Section IV The General Proportions of the Problem
The outstanding characteristic of the phenomenon of non-medical drug use is that it is always changing. Moreover, there are great differences in the drugs used and the levels of use among the different using populations. It is, therefore, virtually impossible to sum up the phenomenon at any given time with a reasonable degree of accuracy. At the same time, there is a strong desire for a sense of the general direction in which the phenomenon is moving, for an identification of its significant trends, and an estimation of the relative seriousness of its various manifestations. Despite the limitations of generalization about such a multi-faceted and rapidly changing phenomenon, there is an understandable desire for some general perspective. What people wish to know may be expressed in a general question such as: Is the situation getting worse or better?
Such a general question, however, requires some definition. We must know what we mean by the "situation" and what we would consider an improvement or a deterioration. What, in the terms of the title of this section, is to be considered the "problem" for purposes of an attempt at a general appraisal? The "situation" or the "problem" might be considered to encompass all the negative aspects of the phenomenon of non-medical drug use, including not only the harm caused by the drugs themselves, but also the harm caused by various aspects of our individual and social response to non-medical drug use. In subsequent sections we address ourselves to social policy. In the present section we propose to limit ourselves to a very general commentary on the relative potential for harm and the extent of the various forms of non-medical drug use.
It is not possible to summarize the detailed discussion of effects, sources and distribution, and extent and patterns of use which is contained in Appendices A, B and C. For an adequate understanding of the Commission's findings on these matters it is necessary to read these appendices. Nevertheless for the reader's convenience, certain general observations may be made here to draw attention to particularly significant points. The reader should bear in mind, however, that many of these general statements will inevitably be oversimplications, and he should have recourse to the appendices for a fuller understanding of the necessary qualifications.
It is our impression that the overall extent of non-medical drug use, in one form or another, is increasing rather than decreasing in the general population. In any event, we do not see any signs of a marked trend in the opposite direction. The rate of overall increase may be diminishing, and it may even be reaching some kind of plateau or stabilization, but there are no clear signs of a movement in the direction of a general reduction in the extent of use. This observation is of particular significance, since the attitudes reflected in the general drift or tendency of non-medical drug use have an influence on individual decisions.
The widespread use of alcohol and tobacco continues to provide the supporting climate for other non-medical drug use. So long as their use continues to spread in all age groups of the population, including adolescents, there is little hope of being able to develop a general climate of restraint with respect to non-medical drug use. The damage caused by alcohol and tobacco is now so well understood that our continued toleration of these forms of non-medical drug use, and our apparent inability to bring about any significant reduction in them, raise profound doubts about our seriousness of purpose with respect to the phenomenon of non-medical drug use as a whole.
The effects of alcohol, its distribution (as well as the dependence of government on it for revenue), and the extent of its use are set out in Appendices A, B and C. A careful reading of this material can leave one in no doubt that alcohol is, and is likely to remain, Canada's most serious nonmedical drug use problem.
From almost any point of view the effects of the excessive use of alcohol are more harmful than those of any other form of non-medical drug use: in physical and mental injury to the user, in increased mortality from a variety of causes, and in drug-related behaviour causing personal injury to others. If we take the total incidence of such effects—which reflects the total numbers engaged in the excessive use of alcohol—there is little comparison with other drugs. To name a few, alcohol is a major factor in a large proportion of traffic accidents, violent crimes, suicides, serious family disruptions, and numerous physiological and psychological disorders in North America. Estimates of the extent of the use of alcohol vary, but we think it is reasonable to assume that at least three-quarters of the population over 15 years of age have used alcohol. The proportions who use it regularly and the proportion who use it excessively are, of course, much smaller, but they represent populations of considerable size. For example, there are probably at least twenty times as many alcoholics in Canada as there are opiate dependents. In addition, there are another several hundred thousand problem drinkers who would not be considered alcoholics at this time.
As a public health problem the excessive non-medical use of alcohol is in a class by itself. Although there is growing public awareness of the seriousness of this problem, and a good deal of editorial leadership from the press, the liquor industry continues to fight a rear-guard battle to persuade the public not only that alcohol is not a drug, but that the problem presented by its excessive use is grossly exaggerated. Governments are expressing increasing concern about the problem, but so long as they draw a substantial revenue from the sale of alcohol, their own seriousness of purpose may be suspect. It would appear that in the present social context the answer lies in greater self-restraint by the general public. The existence of a highly profitable liquor industry, legal distribution, and a large government revenue from sale, all make it clear that we cannot look to any significant restrictions on availability as a potential mechanism to reduce the extent of alcohol use.
The decision of several provincial governments in recent years to lower the drinking age to 18 or 19 is also in apparent conflict with public expressions of concern about the problems of alcohol, particularly among young people. From local surveys since this change in the law there is reason to believe that it is likely to have led to an increase in the consumption of alcohol by persons above the age of 18 or 19 and to an increased availability of alcohol (through friends) for persons under that age.
