For over a century, criminalized drugs have been demonized, as were the people who used and sold them. Criminalized drugs have long been linked to marginalized and racialized groups, who have been depicted as outsiders to the nation threatening moral Canadians. Politicians, law enforcement, media and vocal spokespeople fuelled drug scares and circulated fabrications and lurid, exaggerated accounts of drug use and trafficking in support of punitive drug policies. Worn out tropes about people who use and/or sell drugs have promoted social injustice. However, today Canada is at a crossroads. Increasingly, drug prohibition is understood as a social justice and human rights issue.

History, however, is never definitive. Local stories, new discoveries and uncovered material can emerge, illuminating once again the danger of assuming history is static. Over the years, there have been many pivotal moments in Canadian drug prohibition and challenges to it. Community activists, people who use drugs, constitutional lawyers, researchers and service providers have long challenged Canadian prohibitionist policies. Knowing the history of Canadian prohibition can guide us to better understand current events and notions about drugs and the people who use them. Knowing about Canadian drug prohibition allows us to critically reflect on past practices, legal regulation, law enforcement, moral reformers and their agendas, new events and avenues to adopt. The field is wide open because people implement drug prohibition, and people can also dismantle it or change its course. Laws and policies are not static, nor neutral.

For more than a century, drug prohibition has been and continues to be an expensive failure. Our reliance on the criminal law to eliminate illegal drug production, selling and use has not proved effective. In fact, it has only worsened the health and well-being of those who use drugs, and it has also resulted in increased imprisonment, child apprehension and human rights violations. Importantly, criminalization (prohibition) has undermined health services such as harm reduction services and other programs that effectively counter hiv and hepatitis C epidemics and drug overdose deaths. The harms stemming from prohibition are not limited to illegal drug users and traffickers — families and communities also bear the brunt of our drug policies, as do other nations outside our borders such as Mexico and Colombia. For this reason, Mexico and Latin American nations have been critical over the last thirty years of international drug conventions and the devastating damage the Western-driven war on drugs and neoliberal policies have on them. Activists in Canada and around the world are striving to change all this.

International drug control treaties are outdated, inflexible and do not reflect contemporary societal, cultural and public health concerns. In fact, the Canadian Report of the Senate Special Committee on Illegal Drugs noted in 2003 that “the international classifications of drugs are arbitrary and do not reflect the level of danger they represent to health or to society.” The International Control Board (incb) has also come under scrutiny. Their lack of dialogue with nations, of accountability and of transparency, and their criticism of policies and public health and harm reduction initiatives have been increasingly questioned by scholars, government officials, drug user unions and national and international drug policy reform groups, such as Canadian Drug Policy Coalition, Canadian hiv/aids Legal Network, Global Drug Policy Conservatory, Mexico United Against Crime, Transform Drug Policy Foundation, Transnational Institute, International Centre on Human Rights and Drug Policy, Drug Policy Alliance, and Washington Office on Latin America. 

Supporters of punitive drug policies fear that drug use rates will skyrocket if prohibition ends. However, recent history demonstrates that such fears are misguided. In 1976, the Netherlands implemented de facto decriminalization through the Dutch Opium Act for the possession and sale of up to 30 grams of cannabis. In order to protect youth and separate them from illegal markets selling “harder” drugs such as opiates and cocaine, cannabis shops (similar to coffee shops) were allowed to be established under strict rules and regulations. Using the most recent drug-use statistics available, cannabis rates have not increased in the Netherlands, and cannabis use is much lower there.1 

Responding to sharp increases in heroin use, overdose deaths, and hiv/aids in the 1980s and 1990s, the decriminalization of personal use and possession of all drugs, not just cannabis, came into force in Portugal in 2001. The move away from criminal sanctions and stigma related to criminalization was part of a much wider social and health public policy strategy in the country. Decriminalization in Portugal co-exists with other measures, such as expanded prevention, treatment, harm reduction services and social supports. Rather than criminalization, pragmatism, humanism and social integration are key to Portugal’s drug policy. Since 2001, drug-related deaths and hiv infections have decreased, drug use has decreased for adolescents and those ages 15 to 24, and drug prices have not lowered (as opponents claimed they would).2

When Canada established the first federal medical marijuana program in the world, the sky did not fall down. Twenty-nine U.S. states have legal medical marijuana programs. Uruguay became the first nation in the world to end cannabis prohibition in 2014. Eight U.S. states and the District of Columbia also ended cannabis prohibition between 2012 and 2016; 20 percent of Americans now live in states that have legalized and regulated cannabis. The cannabis plant did not change; rather, attitudes about prohibition and the plant changed.

In those states, provinces and nations that have turned away from punitive drug policies, addiction and drug use rates have not increased substantially and youth were not negatively affected. Given Canada’s drug overdose death crisis, will all levels of government move quickly to set up more supervised injection sites, heroin assisted treatment, other flexible drug substitution programs and public education as the first steps to saving lives? In order to save lives now, will provinces defy federal law and set up overdose prevention sites that allow smoking, ingestion and injection (as B.C. has done) rather than waiting for federal approval?

Until 2016, Insite stood alone as the only authorized safer injection site in Canada. By May 2017, eight other sites received approval and the application process has become less obstructionist. Health Canada also announced a new process that will allow the importation and use of medications not yet authorized in Canada, such as legal heroin, to help stem the drug overdose crisis. Public health officials can now send a request to Health Canada for bulk quantities (instead of individual special access requests) of the drug so that it can be more efficiently prescribed to those most in need at clinics and other locations. It is too early to know whether long-held prohibitionist attitudes will curtail some public health officials from implementing change.   

The Federal Government also passed the Good Samaritan Drug Overdose Act in 2017. The Act provides an exemption from criminal charges of simple possession of an illegal drug for anyone who calls 911 for themselves or another person who is overdosing, and for anyone else at the site when emergency help arrives. Yet, people are reluctant to call 911 if they fear that they may be charged with another drug charge, such as possession for the purpose of trafficking.

