[Recorded by Electronic Apparatus]
Tuesday, December 3, 1996
.0910 
[English]
The Chairman: Good morning, everyone. We'll call the meeting to order now and get on to our round table discussion on illicit drugs. We welcome four witnesses. I'm going to invite them to introduce themselves for the record, starting with Dr. Pierre Lauzon.
[Translation]
Dr. Pierre Lauzon (General Practitioner, CRAN Program): Good morning. My name is Pierre Lauzon and I am a general practitioner from Montreal.
[English]
Professor Harold Kalant (Director Emeritus, Biobehavioural Research Department, Addiction Research Foundation): I'm Howard Kalant. I'm a professor of pharmacology at the University of Toronto and director emeritus of biobehavioural research at the Addiction Research Foundation.
Dr. William Corrigall (Director, Biobehavioural Research Department, Addiction Research Foundation): Good morning. I'm Bill Corrigall. I'm a scientist at the Addiction Research Foundation in Toronto and currently director of the biobehavioural research department.
Professor Juan Carlos Negrete (Department of Psychiatry, McGill University and University of Toronto): I am Juan Negrete, professor of psychiatry at McGill and at the University of Toronto and head of the addiction psychiatry program in Toronto.
The Chairman: Gentlemen, we thank you for coming. As you've probably heard, we're well into a review of Canada's drug policy. In that context we're particularly glad to have your participation.
I understand you may have some opening statements. I invite Dr. Kalant to begin. Leave some time so we can have an exchange, not only among you people but also between you and members of the committee who have you here to pick your brains. Dr. Kalant.
Prof. Kalant: Thank you. I'd like to begin by thanking the committee for inviting us to take part in these discussions. We hope what we have to say will be useful. I shall certainly try to keep my remarks as brief as possible for the purpose of leaving as much time for questions as you find useful.
We've divided up the area we're going to cover among Dr. Negrete, Dr. Corrigall and myself. Then there'll be other topics we won't cover formally in our presentations but hope you will feel free to ask about in the question period. Dr. Negrete's going to talk about opiates, Dr. Corrigall about cocaine and amphetamine or central stimulants. I'm going to talk about cannabis. I hope we'll be able to field questions about the other drugs as you see fit.
We were asked to cover some basic facts about these various drugs and I've prepared some notes that I believe you have about cannabis. Some of the things I say will perhaps be less than what's in the notes, with the expectation that you'll be able to read that later.
As far as the basic pharmacology of cannabis is concerned, it's enough to remind you that it is a plant. The crude preparations, marijuana and hashish, as they come from the plant, are: marijuana is the dried leaves and flowering tops and hashish is the resin that coats these. The active ingredients that are responsible for the actions for which cannabis is used are called cannabinoids, of which delta9-THC is the only significant active one in the marijuana plant or cannabis plant itself, but there are synthetic modifications that are becoming increasingly important, as I'll explain in a moment.
The actions of the THC, or of the cannabis preparations, are rather mixed. They are complex. At the beginning, within the first few minutes of smoking or taking the drug, there is a stimulant effect, which is additive with that of amphetamine or cocaine. After 10 or 15 minutes, this changes into a sedative effect, which is additive with the sedative effects of alcohol, barbiturates, tranquillizers and so on.
.0915
In this sedated state, which is the one that makes up most of the period of action, there's a sort of pleasant, dreamy, pleasurable feeling. During it people tend to be more sociable and less aggressive than with alcohol, for example, or other drugs. After a while the person goes into a sleepy state and eventually wakes up and the experience is over.
The physiological effects are not very prominent. There's increased heart rate and some reddening of the eyes. The blood pressure when the person stands up is a little bit unstable. But these are not major effects.
The sensory and the psychic effects are the most obvious ones. The acute effects - that is, the effects of a single dose - are similar in many ways to those of alcohol in the sense that acuteness of perception, speed of reaction and ability to monitor different sources of information at the same time are impaired by cannabis just as they are by alcohol. For example, when you're driving a car, you have to watch the road, you have to watch the speedometer, you have to watch the side streets and so on.
At much higher doses one gets into effects that are somewhat like those of the hallucinogens. There can be distortions of perception, strange feelings and in very high doses feelings of being outside your own body, for example. For the experienced user, those can be part of the attraction; for the inexperienced user, it can be a source of panic or intense anxiety.
There are some other effects I'll refer to a little bit later on because of their possible medical applications.
The acute effects, of course, pose health risks in the sense that when perception, speed of reaction, attention and so on are impaired, the risk of accidents is correspondingly increased. But the major concerns about health are the ones that attach to the chronic effects of cannabis.
