Harm Reduction Comes of Age in Canada, or Does It?

The Supreme Court of Canada’s September 2011 decision allowing Vancouver’s supervised injection site, Insite, to keep operating was a critical milestone for harm reduction in Canada. One only has to look at the list of interveners in the case in support of this innovative service to see that it has become a valued and mainstream service in Canada. Canadian health organizations including the Canadian Medical Association, Canadian Nurses Association, Canadian Public Health Association and 11 others saw fit to come before the court to support Insite. But even with this high level of support, scaling up harm-reduction services in Canada remains a challenge.

Harm reduction gained traction as a result of the HIV/AIDS crisis in the early 1980s and played a critical role as a strategy to engage injection-drug users in HIV prevention. Harm reduction’s more recent challenges have elevated the critique of policy-related harms – harm caused by policies that criminalize people who use illegal drugs.

ImageHarm reduction acknowledges that there are significant risks associated with illegal drugs and also attempts to work towards mitigating harms within the criminalized environment where drug use occurs. This often puts the public-health goals of engaging people who use drugs in conflict with traditional public-safety strategies that rely on disruption of illegal drug markets, and in turn disruption of the lives of people who use illegal substances.  Harm-reduction approaches balance these realities and focus on creating safer environments as much as possible within a context of criminalization. Some examples include promoting supervision of consumption or discouraging using drugs while alone, promoting rapid response strategies in the form of peer-delivered naloxone programs and strategies that work towards achieving a kind of détente between health efforts and enforcement practices. Given the context of criminalization, a key goal of harm reduction is to maximize the benefits of public-health interventions and minimize the harm of drug use and the enforcement of drug policy.

So what should Canada be doing to facilitate the development of a more robust harm reduction approach as a part of a comprehensive response to drug use? We urge governments to begin with a review of current drug policies to determine the benefits and harms to individuals and communities that accrue from the criminalization of drugs and the people who use them.

Other countries have done such an analysis and have decided to eliminate criminalization as a response to possession of drugs for personal use in an effort to maximize the benefit of a public-health approach to drug problems. Portugal (2001) and the Czech Republic (2009), are two examples of jurisdictions that have taken this step. Both have decriminalized all drugs that are deemed to be for personal use. Portugal decriminalized drugs as part of a response to an HIV epidemic and high rates of drug overdose. The Czech Republic did the same as a result of an extensive evaluation of the previous policy of criminalization.  Evaluation of the experience in Portugal has shown that results have been positive overall – HIV incidence and overdose deaths have been reduced, police are supportive of the new law as it has given them more meaningful and helpful involvement in steering individuals towards health services, more people are accessing treatment and other health services which were improved as a part of the decriminalization policy. Additionally no negative trends have been seen in terms of increased harms attributed to this policy change.

Achieving a policy shift as significant as decriminalization will take some time. In the meantime, the Canadian Drug Policy Report, Getting to Tomorrow, outlines some possibilities for improving the development of harm reduction in Canada in the short term:

  • Acknowledge that harm reduction is much more than supply distribution and is an essential component of a comprehensive public health response to problematic substance use that offers client-centred strategies with health engagement at their core.
  • Acknowledge that harm reduction values the human rights of people who use drugs and affirms that they are the primary agents of change for reducing the harms of their drug use.
  • Provincial governments can commit to articulating harm reduction strategies across mental health, addictions and infectious disease policy frameworks.
  • Where harm reduction language is present within policy frameworks ensure implementation at the community level.
  • Support innovation at all levels. An ethic of experimentation will help create an environment where new ideas and novel approaches can be developed and explored.
  • Provide leadership to bring health and policing agencies together to get “on the same page” with regard to harm reduction. Opposition by some in the policing community is unfortunate and an unnecessary barrier to scaling up harm reduction programs.

Developing a robust and equitable harm-reduction approach for Canadians will necessitate new thinking about old strategies —thinking that exposes the harms that flow directly from our current policy frameworks and will open the door to new ideas and approaches that are emerging around the world.