In order to more fully stem the harms associated with prohibition, including overdose deaths, diverse Canadian groups and individuals have long advocated for an end to drug prohibition and the criminalization of marginalized groups of people, as have international groups. Yet, each group’s blueprint to legally regulate currently criminalized drugs differs slightly. Similarly, each U.S. state that voted to legalize cannabis created quite different policies for the production, sale, distribution and possession of the plant. And there are different city initiatives too. For example, in 2017 Oakland City Council in California adopted an Equity Permit Program for medical cannabis production licences. The Program prioritizes those who were unfairly impacted by the U.S. “War on Drugs”: long time residents in high arrest areas, racialized and poor people, including people convicted of a cannabis offence. The policy will extend to recreational non-medical cannabis producers in 2018.

On April 13, 2017, the Canadian Government tabled Bill-45, the Cannabis Act, to the House of Commons. The Act fails to make a clean break away from prohibition. Unlike tobacco regulation, the Cannabis Act includes harsh criminal penalties for some offences. However, changes can be made to the Act prior to its enactment. It is also unknown how each province, territory and municipality will take up their responsibilities in relation to cannabis distribution and sale.

The Canadian Government, thus far, has refused to direct law enforcement to stop arresting people for cannabis possession now rather than waiting until the Cannabis Act is finally enacted. It is unclear whether small cannabis producers, compassion clubs and dispensaries will be supported by federal and provincial governments to participate in the legal cannabis market if and when the Act is made into law. Will the expertise of medical cannabis and illegal cultivators be recognized in the policy making stage and invited to participate in the legal market set up? Will people who have a criminal record for cannabis possession be exonerated?

Will Canada choose to decriminalize and/or to legally regulate all illegal drugs? Will the Government address the historic violence and injustice of drug prohibition? If so, will Canada be successful in eliminating social structural violence and systemic race, class and gender discrimination against people who used drugs/plants that were criminalized? Or will we create a new regime to continue punishing people? Eventually, these and many other questions will be addressed in Canada. Current events will affect people’s experience of drug policy and ultimately, shape history.

Busted is available in stores and online from Fernwood Publishing.

More information on the Outcasts Project can be found at outcastsproject.com.

Cheryl prepares to use drugs in her apartment in Vancouver’s Downtown Eastside.

We need for you people to see that we’re not stereotyped monsters. We’re people just like you, just with an addiction. Something that we do a little bit more than others… When you look at this, take it with a grain of salt, because it could be your own daughter, it could be your own son out there doing exactly what I’m doing, but they had the door closed.

A drug addict’s world is not just the drugs, it’s how they get them, what you gotta’ do to get them. Sex trade, you know. Stealing, killing, whatever it might take just to get that extra dollar to get that extra fix so you can feel numb for the rest of the day. Not necessarily it’s always that, but in my life, I just want you to know that I’m struggling and I need that extra help.

Cheryl cries in the yard of a church where her father’s funeral was held.

I hope the people see through this [essay] all the points, all the emotions and desires, needs, and wants that we need, that you can help us down the road be able to successfully show our governments that people need the extra bit of help because we can’t do it on our own.

Cheryl self-injects her medication at Providence Health Care’s Crosstown Clinic in Vancouver.

I want to show the people that this place is where we get our injections for our heroin opiate program, just show them that we need these places so heroin addicts can get off the streets. Heroin can be contaminated with many different poisons out there that can severely give us infections, because they put hog dewormer in the heroin on the streets. The clinical heroin here, there’s no bad chemicals or poisons in the drug. It helps us through the day, takes our aches and pains away, everything that heroin used to do.

In other places of the world, they had this study and it’s helped them, that’s why they brought it to Canada, here to [British Columbia]. And for us, the people who are in it, we’re so lucky and should be so grateful to have such a great program.

Cheryl paints her nails prior to a court appearance for a sexual assault she experienced.

I’m sure there’s hundreds of photos that could show my life different. But my life today is a recovering heroin addict. I’m 124 pounds. I used to weigh 97 pounds. There’s so many good things, and positive ways of looking at my life. If a picture could show all that emotion in one? That would be great, but it won’t and that’s all that my voice could tell you.

Cheryl self-injects drugs in her apartment in Vancouver’s Downtown Eastside.

I think that people see a girl looking in the mirror, looking in fear, like what is she doing with the needle in her neck, sticking in her neck, that’s a pretty dangerous site to be injecting. But that’s the reality of that picture. It’s me being all strung out on dope, trying to get that shot into me, and it’s filled with blood and I’m trying to plug it into my vein cause I need that drug that’s in there so I can get off and get high, numb whatever pain I’m going through in that moment.

I was all fucked up on drugs that day, yeah. It shows my emotion, my fear, my determination. [I wish the photo had] maybe a little bit more light… Just to show it’s hard to inject into your neck like that. Just to show the picture more. To see what kind of struggle it is to inject in your neck. And to show maybe just a little bit more emotion to the people just to show what and why I’m doing that to myself.

Cheryl returns to an alley in Vancouver’s Downtown Eastside where she lived for several years.

People viewing this photo might see some young girl, downtown, in a back alley. Looks like it’s a rough alley. A young girl, maybe she’s strung out, or maybe she’s determined to find drugs or who knows what they see in this photo. They just see a young girl smiling and looking down the alley.

Yeah, it shows all of me. I just hope the people see me in this photo—that I’m a striving, struggling drug addict. That I’m trying to better my life.

A woman, Cheryl, self-injects at Vancouver’s Crosstown Clinic. From Aaron Goodman’s The Outcasts Project.

Except for a long line at the barbecue, where hungry older folk wait for a free meal, most people have left Oppenheimer Park for the day. But not Jim McLeod, who’s clutching a hot dog wrinkled with the cold, so engrossed in telling me his story that he’s forgotten about his dinner. It’s late February and we’re standing in Vancouver’s Downtown Eastside, the epicentre of Canada’s overdose crisis, talking about harm reduction—two words very much in vogue.

“You don’t bounce back from torture,” McLeod says almost casually, wind whipping tendrils of his long hair into a frenzy. He tells me that past trauma has much to do with his morphine use today. “I’m wired to it,” he says. “I use it daily because I’ve had physical pain most of my life.”