It has been proposed that raising the relative price of alcohol (in relation to disposable income) would be an effective means of reducing the use of this drug in the general population and thus decreasing the problems associated with heavy alcohol consumption. While some change in patterns of use would undoubtedly occur in some individuals as a result of an increase in the cost of licit alcohol, we feel that this is not likely to be a practical or effective method of bringing about a significant reduction in compulsive dangerous alcohol use. Although such measures might reduce the incidence of some of the acute adverse effects of drunkenness in certain populations, even with this increased financial burden alcohol is likely to be one of the last goods to be sacrificed by the dependent user. In certain low income families with an alcoholic member, an increase in the cost of alcohol would likely result in an even greater diversion of very limited funds away from food and other essential commodities to the purchase of the drug. Further deterioration in child nutrition might be a more probable result than a significant reduction in alcoholic adult drinking under such conditions. Moreover, if the cost of licit alcohol were raised substantially, there would likely be a significant increase in the illicit manufacture and distribution of alcohol, which, as indicated in Appendix B, is already extensive in certain parts of Canada. Finally, it seems unlikely that the general public would support the level of taxation and law enforcement which would be required to bring about a substantial change in heavy alcohol consumption.'
Not only is the excessive use of alcohol serious in itself, but it also figures prominently in various patterns of multiple drug use. Indeed, alcohol plays a significant background role in most dependent drug use, including the use of the opiate narcotics. It also frequently becomes the alternative or substitute for other forms of harmful drug use. For example, in many of the cases in which there is an apparent cure of opiate dependence, the user turns to the excessive use of alcohol sometimes with even more deleterious consequences. Alcohol also plays a serious role in producing harmful effects in combination with other drugs, such as the barbiturates and other sedatives. In our Cannabis Report we commented on certain additive effects of alcohol and cannabis.
The use of tobacco continues to be a very serious public health problem and is one of the leading contributing factors in disease and premature death in Canada. Tobacco use, itself, does not generally lead to injury to third persons, as in the case of alcohol, nor does it cause psychological damage, but it creates a serious risk of physical harm and substantially increased mortality rates in heavy users. It also creates strong psychological dependence which makes it difficult for users to break the tobacco habit despite its dangers to health and, frequently, its offensiveness to others. Indirectly, tobacco smoking is often a significant factor in property damage, personal injury and death caused by urban and forest fires. Today about 40 per cent of Canadians over the age of 15 smoke tobacco regularly. There has apparently been some slight reduction in recent years in the total proportion of the population engaged in the use of tobacco, but there has been little change, or perhaps some increase in the number of heavy users. As well, there are indications of increasing use among young people—particularly teenage girls. There is no reason to believe that there has been a decrease in the incidence of harmful effects of this drug. The use of tobacco continues to play a significant role in multiple drug use as indicated by its close associations with the use of alcohol, cannabis and other drugs. The general presence of inadequately attended cigarette dispensing machines and lax sales practices of many vendors make tobacco easily available to all, including the very young. Increasing concern is being expressed over the right of non-smokers to breathe uncontaminated air in public places often dominated by heavy smokers.
In addition to alcohol, there has been an apparent increase in the nonmedical use of other sedative drugs, in particular, barbiturates and related sedative-hypnotics and minor tranquilizers. These drugs have close affinities with alcohol. Indeed, many complications arise from their use in combination with alcohol. It is impossible to estimate the full extent of the non-medical use of these drugs, particularly by adults, because the supply for such use often originates under prescription which is not routinely monitored. But there has been increasing evidence of an illicit market in certain of these drugs and clear indications of an increase in their use by young people. The extent of the non-medical use of barbiturates and related drugs in Canada is not comparable to that in the United States, however. As part of the general increase in the use of drugs with sedative action—sometimes referred to as downers'—there apparently has been a continuing increase in the use of cannabis, which is sometimes taken for its tranquilizing effect.
Among the sedative drugs, the most evident increase is in the use of certain non-barbiturate sedatives and minor tranquilizers, which in recent years have tended to replace the barbiturates in many medical applications. The rapid increase in the non-medical use of methaqualone (e.g., Mandrax®) is particularly noteworthy. There have been a number of reports of the use of these drugs simultaneously with alcohol by adolescents to achieve very intense intoxication.
