Prepared by Colin Mangham, PhD.

Director Prevention Source BC
Faculty Associate
Institute for Health Promotion Research, UBC

Adjunct Professor
Faculty of Health Professions
Dalhousie University

September 17, 2001

I am pleased to be able to present this brief to the Committee. The issues you are considering are of vast importance. I know you have heard from many individuals and groups already.

I come before you as a community health expert, educator, and professional, and as one who has worked in the substance abuse field in Canada for over twenty years. My work is in the area of prevention, the most misunderstood, most oft neglected and inconsistent, but I think most would agree the most vitally important facet of any drug response. My views are my own and I do not pretend to speak for any organization or government. I have nothing to gain by my testimony except a better society. I certainly have nothing to gain financially or professionally. My views are not consonant with those of so many of the presenters thus far before this committee, and certainly not in the views being promoted by much of the media. Canada, for me, stands for so much that is good, and still right with the world. I believe that if we change our view on drugs, we will be opting for a baser road, and selling ourselves out.

The central message of my testimony today is this:

We must never lose sight of the truth, and the truth is undeniably that drugs used "recreationally" hurt people. They don’t do anything good. They hurt families, which form the very basis of our civilization. They entrap through addiction, they divert from productivity, they lead to antisocial acts, they breed crime, and they attract in particular the most vulnerable among us: the young, the "at-risk", those among us who are vulnerable emotionally or socially. The preponderance of evidence, and common sense itself, tells us that to let our guard down, to accept certain drugs as somehow safe enough to decriminalize – or, de facto, to legalize, to increase the acceptability and availability of substances, will if it will do anything, increase consumption, and send the wrong message to the rising and future generations. Canada can and should do much better than this. I urge the committee, rather than to foster a liberal drug policy decriminalizing cannabis and the reneging on international treaties, to call for increased emphasis on primary prevention of drug use, increased efforts to reduce the incidence of drug use, a renewal of rejection of drug use as an acceptable or viable lifestyle, and renewed efforts to improve the availability and adequacy of drug treatment in this country. These are where the needs lay.

I would like to direct my testimony around the two key issues I see the committee to be considering, that of decriminalisation of marijuana, and that of adopting a "harm-reduction" centred drug policy.

Cannabis, or marijuana, is not in any way a harmless drug. It is a mind-altering intoxicant with distinct risks and special ramifications for youth. It is not the harmless herb, or "no big deal" that those dominating the information waves say it is, so often with vested interest. Let me cite just a few studies about this substance that belie claims that imply it is relatively benign. I limit this to recent, empirical studies published in credible journals or reports. I limit myself to medical issues, which make up only one narrow slice of the entire potential impact of the substance on individuals, families and communities.

We already know and accept that cannabis negatively affects the respiratory system, immune system, short-term memory, and attention.^1,2 As an aside, it is hard to fathom why many of the same persons who are militantly opposed to tobacco use, are actually FOR measures that would make cannabis use easier and more acceptable.

In addition, there have been several recent developments in cannabis research:

• Studies confirm what we have long suspected - that a definite, and acute withdrawal syndrome is associated with cannabis use.^3,4 A withdrawal syndrome is a marker for physical dependency on a substance, and also a marker for treatment.^3,4 It is also a strong indicator that use could be continued to avoid these symptoms. This is no surprise to anyone who has heard the stories of young people who have tried to stop using, as I have so many times. Keep in mind as well that cannabis today is much stronger than the cannabis that some middle-aged people recall from their college days. Instead of the 1 or 2% THC content of thirty years ago, such strains as "Nederweit" and "BC Bud", are reaching THC concentrations of 30 to 40%

• Cannabis apparently has effects on the developing fetus.^5,6,7 Specifically studies are suggesting that use during pregnancy may negatively affect intelligence and development of children.⁷ The American Academy of Pediatrics warns about the dangers of the drug both in pregnancy and when used by young people, based on effects of cannabis on fetal development and adolescent cognitive and social development.