At 14, McLeod’s foster father threw him into a doorknob. The impact permanently damaged his spine. Years later, his best friend suffered a psychotic episode and nearly beat McLeod to death, confining him to a room for hours at gunpoint. “I was worked head to toe with the claw of the hammer, tearing strips out of me,” he says. McLeod rolls up his sleeves, revealing a scar that runs from elbow to wrist, the stitch marks still visible—like slashes of red ink from a pen. He gestures to his knees, pointing to places the hammer punctured his body, creating wounds that never quite healed. “I’ve suffered the kind of violence most people don’t see, unless it’s on TV.”

McLeod gets his morphine from the streets, relying on dealers rather than doctors to manage his pain. But he considers himself lucky. The morphine he takes comes in an uncrushable pill, making it hard to adulterate. He can always tell if someone’s been sneaking in additives.

It’s impossible to know what’s in other drugs. Fentanyl, a painkiller so powerful that only a few sand-like grains are needed for a lethal dose, has breached the illicit opiate supply. It’s found in everything from heroin to fake Oxycontin pills. Stimulants such as cocaine and methamphetamine aren’t safe either: One Vancouver journalist reported being offered “knock-down jib,” or laced meth, by a street dealer, while fentanyl-laced cocaine hit partiers in Ontario and B.C. last year. A 2016 Vancouver-based study found fentanyl in 86 percent of drugs tested.

In B.C, lives lost to drug overdose nearly doubled over the last two years. In 2016, almost 1,000 people died. In the same period, Alberta saw 343 fentanyl-related fatalities, a three-fold rise in only two years. That’s comparable to diabetes, which consistently stars in the province’s top-10 lethal causes list. Eastern provinces aren’t exempt, either: According to reports, drug-related deaths in Ontario have more than quadrupled since 2000.

But McLeod doesn’t hold manufacturers, dealers, or poor policing accountable for the spike in overdoses. The problem, he says, is a system that doesn’t recognize the social determinants of addiction, the many faces of pain. “If they would actually legalize and regulate drugs, it wouldn’t just end the crisis,” says McLeod. “It would almost end overdoses, period.”

Treat addiction like any other disease: That’s the seemingly radical idea activists like McLeod demand in the face of these fatalities. Calls to set up special clinics, prescribe heroin, and reform prohibition brought McLeod and 300 others to Oppenheimer Park, part of a nation-wide protest organizers called the biggest mobilization for harm reduction Canada has ever seen. The rally doubles as a memorial service; most in attendance clutch wooden feathers scrawled with the names of the dead. It’s not the first time drug users have insisted on their right to equal care. But they’re hoping, in the face of a national crisis, it’ll be the last.

***

Main and Hastings might be Canada’s most notorious intersection. Hotels with crumbling facades hint at a once-thriving entertainment district; many have been converted into welfare housing with patchy hot water and pest problems. Theatres have closed. Walking past these buildings, it’s not uncommon to step around tents fashioned from umbrellas, dodge garbage thrown from windows, or hop over trash cans torn apart by salvagers. The sidewalks buzz with casual drug deals, and residents smoke and inject openly.

The City of Vancouver, to its credit, largely defies traditional approaches to drug use—namely policing, shaming, and abstinence-only services. When I first arrived here last fall, I wondered why nobody was doing anything about the mayhem. I’d see needles in the gutters, people smoking meth under tarpaulin erected on the sidewalks, dealers hawking Valium and codeine at the bus stop. But like anyone else reading the literature, I learned that exhorting drug users to get clean at all costs wouldn’t help those living with severe pain, trauma, or mental illness. All the evidence I could find pointed to embracing the kind of harm reduction that’s blossomed here in the last two decades, such as needle exchanges, low-barrier housing, and cops that turn a blind eye to small-time drug trade.

Perhaps the most convincing data for harm reduction can be found in Portugal, which decriminalized everything from cannabis to cocaine in 2001, effectively ending the drug war. The country saw a drop in drug use, HIV transmissions, and overdose deaths a decade later. While drug use is still punishable by prison time here, Vancouver too has moved away from the “hard on drugs” mentality. On Hastings, unlike elsewhere in Canada, health often comes before penalty.

One activist I spoke to called the Downtown Eastside “a visual living affront to the way mainstream Canadians would like to see themselves,” a place where marginalized populations have come together and formed a thriving community—one with political clout, no less. Among the worn-out buildings and tent cities, it was here in the 1990s where drug users took harm reduction into their own hands, opening illegal injection sites and forming needle distribution teams who would comb alleys to make sure everybody had a clean rig.

Their nose-thumbing resulted in official harm reduction services like Insite, North America’s first “supervised injection site” where clients can legally use their own street drugs. It offers supplies and social workers alongside injection booths, private desks where users shoot up in a clean environment. Nurses have reversed hundreds of overdoses since the service opened in 2003, while HIV infections and crime are down in the area around Insite. Despite the influx of fentanyl, not a single person has died there. “People talk about enabling, but you’re just enabling someone to live longer,” McLeod says. “That gives them a chance to make changes. Dead men don’t detox.”

The federal government seems to be listening to the evidence, but it’s still illegal to open injection sites without a special Health Canada-approved permit. In December 2016, Health Minister Jane Philpott introduced Bill C-37, which would streamline approval so more places like Insite can work their magic across the country. But Toronto, Ottawa, and Victoria are still on the waitlist, and for other communities, the research and surveys required by C-37 to open a site may stand in the way of even applying. “It’s labour intensive, expensive,” says Marilou Gagnon, a nursing professor and founder of a coalition of nurses fighting for harm reduction policy in Ottawa. “Meanwhile, it should just be standard practice.”

I asked Andrew MacKendrick, Minister Philpott’s press secretary, why Health Canada seemed to be sitting on its hands in the midst of these preventable deaths. “We are in a national public health crisis in Canada. Minister Philpott is committed to using every lever at her disposal to combat this crisis, and to working with all levels of government and partners across the country to do so,” MacKendrick said over the phone. “The minister has stood up and said the evidence is very clear: When properly managed and operated the sites save lives.” And while invoking the Emergencies Act, as activists have demanded, would allow Philpott to override these political barriers, MacKendrick says there’s a number of “quite high-profile criteria” to be met before she would consider doing so.*

Having a safe place to use drugs is only part of the solution. Supplying medical-grade heroin means opiate users know exactly what they’re getting and helps severely dependent users lead more fulfilling lives, giving them the time and peace of mind to pursue activities other than drug-seeking. In Vancouver, about 100 patients receive heroin daily from Providence Health Care’s Crosstown Clinic, which opened in 2011. “[It’s] a sanctuary for those people,” says activist and Crosstown patient Dave Murray. “You ask any one of them and they’ll tell you they might not be alive today if it hadn’t been for the clinic.”