I must emphasize here that one doesn't expect to see serious health effects in the person who smokes pot occasionally - we're talking here essentially about regular heavy users - just as in the case of alcohol you wouldn't expect to see brain damage with someone who has a drink once in a while or even a glass of wine with dinner every day. You expect to see that in the regular heavy drinker who takes six, seven, eight drinks a day and more. In the same way, when you talk of health effects of chronic cannabis use, you're talking essentially about the user who smokes every day, probably several times a day, and is more or less under cannabis influence most of the waking time.
The major effects so far identified are on the respiratory system and on the brain. As for the respiratory system, remember that we're talking of smoke, which has a higher tar content than tobacco smoke. Therefore, it's not surprising that the same kinds of inflammatory changes - chronic bronchitis and then pre-cancerous changes in the cells lining the airways - are seen with chronic heavy cannabis use at an earlier stage than is the case with tobacco, probably again because the amount of tar delivered by the cannabis smoke and the depth to which it's inhaled and retained in the lungs add up to a much greater dose of potential carcinogenic material than with tobacco as a rule.
The effects on the brain are subtle. There are behavioural and personality changes. Regular heavy use is associated with poor memory, a loss of drive, poor performance in school or at work, a slowing of thought processes, and a generally apathetic approach to life. Usually this situation clears up if the person stops smoking. So it probably is chronic intoxication rather than permanent brain damage. But in a few cases it does not clear up. In such cases there's good reason to believe there is some degree of brain cell damage similar to what one sees in the severe, chronic alcoholic who suffers irreversible brain changes.
.0920
There are psychiatric effects. There is a dependence syndrome. Cannabis is capable of producing dependence, just as any other drug of so-called psycho-active effects is. The physical component of dependence is minor, for the reason that cannabis is cleared from the body very slowly. Therefore, you don't see a severe abrupt withdrawal reaction, as you do, for example, with heroine. The more slowly a drug is cleared from the body, the less severe the withdrawal reaction. It's similar, in that sense, to methadone rather than to heroine.
The other major psychiatric effect is the risk of precipitating a breakdown in a person who has a psychotic tendency to begin with. Schizophrenics who are controlled or borderline managing may be pushed into an acute breakdown by heavy use of cannabis.
A few other systems are thought to be affected. There is good evidence, for example, that immune cells, lymphocytes that are involved in protection against bacteria or against cancer, are impaired by cannabinoids in the test tube. Whether that happens in the living person or not still remains to be established.
There are mild effects on the endocrine system. Women have anovulatory periods if they're regular heavy smokers. Men tend to have low testosterone levels and low sperm counts. Again, it is not clear how important or how long-lasting those changes are, because it's been suggested there may be the development of tolerance to those effects. That remains to be established.
The only other chronic health effect I'd like to mention at this point is the possible effect on the children born of mothers who smoke cannabis regularly during pregnancy. There is quite good evidence that when the children are born, they're small for their in utero age, they're irritable and they don't feed well. But this recovers. By about four to six months, they have generally caught up to the babies of mothers who haven't smoked cannabis during pregnancy.
However, when they get to school age, they're now starting to show poor word learning and poor verbal skills. The concern is that this may affect their subsequent school career and therefore their lifetime career possibilities.
The best evidence on this subject comes from here in Ottawa. Dr. Peter Fried at Carleton University has been carrying a study on many hundreds of such children who are now in early school years.
Just two other things I'll mention very briefly. How serious are the hazards I've outlined? The answer is that it depends on the extent of use, as I've pointed out. In Canada the most recent figures I had available, which are now a couple of years out of date, show that about 20% of the total population have ever used cannabis - 33% of the 20- to 24-year-olds and 16% of the 15- to 19-year-olds. So it's the late adolescents and young adults who are the heaviest users. Among them the males consistently use more than the females.
Current users, that is, those who have used within the past year, are down to about 5% of the total population - 13% of 20- to 24-year-olds and 9% of 15- to 19-year-olds. The daily use figure is not accurately known because the surveys have generally, until very recently, not asked that. It's probably somewhere under 1% of the total population, but correspondingly higher in the high-risk groups of the late teenagers and young adults.
The risks of acute effects, that is, accidents and things like that, will of course depend on the total use, because you don't have to be a chronic user to have an accident. It can theoretically happen if you get high on pot even once. That's chance. On the other hand, the risks related to the chronic effects will be dependent mainly on those regular heavy users who are in the 1% or so who make up the hard core of users.