• Cannabis interferes significantly with motor skills.⁸ Given the lack of data collection it is hard to say what percentage of accidents are independently associated with cannabis, but the US National Institute on Drug Abuse estimates that in 4 to 16% of fatal accidents in that country, ⁸ the drivers had consumed marijuana but not alcohol. Research shows clearly the impairment of motor function by cannabis. From our experience with drinking-driving alone, from a public health view we certainly would want to do nothing that might increase the number of users, or consumption, of cannabis.

• Cannabis may have an independent relationship with serious suicide attempts.⁹ This is a distinct possibility raised by recent research. Suicide is one of the leading public health concerns today because of its very nature, and its tendency to occur in such young populations. I do not raise this particular issue as a scare tactic, but as an example of just what we do NOT know for sure about this substance.

• Early onset of cannabis use appears to cause specific attentional dysfunctions, in the form of impaired visual scanning and related functions. ¹⁰

• The "gateway" concept still stands, and recent evidence suggests all the more that cannabis is a key gateway drug. This concept holds that cannabis serves as an introducton to the world of drug use and drug intoxication, that for many, vulnerable, to involvement with other drugs, ultimately cocaine and heroin. Recently the National institute on Drug Abuse reported that neuro-toxicological research suggests marijuana "may alter the brain in ways that increase susceptibility to other drugs." ⁶ Moreover, speaking in terms of public health, we do not wait for prospective studies to issue health cautions. Such studies are difficult to perform ethically with human subjects. But, when we apply several key criteria, we can then accept with fair confidence that a relationship exists. In the case of the gateway concept, there is clear evidence that for person going on to use other drugs, marijuana was the introductory drug, in terms of the experience, the high, and the "psychological barrier" that was crossed, from non-use to use. The metaphorical protective "fence" is crossed with the use of marijuana. All the ingredients are present to warrant a strong chain, from cannabis use to other drug use.

Do these findings mean these things will always happen? No. But, there is plenty of evidence to contradict those who argue for decriminalisation based on the safety of the substance itself. Nor do I raise these points because I want marijuana to be a serious potential problem. As a parent and soon-to-be grandparent it would be nice if I could say, based on the research, that it is harmless and there was nothing to be concerned about. I cannot help but wonder what it is that makes many seemingly educated, sophisticated people defend this drug as though it were a misunderstood and maligned wonder drug. I would say simply, as with all drugs – look at what they do. I would caution us all once again to remember, obvious health effects are but one dimension of the potential problem.

Some who argue for decriminalisation acknowledge the drug can be harmful, but point to the relatively greater costs of alcohol and tobacco as if decriminalizing cannabis is somehow needed to avoid a double standard. Simple common sense calls this thinking into question. I leave it with you to sort through the logic and see the obvious flaws. Lets just keep in mind that in Canada, largely because tobacco and alcohol are legal and more socially acceptable, five times as many people smoke, and ten times as many drink, as use cannabis – even with energetic efforts at control them. So, no question why these two substances carry such relatively high costs. Adding cannabis to the endorsed substance list – and decriminalisation will send such message, whatever else we say- seems ludicrous on weighing the facts.

The key difference in consumption is produced by the role the law plays in influencing the dual factors of availability and acceptability. These two factors are well known to be the key influencers of drug consumption. ^{11,12,13,14.15,16,17}

This brings me to address the second issue the Committee is investigating, that of implementing a harm reduction – based overall drug policy. Again, I will limit my statements to those substantiated by credible literature.

When I use the term harm reduction in this testimony, I do not mean harm reduction as an adjunct strategy supporting prevention, treatment and supply reduction. This already exists, save distribution of controlled substances by the government. I mean harm reduction as it is plainly meant and promoted today, as a shift in policy toward increased acceptance of drug use and a primary focus not on consumption but on reducing certain identified harms.

One implication of such a shift is that there is no evidence it works in the way it is intended, to reduce harms of drug use. In countries that have adopted it, increases in numbers of addicts are reported, and no discernible, substantiated advantage in reducing such harms as HIV, over similar countries with restrictive policies. ^18,19,20,21 I speak here particularly of the recent comparison of the drug policies of the Netherlands and Sweden performed under the auspices of the European Congress, where just such was a finding. ¹⁸

And, Both Swedish and US experiences suggest treatment, not harm reduction, remains the most effective strategy to reduce such problems as HIV and hepatitis in drug users. ^18,19 Sweden has had good success in this area with aggressive, comprehensive and sustained treatment. ¹⁸

It really comes down to what kind of society we want.