Four years after opening, a study out of Crosstown found heroin therapy lowered use of street drugs and crime, allowing patients to get their lives on track without quitting opiates. Canada legalized prescription heroin last year, but advocates say accessibility has yet to catch up to the law. Gagnon, who steadfastly believes in the harm reduction philosophy, warns that some doctors aren’t trained in the science—or ethics—underlying these measures, and may not feel comfortable prescribing heroin to patients. “We can’t expect health care providers to embrace harm reduction across the board,” she says.

Aside from Crosstown, harm-reduction services stop short of supplying the drugs themselves. But activists say that’s exactly what should happen to end the overdose crisis: regulated drugs, accessible to anyone who decides to use them, including those who only indulge recreationally. They’ve floated the idea to Justin Trudeau during his recent pilgrimages to B.C., but unlike cannabis, full regulation of narcotics has proved too radical for him to support. In 2015, Trudeau told a reporter he doesn’t believe harm reduction entails the decriminalization of “harder” drugs such as heroin. “Despite some of the examples around the world, I don’t think it’s the right solution for Canada now or ever,” he said. A year later, Trudeau told the Vancouver Sun that “more work has to be done” to determine whether regulating illicit drugs is the best course of action.

That position strikes Gagnon as a blow to harm reduction work. Other experts agree. “We should have the primary goal to reduce drug-related harm, and we should be open about the best ways to reach this,” says Dr. Jürgen Rehm, director of addiction policy at the University of Toronto’s School of Public Health. Insisting on abstinence as the only form of treatment—think ideology-based 12-step programs like Narcotics Anonymous—means that patients like McLeod, who use street drugs to medicate for pain and past trauma, will inevitably fail.

***

Back on Hastings, I meet up with Karen Ward, a woman in a black hoodie frowning into her cigarette. We’re outside the Vancouver Area Network of Drug Users, a dilapidated storefront converted to a user-run resource centre back in 1998. They hold meetings every week, and have recently been letting users inject in a back room—their own unsanctioned injection site, an emergency measure to prevent more deaths. When we go inside, the front desk is plastered with funeral notices.

Activists like Ward hate the way governments have handled the crisis. She tells me, firmly, that fentanyl isn’t even the problem. “It’s always going to be something. If it’s not one substance panic it’s another,” she says. Vancouver suffered another overdose crisis in the late ’90s, when an influx of potent heroin from Southeast Asia flooded the Vancouver market, leaving 200 dead in a six-month period. The problem repeats itself, Ward explains, and bad policy is to blame. “We expect our roads not to collapse. We expect the food we eat to be safe. We expect the buildings we live in to not fall down,” she says pointedly. “We need to acknowledge that people are using substances for pain, whatever pain that is, and give them the substances in the safest way possible.” Her voice trembles. “But instead we turn around and punish them for it. We leave them to die in the street.”

To date, Canada’s response to overdoses has largely focussed on the emergency medication naloxone, which brings someone back from the brink of death. When a powerful opiate like fentanyl enters the system, it attaches to opiate receptors, which can interfere with respiration. Naloxone works by shoving the opiate molecule off its receptor, allowing the patient to breathe again. But it’s not foolproof, and not everyone knows how to administer the medication. When Jerry “Mecca J” Verge, from Surrey, B.C., was found unconscious in a washroom at his workplace with a needle still in his arm, his colleagues didn’t know how to help, and he couldn’t be revived. Even when naloxone is given in time it can take a while to work, which may lead to oxygen deprivation and irreversible brain damage. “I compare it to somebody on the street bleeding to death and having Band-Aids thrown at them,” Ward says. “We can’t naloxone our way out of this.”

There’s been “a lot of talking and not much doing” on the government’s part, according to Gagnon. “The actions that have really made a difference in this crisis have been done by volunteers on the ground.” She means organizations like the Vancouver Area Network of Drug Users, who defy the law to prevent overdoses, refusing to wait months for bills to crawl through Parliament or for public opinion to shift. “There are ways of responding to the crisis where you can overlook bureaucracy and actually save lives,” says Gagnon. Ward agrees. “We just need someone to have the political bravery to say, ‘Go and do it, it’s the right thing to do.’ Saving lives is always the right thing to do.”

For people like Jim McLeod, who may always use opiates, granting these demands could one day save his life, too. When we part ways in Oppenheimer, I pass under a row of leafless trees, wooden feathers from the rally now tied to their boughs. Almost a thousand of these makeshift monuments dance in the wind, names flashing in the sun. Each one a reminder of a human life lost not to drugs, but to radical policy: prohibition, the biggest killer of all.

* UPDATE (MAY 30, 2017): Since this story was published in our May/June 2017 issue, Bill C-37 has passed, and four supervised injection sites have been approved. This paragraph has been updated to reflect these changes, including an updated quote from Minister Philpott’s press secretary Andrew MacKendrick.

Vancouver’s Insite facility. Photo courtesy of Vancouver Coastal Health.

Ottawa: The feds

“I’ve made it very clear to my department that there should be no unnecessary barriers for communities who want to open supervised consumption sites.”—Jane Philpott, federal health minister

Photo by The Canadian Press Images/Lars Hagberg

After decades of court battles that won chronically ill patients the right to use cannabis as medicine, many wonder whether the impending legalization of recreational pot will trample over the progress they’ve made. A government group tasked with creating a framework for legalizing and regulating cannabis published its report in November 2016. Among the suggestions is that medical marijuana be taxed equally with recreational use, and the medical cannabis system be revisited with an eye to phase it out in five years.

But most patient advocates believe this is short-sighted.

“People who are quite sick, who have not found relief elsewhere, to force them to pay potentially premium taxation on these products—for doctor-prescribed medicine—doesn’t make any sense,” says Ronan Levy, lawyer and director of Canadian Cannabis Clinics.