The policy implications of this are that anything that changes the levels of use will change the risk. If you decrease the levels of use, you will decrease risks; if you increase levels of use, you will increase risks. At current levels of use, the risks are probably less, in fact are almost certainly less, from cannabis than they are from alcohol and tobacco, and probably less from heroine and cocaine. But if the use of cannabis becomes much more widespread - and particularly regular heavy use because of easier availability, low price, social acceptance, no legal problems, and so on - then it's safe to predict that the number of people suffering significant health consequences will go up correspondingly. It could conceivably become just as great a problem as current problems with alcohol.
.0925
The last thing has to do with the medical uses of cannabis. It's important to review these very briefly simply because, as you're undoubtedly aware, medical use is being used as an argument for the legalization of cannabis for all uses. The point I would make is that this is a nonsensical argument.
Cannabis is not a new drug. It was in the British pharmacopoeia and in the American pharmacopoeia in the last century and the first third of this century. It was used as a sedative; it was used for treating symptomatically things such as severe diarrhoea, muscle spasms and so on. But it fell out of use because it was not a particularly good, reliable drug. The preparations that were used were liquid extracts or solid extracts of cannabis. They were of unknown or variable composition. They had a poor shelf life. Therefore, the physician prescribing it couldn't know really how much active drug the patient was getting.
When synthetic drugs of known composition, known potency, known purity, came on the market, cannabis simply stopped being used because it wasn't as good as the newer drugs.
What is the potential interest in it now, then? Two uses of the pure THC, either the synthetic THC or some of the semi-synthetic derivatives of it, have stood up to critical, careful examination. These two uses are approved for it: one is the the treatment of nausea and vomiting due to anti-cancer chemotherapy; the other is the stimulation of appetite in AIDS patients. With increased appetite and increased food intake, the patient's general well-being and survival time increases.
There are other possible uses, because the manner in which the drug acts has now been discovered. There are specific receptors, molecules on the surface of certain cells in different parts of the brain, in the lymphatic cells in other parts of the body, that the drug binds to. It initiates its actions at that site.
There are now two different kinds of receptors recognized. There are probably more, because with all of the other substances for which receptors have been found, different sub-types of receptors have grown in number as research has gone on. The hope is that each receptor will be responsible for a different type of action. Therefore, by chemically modifying the THC, by changing it to fit a particular receptor, you'll be able to target it for a particular drug effect.
The effects that are probable as future therapeutic developments are the relief of pain, the relief of muscle spasms, immunosuppression in patients having organ transplants or in patients with autoimmune diseases and glaucoma. There is less probability of some other effects.
The point is that these are medical uses, which will be made by physician's prescription. The pure compounds of known potency and composition and stability will be monitored medically so that one can see what the therapeutic effect is and whether the drug is doing what it's meant to do. If not, the physician will then change the drug to something better.
That is not at all the same thing as saying pot should therefore be available for anybody to smoke who feels like it. If you watched the program on CTV last week or others on some of the American channels, with all kinds of users testifying to the great benefits they have received, I would emphasize that these people did not have medical diagnoses. They were saying what their problems were. They were not being monitored medically for the effect of smoking pot. They were deciding whether it was good for them or not. Their reasons for saying it was good may have nothing whatever to do with medical reasons.
So all I would caution is that the issue of the use of the pure THC or its synthetic derivatives for medical purposes is a totally different issue from the smoking of pot for whatever purposes the smoker has.
Thank you.
.0930
The Chairman: Dr. Corrigall.
Dr. Corrigall: Let me carry on, then, from what Dr. Kalant has done with respect to cannabis and cannabinoids and try to deal with cocaine in the same sort of framework that he's used.
In terms of its basic pharmacology, and what it is in fact, cocaine is another plant product. It's an alkaloid that is extracted from the leaves of the coca plant. Street use or use in drug-dependent individuals or people experimenting with the drug is really of two broad forms of cocaine. One is the hydrochloride salt, which is a water-soluble version of cocaine that can be made up in aqueous solution, in a water-like solution, and injected. It's also the same form of cocaine that is snorted, that is, taken intranasally, or is used by rubbing on various mucus membranes, mouth, nose, rectum, whatever. It's absorbed through the mucus membranes and reaches the circulation that way.