A second implication of adopting harm reduction as our drug policy ensign goes back to the availability/acceptability dyad. One truth, supported by the facts and experience of nations, is that decreasing the sanctions against a drug increases the physical, social and economic availability of that drug. ^11,13,15, Consider all the drugs you can think of. The number of persons using them, and the level of their use, will fall out along a continuum with the most available at the top, the least at the bottom. More people drink than smoke, more people smoke than use cannabis, more people use cannabis than use any other illegal drug. Research suggests strongly that consumption of alcohol and cannabis, for example, both correlate with the rise and fall of availability. With alcohol, the best example is the reduced physical availability of raising the drinking age. ¹¹ With marijuana, it is the reduced economic availability of fluctuating price, and the physical availability of how easy and safe it is to get it. ^12,13

The other important part of this dyad is acceptability – how "ok" it is perceived to be to use a drug. Even more than availability, acceptability is affected by legal sanctions. And even more than availability, acceptability appears to influence consumption. Two good ways to estimate the level of acceptability of a drug are 1) perceived risk in using the drug, and 2) perceived social acceptance of the drug. We have found, for example, that in the case of cannabis, use appears to rise and fall even more with perceived risk than it does with changes in availability. ^13,17

A key determinant of acceptability and perceived risk, is the level of sanction against a drug. In a public health approach to drugs, the law plays an important role in keep consumption down and to send a clear message about society’s view on the substances.

In a harm-reduction-centred approach, with elements as espoused commonly by advocates thereof, common sense tells us that both availability and acceptability would rise.

In the Netherlands (we must be careful because substantial social and cultural differences disallow any extended comparison of that nation with Canada), the harm reduction drug policy makes a clear distinction between cannabis and so called "hard" drugs. ¹⁸ Since the policy was adopted, perceived risk of cannabis has declined and social acceptability increased especially among the young. Youth cannabis use has increased fourfold. ^18,19 Cannabis use in that nation, and in most continental European countries, if we are to believe the statistics offered, is still less than here in Canada. But if anything, this warrants even more caution in our country. The propensity toward a problem, and the potential, seems greater here.

An even better example of the influence of acceptability on consumption is found closer to home. In the US and in Canada, throughout the late 70’s and 80’s, we enjoyed a gradual downturn in cannabis use among young people resulting in a low in the US of 27% of high school students who had used marijuana in the last year. ¹⁶ In my province of BC, the same trend occurred and the figure for 1992 was 25%.²² This downward trend is attributed primarily to a decrease of consistent prevention messages, increased availability, and an increase in "pro-pot" messages. At the end of the eighties, and in the early nineties - and I personally remember this - there was a distinct "relaxing of the guard," as voiced by the chief researcher in the Monitoring the Future major longitudinal observation of US adolescent drug attitudes and practices. ¹⁷ Use seemed to be down, and here in Canada the first Canada’s Drug Strategy ended and prevention was not continued as a prime focus within the second wave of the Strategy. Since Health Canada’s Really Me campaign in 1988/89 in fact, we have had NO federal or, at least in BC, provincially funded drug awareness campaign. During this period, according to Monitoring the Future findings, perceived risk of using cannabis declined significantly and perceived acceptance of use increased significantly. Cannabis use began to climb again, and by 1998 was 37% in the US and 40% in BC. ^17,22 Also observed in this period was an increase in messages such as those sometimes seen in the popular media and by pro-pot groups, claiming directly or indirectly that cannabis is a misunderstood, rather benign, natural substance, that even had medical benefits (something that is highly debatable from a research view).²³ And, with the softening of drug sentences here in Canada and an enormous growth in availability in BC, availability also increased. So we see a firsthand example of the importance of consistent, strong drug policy that minimizes availability and acceptability as much as possible.

It should be pointed out by the way that among Canadians aged 15 and over, less than 10% have used cannabis in the last year and around 2% have ever used cocaine or heroin. ²⁴ Thanks largely to the laws, 90% of the population do not use cannabis, and 98% do not use other drugs.