Jonathan Zaid agrees. Director of Canadians for Fair Access to Medical Marijuana, he says it’s unfair medical cannabis be subject to taxes, despite tax code exemptions for prescription drugs. “Patients need measures to help with affordability,” he adds, pointing out that even now many struggle to afford it.

Though it’s uncertain where the new recommendations will lead, medical cannabis users aren’t just worried about affordability. Some fear full legalization could steer research away from the unique strains medical users need, or that a disappearing medical cannabis system could leave patients stuck purchasing at high cost from dispensaries not designed for them.

Trina Fraser, an Ottawa-based lawyer who is counsel for the Canadian National Medical Marijuana Association, puts it simply: If cannabis is being used for medical purposes, it should be done under the care of a physician.

Many doctors are hesitant to prescribe, being in the uncomfortable position of gatekeepers for a substance they don’t understand.

One solution many patients are advocating for is giving cannabis extracts a DIN (a Health Canada drug identification number) so they can be dispensed by pharmacies. This would gain many patients coverage under their drug plans, and allow doctors more comfort prescribing a substance that would be better researched and understood.

“To me it is incredibly dangerous to put people in a position where they are mixing and combining drugs without medical supervision or advice,” Fraser says, adding that tax breaks and drug plan coverage are needed. “Is a ‘budtender’ going to be qualified to tell you whether it’s okay to use cannabis in conjunction with your antidepressant?”

While the recommendations suggest keeping medical users’ needs in mind as legalization proceeds, it will be up to patients, advocates, and the public to make sure it happens.

The Dirt Chronicles is a delicate alloy of Burroughs and Gallant, walking an uncompromising line where the homeless, the junkies, the punks, and the dispossessed are one and all pushing against a threat sometimes left to vague societal pressures but otherwise embodied in the interweaving stories’ antagonist. The King, a sadist vice cop with a thing for rockabilly bent on breaking the dignities and backs of our heroes, is the Toronto underworld’s answer to Dr. Satan.

Her characters carry chips on their shoulders and monkeys on their backs, from the whipped and broken crackhead Darcy to the fragile, indomitable Ferret to the tragically incarcerated Eddie.

When they’re bent or broken, Dunnion narrates enough pain to pass sympathetic jolts to her reader. A visceral and violent book that could have set out to shock is instead touching. The dance between her characters’ strengths and weaknesses is compelling, readable, and tempers the handful of potshots she takes at the world of the well-fed and gainfully employed.

Creative Commons photo by Flickr user Null Value.

“We do not use statistics as an excuse not to get tough on criminals.” That was federal Justice Minister Rob Nicholson’s astonishing response to Statistics Canada’s finding in July that crime rates in Canada now stand at the same level they did in 1973. Don’t bother us with the facts, was Nicholson’s meaning, our minds are made up. We’re going to get tough on crime—despite the fact that the criminals have gone soft on us.

Stephen Harper’s new majority government vowed last spring to pass an omnibus crime bill during the first 100 sitting days of the new parliament, a deadline that is fast approaching. The bulk of the bill is dedicated to introducing new mandatory minimum sentences for drug-related offences. For instance, the last incarnation of the bill (it was never voted on before the last election and could change) specified a minimum one-year sentence for any drug crime on behalf of a gang or involving a weapon. The minimum raised to two years if the crime was committed near a school. Producing a drug nets a mandatory three years if the production posed a threat to minors or public health.

You don’t have to condone criminality to see that mandatory minimums, especially for drug-related crime, are the kind of cynical laws that play well on voter doorsteps and fail miserably in almost every other context. They don’t make the general public any safer; they harden minor criminals in the crucible of prison; and they cost a fortune.

Judges don’t like them, since they tie their hands and leave no room for context or, well, judgment (Justice John Gomery calls such legislation “a slap in the face” to judges). Prosecutors seldom like them, since they provide defendants no incentive to plead guilty in exchange for a lesser punishment. Corrections officials’ feelings are mixed at best; their budgets inevitably swell, but overcrowding causes greater problems.

Even the United States—the world capital of magical thinking on drug crime—is backpedalling on mandatory minimums for drug cases. A CBC report found a dozen states— Republican- and Democrat-run—that are repealing mandatory minimums. They cite a comprehensive array of complaints, from abstract doubts about the constitutionality of the practice, to practical, bottom-line problems with out-of-control policing and corrections costs.

The facts show that Canadians are safer than they have been in two generations, yet the Harper government is plunging ahead anyway. This policy will inflate the government’s corrections budget to $3.1 billion in 2012–2013 (including $466 million just to build new prisons). For that price tag you’d hope to bag the kingpins—but of course, that’s not what this is about. Instead we will victimize and incarcerate the most impoverished and desperate small time crooks and call it justice. If you believe that poverty reduction, alternative sentencing, addiction counselling, and evidence-based policymaking are better ideas, this government has one word for you: tough.

Apo-TriAvir, the generic HIV/AIDS drug. A Canadian law making its export easier is likely finished in parliament. Image courtesy Apotex.

In March, Canada came improbably close to establishing a system to deliver drugs cheaply and quickly to poorer countries. In a vote of 172 to 111, the House of Commons passed Bill C-393, which would have streamlined Canada’s Access to Medicine Regime, a program to provide low-cost generic drugs to the global south. It wasn’t to be: the senate stalled, waiting for the vote of non-confidence that precipitated a spring election. That vote came four days later, effectively trashing the bill.

CAMR allows generic drugmakers to export cheaper versions of brand-name drugs to developing countries, without needing the permission of the patent-holders. “We have tremendous capacity to help address a particular need,” says Richard Elliott, executive director at the Canadian HIV/AIDS Legal Network. But CAMR’s cumbersome red tape kept manufacturers away. Says Elliott: “To leave in place a regime that is not working would be harming millions of people who need access to medicines.”

The program had only been used once since it was introduced in 2005. In 2007, Apotex, the largest Canadian-owned generic drug company, shipped enough HIV medication, Apo-TriAvir, to treat 21,000 patients in Rwanda [PDF]. Apotex says the final shipment went out in 2008. “We’re not likely to repeat the process under the current regime,” says Bruce Clark, Apotex’s senior vice-president of scientific and regulatory affairs. “It’s not just our decision, it’s a practical reality that no second country has made a request under the regime because it’s so complicated.” Bill C-393 would have simplified that process, but its future looks doubtful.