The other form of cocaine that is used is free-base cocaine, meaning that it is no longer a salt form, it is a base molecule. The advantage of this to the user is simply that it's stable at high temperatures and it's vaporized at high temperatures, so it's susceptible to being smoked. There are really two forms of free-base cocaine. One is the very pure form, which is prepared by extracting the then-formed base with organic solvents, things like ether. This can pose some risk because it's flammable and may explode in preparing the very free free-base form of cocaine that can be smoked. Then there is a cruder form of free-base cocaine that is commonly know as crack, which is free-base nonetheless but contaminated with impurities made in its preparation. So rather than the solvent extraction of ether or ether-like compounds, the free-base form as crack is contaminated.
Crack obviously can be smoked, and smoked and injected forms of cocaine reach the brain very quickly as opposed to intranasally administered or cocaine that is applied to mucus membranes.
At moderate doses of cocaine, the user experiences feelings that he would report as euphoria and increased energy, often manifested as increased talkativeness. The need for sleep is postponed at moderate to higher doses, and appetite can be suppressed. As doses increase, those effects can remain; they may also be compromised, however, or balanced by higher dose effects of the drug that can influence those. Those would include things up to frank paranoia but including erratic behaviours.
Beyond physiological effects, additional effects that can occur are an increase in heart rate, an increase in cardiac workload, a decrease in skin temperature, increased respiration, increased body temperature - essentially effects like that.
Death can occur either from cocaine-induced convulsions or, depending on the rate of administration - and these are extreme cases in which death does occur - from collapse of the respiratory centres, so that actually respiration is stopped. But those are at extremely high doses, and I would mention that we're not talking about death from cocaine overdoses being a regular consequence of use.
In long-term users the high, the so-called high, which is the subjective effects of the drug, can be perceived to be less. This, again, may be because during chronic use the effects are compromised by development of other effects such as paranoias that occur with amphetamines or cocaine.
In terms of initiating drug dependence, in some ways cocaine has been perceived to be the gold standard in that both animals prepared with intravenous catheters, as well as humans using it for recreational purposes, will administer the drug in either small amounts or, given the opportunity, binge amounts, sustained patterns of administration. Cocaine, for that reason, has often been labelled as one of the most addicting substances. We can return to discuss that in questions.
I think the point to make here is simply that it's a drug that has fairly clearly effects on animal motivation and therefore in an experimental situation will produce substantial drug-seeking behaviour. For that reason, it's been extensively studied and it's actually been one of the useful probes to allow scientists to understand mechanisms in the central nervous system that are involved in drug dependence, at least for psychomotor stimulants, of which cocaine is one.
.0935
For cocaine and cocaine-like compounds, it's now clear that these substances block the re-uptake of certain neurochemicals in the brain. By that I mean normal cell-to-cell communication in the brain and the central nervous system is affected by chemicals that are released by one cell, which diffuse across a very small area and bind to the next cell, causing it to initiate an electrical signal. Several of these compounds in the brain are repackaged by our central nervous system so the cell that actually emits the chemical takes it back up to use it again once its message transmission function is fulfilled. Cocaine blocks that, or at least slows the process down, for several neurochemicals: for dopamine, norepinephrine, and serotonin. Certainly it does that.
We now know that the effects on the dopamine system are one of the prominent effects of cocaine with respect to its ability to initiate, maintain and possibly promote relapse to the use of the drug, at least as measured in animal paradigms. It's also clear in humans that cocaine has apparently similar effects on the dopamine system. This, then, has prompted a substantial amount of research into dopamine and dopamine-like compounds and, in general, manipulations of the dopamine system as pharmacotherapies or potential developments of medication.
My colleagues may disagree, but I would say that at this point most of the work with the dopamine system hasn't been overly successful. That may not be surprising in that there are clearly other neurochemical systems that are involved, which would be point one. Point two, dopamine is involved in a wide variety of behaviours and a wide variety of central nervous system functions, and it's very difficult to manipulate the dopamine system and expect specific effects on drug dependence and not have those accompanied by other sequelae that would be perceived as side effects.
Nonetheless, really the research around the dopamine system is one of the key elements of basic drug dependence research, which is a vehicle that is driving research in the mechanisms of a number of other substances such as opiates and nicotine.
One of the outstandingly different things about cocaine with chronic use is its ability to sensitize behaviour. It's not clear at this point how this carries over into effects of the drug on humans, but certainly in animal experiments the drug, with repetitive administration, produces a sensitization. It produces a sensitization of the effects of the drug on motor behaviour, so that there's increased exploration, increased sniffing, head movement, etc., behaviours that come under the general heading of stereotypic behaviours. These tend to increase rather than decrease with repetitive exposure to the drug. It's possible that in the human arena these same effects of sensitization play a role in the effect of the drug in users as they experience the drug sequentially. These effects do appear to involve the same dopamine system that I alluded to earlier, and I think it remains for research to show the mechanisms of those and how important they are, whether yes or no, in humans.
