as safely as possible.

Using injectable drugs is a very major health risk. At least two issues need to be addressed, inadvertent overdose and infectious agent transmission. Having a known concentration(s) of injectable drug so the user knows exactly what they have can eliminate inadvertent overdoses. This will not prevent intentional overdoses or overdoses administered by another person but will require intention, even if consent may be reduced or absent due to prior drug use. Infection is transmitted because of contamination of the syringe, needle or its contents. The needle and syringe can be kept contaminant free by single use needle and syringe technology. The drug and diluant would be pharmaceutical grade and hence not contaminated. As sharing is the way that several infections are transmitted, the single use syringe and the single dose distribution should reduce if not eliminate this major health issue.

Secondary Prevention

This stage recognizes that primary prevention has failed and the individual is a user of one or more products. Many of the provisions of limiting access also act as secondary prevention in terms of information availability; restricted places of purchase, restricted use areas and age restrictions. It needs to be recognized that dependent people may be quite functional, for example tobacco dependent persons. In other cases the effect of the drug itself make the user non-functional in some settings for the duration of drug use. This may be dose dependent as in alcohol use, although any level may impair some functions. The euphoria with opiates would reduce functioning. However, as with tobacco, dependent individuals may be able to function well between uses. For most drugs, alcohol being an exception, even with dependency continual use or continual drug effects are not necessary or desirable, but rather episodic use is more common. With cocaine and alcohol, there are binges where continual use may occur, with marked impairment of function.

Treatment and rehabilitation

Treatment must be available for those who have adverse effects of the drugs whether due to allergic or idiosyncratic responses or due to drug effects themselves. The class of drugs most prominent in this area is the hallucinogens. However with overdoses all of these drugs have direct pharmacological responses. With control of inadvertent overdoses, some deliberate overdoses will occur and require emergency response. The acute effects are currently treated in detox centers. These and hospitals need to be equipped to deal with these problems. With drugs being taken in controlled circumstances and under observation of non-affected persons, acute effects will decrease.

The second area of treatment and rehabilitation is for dependency. Drug substitution i.e. methadone, can be used, if it is in fact safer. Treatment and rehabilitation of dependency is not within the scope of a public health framework, but it is a crucial companion to any strategy.

Tertiary Prevention

This consists of relapse prevention programs such as Narcotics Anonymous and Alcoholics Anonymous programs as examples. Peer support is crucial. These programs are not as well developed as they might be due to the illegal nature of some drugs. Addiction is a chronic relapsing brain disease and this inherent nature needs recognition in designing programs to reduce relapse.

Agriculture

The basic materials for the drugs under consideration are produced by agriculture. That there is already major production is evident. In BC production of marijuana is estimated at 6 billion dollars a year. Illegal drugs are a major commodity worldwide. With prohibition, the production of those drugs is outside government channels for marketing and taxation. Rather the farmers must sell outside legal markets. It also means that those who buy use methods of commerce that may result in farmers being forced to sell without the usual competition to maximize the return to the producer. It also means that land which could be used for production of these crops is either used for less economic production or not used at all. The potential for revenues for governments is clear. The potential for market forces to adjust both prices and suppliers is also clear. Several rebel movements have been funded by illicit drug production, most notable the Taliban in Afghanistan. They banned production for religious reasons in approximately 1998. Other movements have used this source of funding to destabilize legitimate governments. Prohibition has also diverted funds to control that could be used for health and social services in the country. Taxation of these sources would supply more funds for government programs such as Health for All. In Canada, marijuana production is a major, but untaxed industry. The growth of industrial hemp is curtailed by regulations designed for prohibition of marijuana. This is a loss of potential for agriculture and secondary industries.