3. It Violates Treaties And Follows Poor Examples

The International Narcotics Control Board has routinely criticized Canada for the apparent drift in drug policy in this country. ²⁵ Reducing the flow of drugs is an international effort. Holland has isolated itself on the drug issue.²⁰ European Cities for Responsible Drug Policy, the body of cities signing the Frankfurt Accord, calling for decriminalisation of cannabis and controlled distribution of heroin, is under stress and beginning to lose ground, according to its own spokesperson in a recent meeting. ²⁶ On the other hand, European Cities Against Drugs, signatory to the Stockholm Accord and stressing a strong, unequivocal rejection of drugs and which includes many of the continent’s premier cities, is gaining ground. ¹⁸ The US and particularly Alaska, Sweden, Spain, and Great Britain have all acknowledged negative experiences with aspects of harm reduction as a philosophical ands policy approach, and have amended or dropped such policies. ^19,26 I am trying to say here, that harm reduction seems to be, as so many fads, rapidly becoming a "been there done that" idea.

In my experience in this field, we periodically glom onto a panacea that we think is going to be "the answer." It is sexy to go after new ideas. But, what is needed is often to just do a better job at what we are already doing.

And so, I recommend to the committee, three things that this country needs to do in terms of looking at its drug policy. Each is based on sound principles, and each stresses improving our work in each area of the drug policy we already have, which emphasizes supply and demand reduction.²⁷

1. I recommend that Canada look closely at the way prevention, and especially primary prevention – the reduction and delay of onset of use in the first place – has been neglected, inconsistent, and marginalized in comparison to other elements of our drug response. We know that prevention can work, if Consistent, Comprehensive, and Durable. I recommend that Canada consider that a harm-reduction-focused strategy would further devalue prevention, our front line of response, and make it more difficult for prevention to happen. I suggest we look at the examples of drinking driving, ²⁸ smoking, ²⁹ nutrition practices and many other behaviours³⁰ that have improved measurably over the past few decades precisely because of consistent, comprehensive and lasting prevention messages and policies. We have learned much about what it takes for prevention to work, as we have come to better understand that it is a long-term process of shifting norms, rather than a short burst or dose of information expected to produce large outcomes. ^31,32,33 I suggest we adopt prevention, not harm reduction, as the umbrella for our drug response. It is positive, and expresses the hopes and desires of society in a much better way than does harm reduction, which can be argued as ultimately representing a "giving up and giving in." Prevention is the best harm reduction.
2. I recommend that we look seriously at the adequacy and accessibility of our treatment systems to the task of helping people to get off and stay off drugs. Europe generally offers much better examples in this regard than it does for overall drug policy. There is a serious shortage of beds in this country and a seriously lack of the comprehensiveness and duration to complete rehabilitation properly. Treatment is the best harm reduction.
3. I recommend that we NOT adopt or continue to use the idea of harm reduction as its principal drug response. Rather, I recommend that current drug laws be left in place as they provide controls on physical and economic availability, and social acceptability. The focus instead should be placed on further reducing the social acceptance of drug use. If any change is to be made in drug laws, I recommend it be limited to offering alternatives to charges and incarceration, such as treatment, community service, or education. Reducing availability and acceptability of drugs through laws is the best harm reduction.

We are privileged to live in what is surely the world’s best country for all around quality of life. Even still we have many problems to address. Many of our children and grandchildren seek the rewards they so innocently assumed they would receive, when they diligently took their lunchboxes and set off to school., but they are having unprecedented difficulty doing so. We have internal divisions that wrack us and cause many in other countries to wonder what in the world we are complaining about. Families are under enormous stresses, and there is a huge need to improve child development and the impacts of poverty. Our growing population of seniors will continue to require a strong, productive tax base to ensure the care they have earned for their old age. It is my humble view, based on all that I know and have experienced; there is absolutely no need to soften our national drug policy. Instead, we owe it to our children to take a strong stand, and strengthen our resolve to reduce drug use through an earnest focus on prevention, treatment, and supply reduction. To the extent that that is a values statement, I can only say that all of the testimony you have heard or will hear somehow reflects the values of those presenting, and any decision reached should the elected representatives of the people debate this issue, should, and hopefully will, reflect the values and will of our nation, not just this Committee or its witnesses.

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