When C-393 passed in the House of Commons, it was supported by 26 Conservative MPs; 25 of those were re-elected, but the bill’s prospects in the new Conservative-dominated parliament look dim. “We saw what Harper did in the senate with the bill,” Elliott says.

On May 5, Elliott discussed CAMR’s future with other major advocacy groups. They’ve decided it’s not time to give up, but it will take time to re-assess the political climate before drafting some next steps. “The legal landscape is more challenging now than before,” he says. “But it’s worth trying to gather some intelligence and make a more informed assessment as to what the prospects might be before moving forward.”

Even with such slight optimism, Elliott expects the earliest the bill could be re-introduced—if at all—would be this fall.

Photo by Joanna Pecha

On March 18, 2000, Terence Young was at home catching up on the weekend paper when his 15-year-old daughter, Vanessa, came to ask his permission to go out with some friends that evening. Exhausted and not relishing the idea of another conversation about Vanessa’s curfew time, Young asked her to wait until after dinner. There was nothing remarkable about it.

But as Vanessa turned to leave, she suddenly went limp and collapsed, her head making a loud thump on the carpeted floor. Young ran to her, calling out to ask whether she was okay, thinking momentarily that it could be a joke, an overdramatic gesture by his teenage daughter. It wasn’t. As she lay motionless on the floor, Young frantically felt for a pulse, finding the spot on her neck where his first-aid training had taught him to press his fingers, but there was nothing. An ambulance rushed Vanessa to the hospital, and an exhausting, haunted night followed as the family kept vigil in intensive care. The next day, Vanessa Young died.

Her cause of death was later determined to be cardiac arrest, caused by the effects of Vanessa’s bulimia nervosa and possibly an undiagnosed underlying heart defect. But there was another factor: Vanessa had been prescribed a drug called Cisapride—better known by its trade name, Prepulsid—to assist her digestion and prevent vomiting. Terence Young was later to learn the drug had been linked to irregular heartbeats and other cardiac problems. In July 2000, Janssen-Pharmaceutica Inc., a subsidiary of drug giant Johnson & Johnson, voluntarily pulled Prepulsid from U.S. pharmacy shelves. In August 2000, Health Canada pulled it from the Canadian market. On April 24, 2001, a coroner’s jury concluded that Vanessa Young’s arrhythmia and cardiac arrest resulted “from the effects of bulimia nervosa in conjunction with Cisapride toxicity and possibly an unknown cofactor such as congenital cardiac defect.”

The potential danger of Prepulsid was known, but key information about the drug didn’t make it to the right people at the right time. Eventually the right decision was made—but it was too late for Vanessa Young.

Canada’s drug-approval process suffers some serious flaws. The proceedings lack transparency; scientific data often goes fully or partially unpublished; once on the market, approved drugs seldom receive long-term monitoring for adverse effects; compared to other countries, drug labelling is less rigorous; and the whole process is paid for, in large part, by the same companies it is supposed to be regulating.

To be fair, Health Canada, the ministry responsible for approving pharmaceuticals, is often in a difficult position: patients and doctors want effective treatments made available quickly, but the department’s job is to thoroughly test drugs for safety, which takes time. Speeding drugs to market and protecting public health are two mutually exclusive goals, afflicted at every stage by interests that are often financially, and sometimes emotionally, vested. And at every stage, the pharmaceutical companies themselves are there, embedded in the approval process.

The result is a system with conflicting loyalties, bizarre blind spots, and, sometimes, dangerous outcomes. Why is it that Canada lags so far behind in providing an open, accessible drug-approval process? I sought out some of Canada’s leading experts on health policy and drug safety to try and understand what in our drugapproval system is broken—and how we can fix it.

Part of the problem of understanding Canada’s drug-approval process is that so much of it takes place behind closed doors.

“The way that we deal with drug approvals is actually quite different than the U.S., in that theirs is a much more open process,” says Dr. Barbara Mintzes, assistant professor in the department of anesthesiology, pharmacology and therapeutics at the University of British Columbia. When the U.S. Food and Drug Administration, for instance, approves a drug for the market, the full review report is published online. Expert advisory committee meetings are open to anyone and transcripts are published on the FDA’s website. The public is invited to submit input, and scientific reviewers’ comments are also made public. Almost none of that happens in Canada.

Dr. Joel Lexchin, a professor at the School of Health Policy and Management at York University in Toronto, agrees that lack of transparency is a problem.

“The FDA demands that drug companies submit the raw, clinical data,” says Lexchin. “Then they will do their own reanalysis of the data to make sure that the way the companies analyzed it is appropriate.” Drug trials in the U.S. are also catalogued with redacted information in an online registry. “Not only do you know what trials were started but you’ll be able to see what the results of those trials are,” says Lexchin. “Health Canada doesn’t require the posting of trial results.” In contrast, the comments of Health Canada researchers reviewing drug company applications are never made public. In fact, the public may not even find out that a drug is under review.

“The drug-approval process in Canada is secret,” says Mintzes, “in that when a drug is being considered for approval, there’s no announcement to the public by Health Canada to say that’s happening. It’s up to the company whether or not they want to publish the clinical trials [they submit] and often they will decide to publish only a subset of their studies.”

Health Canada’s approval process, then, is a kind of black box: drugs go in one end, and some emerge at the other, but what exactly transpires inside to influence that decision is unclear. (Health Canada’s only response to interview requests for this story was to refer me to its website.)

Many critics say that money exerts too big an influence on approvals. The biggest culprit is user fees, in which pharmaceutical companies pay the government to fund the approval process. User fees were introduced in 1995, partly in response to federal budget cuts, based on the idea that, because they benefit from having their drugs for sale, drug companies should shoulder some of the cost of approving them.

“I think this is a mistake,” says Lexchin. By 1999, the Therapeutic Products Directorate, the Health Canada department responsible for assessing drugs’ safety and efficacy, got close to 70 percent of its budget from the companies it was supposed to be regulating. Today, Lexchin claims, it’s about a third, though recently proposed regulations from Health Canada aim to cover 50 percent of TPD’s budget with user fees. At that level, critics question who’s actually setting the agenda—the pharma companies or the public interest?