Author: Donald Macpherson, Executive Director of the Canadian Drug Policy Coalition

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

The New “Marihuana for Medical Purposes Regulations”: Will they improve access?

Between 420,000 and a million Canadians use cannabis (marijuana) for medical purposes to alleviate symptoms such as pain, nausea, appetite loss and muscle spasms associated with medical conditions such as cancer, HIV/AIDS, arthritis, multiple sclerosis, glaucoma, migraines, and epilepsy, to name a few. In 2001, the Marihuana Medical Access Regulations (MMAR) were established by the federal government allowing Canadians to possess cannabis for medical purposes without fear of criminal sanction. With this authorization to possess cannabis, Canadians had three legal options to obtain a source of cannabis: 1) purchase cannabis grown under contract for Health Canada, 2) obtain a license to produce their own or 3) designate a person to produce cannabis for them.

Since that time, approximately 35,000 Canadians have obtained authorizations under the MMAR. This still only represents a small fraction of the actual number of medical users of cannabis in Canada, suggesting that there are barriers for access in this program. Barriers include difficulty finding a physician to support an application, dissatisfaction with the quality of the cannabis available from Health Canada’s supplier (which only offers only one strain of cannabis), and cost, among others.

As a result, many people rely on unauthorized sources of cannabis such as friends, acquaintances or street dealers for their supply. In addition, Canada has approximately 50 medical cannabis dispensaries (a.k.a. compassion clubs) which currently serve about 40,000 Canadians upon recommendation of a healthcare provider. Despite court decisions which recognized the value of the services provided by dispensaries, they are not included in the legal framework.

In June 2013, the government of Canada enacted new Marihuana for Medical Purposes Regulations (MMPR), and the existing Marihuana Medical Access Regulations (MMAR) will be repealed as of March 31, 2014. So what does this mean for Canadians who wish to use cannabis to alleviate their symptoms?

The good news is that under the new MMPR, people who wish to use cannabis for medical purposes will need to get a much more simplified medical document, similar to a prescription, directly from their physician or from a nurse practitioner. This document will then be submitted to one of several new licensed commercial producers which will provide a variety of strains to several clients. However, physicians continue to be reluctant to support the use of cannabis for medical purposes since their professional associations, colleges and insurers express concerns about the lack of sufficient information on risks, benefits, and appropriate use of cannabis for medical purposes. It remains to be seen whether a simplified process will address this barrier.

The bad news for many is that the 28,000 Canadians who currently are licenced to grow their own cannabis or have a designated grower will no longer be allowed to do so. Of particular concern if people continue to produce their own is the Safe Streets & Communities Act: Increased Penalties for Serious Drug Crime currently in effect in Canada which imposes Mandatory Minimum Sentences of six months to 14 years for the production of six or more cannabis plants. There is already a court challenge brewing to prevent the phasing out of these licenses.

More bad news is that with the new commercialized model of distribution of cannabis for medical purposes, the cost of cannabis will  increase significantly, which will be prohibitive for many. Cost effectiveness is a major consideration for those who produce their own cannabis. Medical cannabis dispensaries, especially the not-for-profit ones, often offer cannabis at a reasonable price, and in some cases will even offer some donations to their lower-income members depending on the supply.

Public support for the use of cannabis for medical purposes is strong and there is international momentum to reform existing laws and policies regarding cannabis in general. How restrictive and commercial should access be? Is reducing options for access to cannabis for medical purposes the best way to reduce barriers to access? How can a well-established network of existing medical cannabis dispensaries with a rigorous accreditation program continue to be left out of the regulations? How much do stigma and a history of criminalization play a role in the direction of these new regulations? Where is the best interest of the patient in all of this?

For more information, please visit:  Canadian AIDS Society & Health Canada


*Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC


Lynne Belle-Isle is a PhD candidate in the Social Dimensions of Health Program at the Centre for Addictions Research of BC at the University of Victoria. She is a National Programs Consultant with the Canadian AIDS Society and the Chair of the Canadian Drug Policy Coalition.