We believe that because of the widespread adult reliance on these drugs with sedative-like action from supply originating under medical prescription and the stressful conditions of modern life for which they appear to offer relief, it is reasonable to expect a continuing increase in their non-medical use in all groups of the drug-using population. These drugs vary considerably in their potential for harm, but all have the capacity to produce dependence, and certain of them have significant potential for physical toxicity and death by overdose, either alone or in combination with other drugs. Barbiturates are the drugs most frequently involved in fatal self-poisoning or suicide, perhaps because they have been prescribed for the last half century, while most of the other non-barbiturate sedative-hypnotics have only been developed during the last 10 or 15 years, and consequently are less known to the medical profession and the public. Even the less potent of the sedative drugs can have serious effects when used, as they often are, with other drugs such as alcohol. One of the most insidious aspects of this general category of drugs is the tendency of those who are attracted by them to use them in combination.
There continues to be an extensive non-medical use of stimulants. The desire for stimulant effects is, of course, reflected in the heavy consumption of caffeine in the form of coffee, tea and cola drinks. There is also widespread non-medical use of amphetamines and amphetamine-like drugs. Although most of the non-medical use of amphetamines in the general population apparently involves oral use of relatively moderate quantities, much concern has developed over the high-dose intravenous use of methamphetamine or 'speed' by certain groups. The total number of persons involved in the intravenous use of amphetamines appears to be fairly stable, and may even have declined somewhat in recent years. It would appear that many who drop out of the 'speeder' population after a few years, because of the severe strain which the 'speed' life style imposes, are more or less balanced by the initiation of new users. It is our impression, however, that the non-medical use of oral amphetamine and amphetamine-like drugs, such as Dexedrine® and PreludinO, often supplied from an illicit market, has increased in recent years, particularly among young people. The medical use of amphetamines has decreased in the past few years, and may be expected to decrease still further as a result of the restrictions imposed by the Federal Government at the beginning of 1973 on the purposes for which such drugs may be used in medical treatment. But it is likely that the non-medical use of such drugs, supplied by an illicit market, will continue to increase. As well, many persons who have been obtaining amphetamines on prescription will likely continue to receive from legitimate sources other amphetamine-like prescription drugs which are not subject to the above restrictions. Taken occasionally and in moderate doses, amphetamine and amphetamine-like drugs are not particularly harmful, but tolerance develops with frequent use and they have a significant capacity for producing strong psychological dependence in certain users. Ai; higher doses, they can produce serious psychological and physiological &orders. Additional problems are frequently caused in 'speeders' by the use of unsterile injections and insoluble contaminants in illicit drugs. The reliance which many people place on these drugs for additional energy and confidence to meet the demands of modern life creates 4 serious health hazard. In recent years there has been an increase in the non-medical use of the stimulant cocaine, although it has not yet become very extensive.
There has been a marked increase in recent years in the non-medical use of the opiate narcotics, particularly heroin and methadone, and an apparent increase in the proportion of young people engaged in such use. In 1972, the records of the Bureau of Dangerous Drugs showed approximately 9,000 "habitual" users of illicit opiate narcotics (formerly called street addicts). There is reason to believe that the total number of opiate dependents shown on the records of the Bureau at any particular time is considerably below the total number actually in the country at that time, but it is not known by how much it falls short. It is felt that sooner or later most of the opiate-dependent persons will come to the attention of the police, the treatment agencies or private physicians, who are the main sources of the information on which the Bureau bases its records, but there is a considerable timelag and other gaps in information channels which probably leave a significant proportion unknown to the Bureau at a particular time. There has also been a greater dispersal of opiate narcotic use in recent years and a marked increase in experimental or occasional use, so that the total number of persons in the process of becoming dependent is likely to be less exposed to law enforcement and treatment personnel than it formerly was. Our own estimates of the probable number of opiate dependents in 1972, based on field studies and other Commissioin research as well as estimates by the R.C.M. Police made about the same time, suggest that the actual number is probably somewhere between 12,000 and 15,000. In order to avoid any danger of underestimation we are prepared to accept the figure of approximately 15,000 as a reasonable estimate of the number of daily users of opiate narcotics in Canada at the present time. We certainly feel that this is a safe estimate, and that there is little likelihood that the total number exceeds this figure. There is reason to believe, however, that there are also tens of thousands of persons experimenting with the use of opiate narcotics, an unknown proportion of whom are probably at serious risk of becoming dependent. Thus the situation with respect to the use of opiate narcotics is a dynamic one, with a definite tendency to increase in numbers and to spread geographically. At the present time, such use is still very heavily concentrated in British Columbia—and to that extent the use of opiate narcotics can be regarded as still very largely a regional problem—but there has been a significant increase in use and dependence in recent years in certain parts of the prairie provinces, particularly Alberta, and in certain parts of eastern Canada, especially in Toronto and other cities in southern Ontario. In some areas, there are reports of youthful "primary methadone addicts" who have not been significantly involved in the use of heroin.