“User fees are totally inappropriate,” says Terence Young, Vanessa’s father, who is also a Conservative MP in Oakville, Ontario, and founder of the advocacy and research group Drug Safety Canada. “They create a situation where a drug reviewer feels that the company is like a client, that they should be working fast to get this drug approved because these companies are paying up to 50 percent of the cost of having drugs reviewed for approval. That is an inappropriate relationship.”

After the death of his daughter, Young became a fierce critic of the pharmaceutical industry and wrote about the civil and classaction lawsuits subsequent to Vanessa’s death in his book Death by Prescription. He echoes the sentiment—common enough to have become cliché—that drug companies have put profits above patients.

“Big Pharma’s profits are multiples, in most cases, of other industries,” says Young. “You cannot overstate their influence on modern medicine. We spend more money on pharmaceuticals, both prescription and non-prescription, than we do on doctors.”

In Canada, the effect of user fees is not just that it makes the drug companies clients of Health Canada, expecting value for money; the user-fee structure also influences approval deadlines. The 2004 User Fees Act gives Health Canada a set timeline to approve new drugs; if the agency misses its deadline, there are financial penalties: user fees for the following year are cut. “If you go, say, 20 percent over deadline, then next year the user fees are going to be cut by 20 percent,” says Lexchin.

That pressure to approve, says Young, inevitably influences the decisions of Health Canada reviewers. “Drug reviewers should not feel that their job depends on, in any way, approving a drug,” he says. “You approve a drug when you believe it’s effective and safe,” he says. “You don’t approve it by any given date. And if it’s doubtful, you don’t approve it.”

Lexchin and Young both argue for the elimination of user fees, to make the whole process publicly funded and cut down on industry influence. Young proposes a mandatory levy on pharmaceutical companies so they still fund the process, but without the strings attached.

Once a drug is on the market, additional problems crop up: follow-up research on drugs is relatively rare, and drug labelling is inconsistent.

With few exceptions, once a drug reaches the market and is being prescribed routinely by doctors, there is no system evaluating the long-term effects or adverse reactions for prescription drugs.

“Health Canada, at this point, doesn’t have the ability to require companies to undertake post-market trials; all they can do is ask companies to do it,” says Lexchin. He draws attention to a Health Canada policy called Notice of Compliance with Conditions that approves the drug but requires further testing. “They will approve it on the requirement that companies undertake additional trials to show that what looks promising actually is promising.”

But there’s no reporting on the progress of meeting those conditions. “You have drugs that were approved nine years ago under this policy that still haven’t met their conditions, and you can’t find out why because it’s considered confidential,” says Lexchin. “With the cancer drug Iressa, the trials showed it didn’t work, but Health Canada still left it on the market.”

Lexchin believes it’s probably still on the market because some cancer doctors think that, although it doesn’t work statistically, it might work on individuals. “We’re always dealing with statistics,” he says.

Monitoring of adverse drug reactions across the country is largely confidential. Young says it’s meaningless: “Health Canada never insists follow-up studies be done; they don’t even call the drug company back and say, ‘Did you do those studies?’ Because they get approval, and it’s open season.”

Pharmaceutical labels are notoriously difficult to read, and potential side effects or drug interactions get lost in a sea of technical and legal language. “They’ll say, ‘See look, here on page 19, right near the bottom it says you shouldn’t take it with grapefruit juice, so don’t say we didn’t warn you!’” says Young. “The labels are written by lawyers, for lawyers, to confuse. They should issue effective safety warnings in plain language so patients and doctors will know when a drug is safe.”

To try and reform some of the problems he and many doctors see with the Health Canada drug-approval regime, Young has tabled a private member’s motion to create an independent drug agency that focuses purely on safety. “If Air Canada had a crash of one of their planes, you wouldn’t ask Air Canada to investigate the crash. So when a drug company has a crash of its drug, like Prepulsid, why would we ask them to investigate their own crash?” he asks. “Prescription drugs used as prescribed in hospitals with no error are the fourth leading cause of death in our society. That’s why everybody has an interest in this.”

While the picture is troubling at the federal level, experts say provincial drug-review bodies do a better job of sorting pharmaceuticals by safety and efficacy. Because the provinces bear most of the cost of providing health care through provincial health plans, they have traditionally done a better job of prioritizing drugs that actually work well, since they don’t want to pay for ineffective treatments. Even so, the provincial bodies suffer some of the same problems of transparency and accountability.

Once Health Canada has approved a drug, the second level of screening is the Common Drug Review, a body funded jointly by the federal government and the provinces. There, a group of experts examines new drugs coming to the market. The provinces, though their processes vary, are responsible for deciding what drugs will go on pharmacy shelves, how much they will cost, and how to best use provincial dollars to pay for them.

“What they will do is look at that drug and compare it to other treatments in its class. They will determine whether the drug is costeffective to be used by the provinces,” says Alan Cassels, a drug policy researcher at the University of Victoria’s faculty of human and social development.

“Health Canada might review a dozen cancer drugs and say they’re all safe and efficacious. But that doesn’t help the provinces decide if they should fund it or not,” says Cassels. “And that’s really the information the provinces need in order to make decisions about whether they should be covered.”

“Health Canada’s standard of efficacy is so low that all you have to do, because of so-called commercial rights, is prove that your new drug works slightly better, even one percent better, than placebo and you can get it approved based on efficacy,” says Young. “The provinces, on the other hand, because they’re concerned with money and the cost of the drug, they actually demand a higher standard of efficacy than Health Canada.”

Two projects are trying to address some of these problems, to make at least part of Canada’s drug-approval process more transparent and open to the public.

Set to launch this spring, the pan-Canadian Oncology Drug Review, or PCODR, is a national review board specifically for cancer drugs. Funded by the provinces (except Quebec, which opted out) PCODR will make recommendations to the provinces on which cancer treatments would be most effective to fund. Notably, the PCODR review process will be much more open and transparent than the current structure.

“I’m very pleased that PCODR is going to include patient representatives,” says Dr. Chuck Blanke, head of medical oncology at the B.C. Cancer Agency and PCODR steering committee co-chair. “Everything is going to be as transparent as possible. Reviews will be posted on the website and there will be invited commentary from pharmaceutical companies, but also from patients and patient-advocacy groups.”