Manufacture, Supply and Distribution

Tobacco gives an example of manufacture and distribution that is counterproductive to public health goals. While recognizing the right of individuals to choose to use if they wish, the industry in order to maximize profits, pushed use through advertising and sponsorship. With the potential profits from the drug trade, the regulations will need to be equal to the task of keeping public health as the overriding principle. Current regulations on prescription drug advertising are examples of limiting marketing. Alcohol advertising regulations are similar examples. Distribution needs to follow the regulations proposed for herbal or natural products for those products taken orally or smoked and for pharmaceuticals for those products injected. Those products that are concentrated over the natural source will require more regulation than those that are in their natural (low concentration state) will. With increasing concentration the user needs more information on dose and control to reduce overdose risks and risk of abuse and dependency.

Opposition

There will be predictably several arguments against legalization. Firstly will be those who give the basically "moral" argument that it is acceptable for government to make rules on behaviours that harm mainly if not exclusively the person who carries out those behaviours. This argument accepts that the criminal sanctions are needed to reduce the risk of harm to others. It accepts that the harms demonstrated for illicit drugs of inadvertent overdoses resulting in death, modes of use resulting in infections such as HIV, HC and HB are necessary to protect others. It implies that use is not a choice to make in an informed manner but one to be proscribed. That this approach has been not only unsuccessful in stopping drug supply, distribution and use but has resulted in many deaths and many individuals being jailed seems to be acceptable to those who support prohibition as the most effective option.

Among those who will also support continued prohibition are those who benefit directly from these laws. Police, the judicial system workers and prison system workers all directly benefit from prohibition. Although they have a voice, they are biased by their own need for justification of their previous and ongoing acts and for their need for income security. They are similarly compromised, as are tobacco company officials who have argued so strenuously and until recently successfully against the harms of tobacco.

Although legalization of drugs will change the criminal mosaic of Canada, it will not eliminate or necessarily even reduce the need for police. There are many under-policed segments of the law that protect the innocent from a variety of predators.

Advantages

In a relatively short time, the health care system should also see a reduced demand for services. With sharing of injection apparatus reduced, the blood borne transmission of viruses should also decrease.

There will be a substantial shift in revenues based on taxation policies developed for these products. Agriculture will benefit with more choices of cash crops. The hospitality industry will benefit with a greater range of services to be offered. Some of the revenues will need to be put into place to strengthen acute and long-term treatment availability. This is not necessarily because of an increased need but to meet current demand.

The public health model is intended to reduce the numbers of people who are considered criminals and who are being presented to the court system and the penal system because of drug related charges. Many people who currently have marijuana possession records should have their records removed from the justice system. The extent of criminal activity to support drug use will be reduced, depending on the costs controlled by the supply and distribution and taxation. Those revenues generated will be through licit and taxable channels resulting in loss of income for organized crime syndicates.

Disadvantages

It is very likely that drug use will at least apparently increase for a transition period. Drug use varies with social changes and will continue to do so. Although there may be reductions because use is no longer rebellion against authourity, this may be offset by increased use. There will be only marginal, if any, increased availability as the current drug trafficking efforts are extensive at all ages and especially among youth. With public health regulations there may be a decrease in availability and certainly an increase in safety of supply.

There will be international repercussions from those states that believe that the sacrifice of their citizens to drug laws is justifiable. Such is not a very strong reason to allow Canadians to die unnecessarily and preventably.

Conclusions and Recommendations

Current drug policy as evidenced by Canada’s drug laws is responsible for many preventable illnesses and deaths of Canadians.

Legalization and regulation using established public health methods will reduce the numbers of illnesses and deaths due to illicit and perhaps even licit drugs. It will reduce disease and disability among those who are users, abusers and dependents on drugs by a combination of prevention and treatment through evidence-based regulation.

Legalization of drugs will result in informed consensual use of drugs to prevent abuse and dependency and treat these conditions when they do occur

Legalization will return to civil society a group of people now at great risk to their health due to laws that impair their ability to reach their full potential as human beings. In the case of those who are dependent on drugs, legalization will assist the health care professions in the prevention and treatment of dependent peoples chronic relapsing brain disease.