The chief danger from the use of opiate narcotics is, of course, the great difficulty in curing a typical case of opiate dependence. Where the drug must be obtained in an illicit market the consequences of such dependence are likely to be very serious both for the individual and the society in the form of drug-related crime. There is also the general effect of such a style of life on the health of the dependent person, and the ever present danger of death or serious injury from various causes including suicide, accidents, drug toxic reactions or overdose, and numerous diseases and other effects of unsterile intravenous injection. Even where the drug may be obtained legally, as in the case of methadone maintenance, such dependence is a serious qualification of the individual's freedom and a pharmacological necessity which renders him increasingly vulnerable to the will of others. The increase in the experimental use of opiate narcotics, and in the extent of opiate dependence in Canada in recent years is undoubtedly a serious problem requiring determined efforts by government and community resources of various kinds. It is impossible to estimate how it may develop in the future. It may well not take the course it has followed in the United States. There are number of circumstances that are different in the two societies, including the absence in Canada of the urban ghetto phenomenon on a comparable scale. At the same time, there is no ground for confidence that opiate narcotic use is about to level off or decline in Canada. It requires continuing vigilance.
In recent years there has been an apparent levelling off, and possibly even a decrease, in the total number of persons using LSD, although there is still a relatively heavy concentration of such use among high school and university students and certain other populations. At the same time, there has been a marked increase in the use of MDA, a physically more toxic hallucinogen with certain amphetamine-like properties. There has also been an increased use of PCP. In spite of persistent rumours of exotic psychedelic drugs in North America, there is little indication of significant use of hallucinogenic drugs other than cannabis, LSD, MDA and PCP in Canada. The use of the stronger hallucinogens remains for the most part an occasional one. Heavy dependent use of these drugs is uncommon. Few of the psychedelic ideological connotations of the mid-1960s are associated with current drug use. Typically, hallucinogens are now among a wide variety of drugs involved in a general multiple drug-using pattern of behaviour.
The use of volatile solvents appears to be concentrated in certain parts of the country, of which Manitoba is one. It is our impression that while such use may have increased locally from time to time it has, on the whole, levelled off or perhaps even declined slightly in recent years. There have been changes in the form of the substances most frequently used; in particular, nail polish remover has tended to replace glue, although the same volatile solvents are generally involved. While a few solvent-related deaths (primarily involving plastic bag suffocation) have been given considerable attention, serious adverse reactions from volatile solvents do not appear to constitute a significant public health problem at the present time.
As indicated in preceding sections, the dominant pattern of non-medical drug use is one of multiple use. The individual about whom there is major cause for concern is the youthful chronic multi-drug user who is indiscriminate in his choice of drugs. He is sometimes referred to in the drug culture as a "garbage head". The hazards of drug use increase with indiscriminate experimentation and the mixing of drugs which have additive or potentiating effect. It is impossible to estimate the size of the hard core chronic multidrug-using population—there are certainly several thousand—but this group likely has a potential for stimulating the spread of harmful drug use out of proportion to its size.
There is reason to believe that as youthful drug users have become more experienced and sophisticated they have been able to reduce the number of acute adverse reactions—"bad trips" or "freakouts"—or have been able to cope with them better. In the last year or so, emergency treatment services have seen a smaller number of such cases than they did in the late 1960s.
Thus, we may sum up by saying that while some forms of non-medical drug use appear to have levelled off, and even in certain cases decreased, non-medical drug use as a whole has continued to increase; alcohol and tobacco remain the major sources of drug-related public health problems; the dominant pattern has become one of multiple drug use, with a hard core of indiscriminate, chronic multi-drug users who encourage the spread of harmful drug use; there has been a marked increase in experimental and dependent use of the opiate narcotics; and there is some evidence that hallucinogen users have become more sophisticated in their ability to avoid acute adverse reactions.
1. It should be observed that the proponents of this suggestion think of it as a preventive rather than a curative measure. They concede that it might not have too much effect on the present population of users with alcohol problems, but they contend that by discouraging future use it would reduce the incidence of new cases of harmful use. We remain skeptical. We believe that two factors are likely to defeat the purpose of this measure: the compulsive character of the increasing reliance on alcohol by persons who become problem drinkers and alcoholics, and the relative disposable income of the middle-class who contribute significantly to the total extent of excessive use of alcohol. The size of this middle-class, the extent of its reliance on alcohol and its relative disposable income are factors which were never encountered before in the experience of other countries and other periods on which the proponents of relative price rely. For the others in the population, this proposal, as we suggest above, is more likely to result in a further deterioration in child nutrition and other family neglect and in the development of an illicit market. Further, we place no confidence in the proposals of differential taxation to encourage preference for the so-called "moderate" beverages, such as beer. Both beer and wine may be used to excess, and the excessive use of both are capable of leading to alcoholism and other drug-related problems. We are not convinced by the evidence that the differences in the rate and other conditions under which excessive use of the various alcoholic beverages can lead to alcohol-related problems justifies a public policy of encouraging the use of some rather than others.