The Therapeutics Initiative is another example of an effort to pry open the approvals process. The initiative acts as an independent drug bulletin. Researchers look at the clinical trial evidence of safety and effectiveness of drugs after they’ve been approved for marketing, and the “independent” part is what’s key. “With independent drug bulletins, there’s a commitment not to have any financing or advertising from pharmaceutical manufacturers,” says Mintzes, who does research for the group.

Mintzes agrees that the provinces generally have a more transparent, better-informed drug-approval process. The Common Drug Review, she says, has improved the situation because provinces can share the cost of research, eliminating expensive duplication. “I think it’s been a big advance, and useful particularly for the smaller provinces, not having to review the same scientific data separately. Recommendations are posted on the Common Drug Review website, so it creates a situation of greater trust.”

Time constraints remain a problem, however. “Clinical reviewers are being asked to do a full systematic review within a short time frame of six weeks,” says Mintzes. “That’s a pretty short period of time for the depth of the report being expected. They get the same pressure from industry in terms of drug approval for marketing—pressure for the decisions to be made very quickly.”

And like at the federal level, technical details are still bound by confidentiality agreements. “Which is crazy,” says Mintzes, “if you think that this is evidence of potential for benefit or harm of a pill or medicine that a person is actually going to take. Those people, and the doctor who is recommending it, and the whole community, should have access to the full body of scientific evidence.”

Pharma companies generally come across as the villain in these stories, and for good reason: these are large, multinational corporations that reap huge profits exploiting government-aided monopolies on life-saving drugs. Stories abound of Big Pharma wining and dining doctors to cajole them into prescribing more. Of flying them to Caribbean resorts for what in the industry are called “continuing medical education” sessions, but which are actually just marketing junkets. Of drug-company sales representatives quietly persuading doctors to prescribe “off-label,” for conditions the drug wasn’t originally intended.

But experts say that what the pharma companies don’t do can be just as harmful to patients.

Fewer than 10 percent of new drugs are considered “breakthroughs” that substantially improve efficacy or attack a disease with a novel approach. The rest of the business consists of making slight tweaks to already-successful compounds. “It’s always these ‘me too’ drugs,” says Cassels. “You have a product, and if you modify a few molecules you can come up with your own version that’s almost the same but different enough so that you can get your own patent. ‘Me too’ drugs … are much less expensive to develop.”

“There are lots of diseases out there that we just don’t understand enough about,” says Lexchin, “and putting all your money into looking for drugs that are actually going to cure something—when you’re dealing with processes that are not well understood—is a big gamble that drug companies don’t want to take. So they’re going to go for, in general, the easy processes for new drugs, rather than looking for these real major breakthroughs.”

Frustratingly, there have been breakthroughs in Canada that, because they aren’t patented—and therefore are unlikely to be highly profitable—struggle to find funding even to finish clinical trials.

For example: dichloroacetate, or DCA, an inexpensive substance that has been used for decades to treat metabolic disorders. Researchers at the University of Alberta believe it could be used as an effective treatment for many forms of cancer, too. Research has shown that DCA can cause regression in several cancers, including lung, breast, and brain tumors. The next step is to run clinical trials on human cancer patients. But these trials may have to be funded by charities, universities and government. Drug companies aren’t interested, because without a patent, there’s little money to be made.

“Because drugs tend to be developed by for-profit companies, they’re only interested in products where they’ll have a monopoly for whatever the patent period turns out to be,” says Lexchin. “If they’re going to put all this money into it, then they’re going to want to be sure that nobody else can make that drug for whatever that patent period is. These things tend to be orphans.”

As Cassels confirms, “So much of what drives drug discovery is the ability to patent stuff. If they discovered that apple seeds cured cancer, no one would ever hear about it. Sad, but true.”

It doesn’t have to be this way. Despite the seemingly insurmountable obstacles facing those who would like to see a more open, transparent drug-approval process, the more engaged the public is through knowledge and dialogue, the better chance we have in creating a fully accountable process.

The experts concur that a more transparent, independent drug-approval process would raise Canada’s drug-approval system to levels already attained by many European countries and the U.S. One thing is for certain: an approvals process funded largely by the pharmaceutical industry itself is unacceptable and represents a threat to patient safety.

Prioritizing efficacy and thorough, truly independent safety testing will help create a situation of greater trust. Research focused on developing better drugs through patent reform is not an outlandish gamble, and should be recognized as inherent to the pharmaceutical business model and supported by government regulation. Safe, effective drugs are an integral part of our health-care system. But the current approval process is needlessly secretive, incomplete, and vulnerable to private interests. What’s at stake is not simply the public’s right to know, or wasted government spending, but the health and well-being of millions.

The birth control pill has been a major game changer in the arena of women’s reproductive rights, opening up new doors in society and the workplace. But, in the wake of the birth control pill’s 50th anniversary on the market in the United States and its 40th in Canada, a major question remains: will there ever be a version for men?

The development of a male pill has been a longstanding joke in the pharmaceutical industry, where someone is always willing to predict that the pill is “five to 10 years away” from becoming a marketplace reality. While this ongoing delay is due in part, to the technical challenges of developing a reliable contraceptive formula for men, backward assumptions that men would refuse to take a male birth control pill have arguably proven to be a much greater obstacle.

Researchers, however, have actually proven the opposite. A 2005 international survey conducted by Berlin’s Center of Epidemiology and Health Research found that a majority of men reported interest in using some form of oral contraception, a finding that is supported by two other studies. “I think modern men would like to take part in this decision,” says Ken Rosendal, the CEO of Spermatech, a Norwegian company currently in the early stages of developing a non-hormonal male birth control pill. “A pill for men would have less side effects than a hormonal pill for women.” Rosendal says, however, that funding is a key barrier in the development of such a pill; while biomedical research companies like Spermatech may have the scientific know-how to make the male pill a reality, finding investors to cover the costs necessary to bring the drug to market (an estimated US$2 billion, according to Rosendal) remains a constant challenge.

This means that, until society decides to catch up to science, the male pill will continue—year after year—to remain five to 10 years away.