Finally, to match with what Dr. Kalant discussed in terms of extent of use, let me just point out the current picture of cocaine, at least roughly in Canada and a little more explicitly in Ontario, where there is data.
First of all, I should point out that the rates of use in mainstream populations are certainly higher in the United States than in Canada. I think that's important to recognize, because some of our information gleaned popularly about extent and prevalence is coloured by American news stories. For example, in 1981 the percentage of Americans aged 12 and over who had used cocaine in their lifetime - so this is reported use ever, or more than once, in a lifetime - was 11.5%, while a year earlier, for roughly the same age group of Canadians asked the same question, the response was 3%. So we were by a factor of 3 to 4 different from the U.S. in the early 1990s.
.0940
Unfortunately, Canadian surveys estimating general population use are really fewer in number than the U.S. surveys. Three studies have covered general populations between 1985 and 1990.
Over that period the data do not indicate a significant change. These studies are showing that over periods of 12 months, use varied between 0.9% of Canadians in 1985, 1.4% in 1989, and 1% in 1990. So the use was roughly level.
More complete trend pictures of cocaine use are evident in Ontario in the Ontario student drug survey, which has been conducted by the Addiction Research Foundation. and this study now has an 18-year history. It's administered every second year to high school students in grades 7, 9, 11 and 13.
Until the previous administration of this survey, which was last done in 1985, data showed more or less a sustained, slow and gradual decline in the extent of use of cocaine by students in those grades, from a high of about 5% down to a low of about 1.5% in 1993. So over that period of slightly longer than a decade, there was a sustained decrease in use.
However, the 1995 data suggest that the declines have ended. In fact, from a low of 1.5 in 1993, the Ontario drug survey reported 2.4% of students in 1995 reporting use on a single, or more than a single, occasion in the previous 12 months. So there was an increase in use.
Now, this was not for cocaine alone, and if you have a look at the Ontario drug survey, you would find that the use of a number of substances increased, including tobacco, cigarettes, cannabis, alcohol, solvents used by inhalation, etc.
So it's not clear at this point.... These are certainly statistically significant increases; they're certainly not specific for cocaine or any other drug. There's a general trend towards increase. It's not obviously clear whether that trend will be maintained or not.
Having raised the spectre of increased level of use, I would point out that use is nonetheless low. This is a very small percentage of students in these grades. There may be some encouragement in the data, in that if it was examined across grades, use was highest in grades 9 and 11, lowest in grades 7 and 13.
So if you take that in a causal-temporal kind of view, you could come away with the picture that earlier use is experimental - which it probably is at this level of use - and is decreasing again at the time students have reached grade 13. So there may not be progressive recruitment to drug use going on, but merely experimental sampling.
Regarding the data I've talked about, the questions were not particularly specific about route of administration and type of drug use, but they would likely have captured non-crack use, so it would likely have been intranasal or mucous membrane application. It would have included injection drug use, but that would be expected to be small in this population.
Finally, just to bring to an end the prevalence, crack use in general in Ontario, particularly in students, is small. Crack first appeared on the scene in Ontario in 1986. The first estimate was in the Ontario student survey in 1987. It varied between 1.4% and 1%, high to low, from 1987 to 1993, and in the 1995 survey it increased slightly to 1.7%, but that's a non-significant increase.
So I think, then, overall with respect to cocaine in terms of prevalence, at least among Ontario students, we're looking at an increase that is not cocaine-specific, and it's not clear how that will play out over time.
Finally, in terms of medical use, there is little that is made of cocaine now. It can be used. It's a local anaesthetic. It blocks the initiation and propagation of nerve impulses, quite apart from its effect on the dopamine system, and it decreases the size of blood vessels so that it can be used for -
.0945
Harold, perhaps you know this. It used to be used for intraocular surgery. I'm not sure whether it still is.
Prof. Kalant: It's still used for both nasal and nose and throat surgery.
Dr. Corrigall: It not only anesthetizes but also tends to decrease bleeding.
So that's the extent of medical use for cocaine, which obviously is apart from any use by drug-dependents or experimenting students.
[Translation]
The Chairman: I'd like to remind the members of the committee that they have received some documents that have not been translated, including Dr. Kalant's brief. This document is in English only. We also received a document from Dr. Pierre Lauzon that is only in French.
[English]
I want to make it clear to members of the committee that while it all balances out, as my friend says, the fact is that we're departing from our normal practice here. We like - we insist - that documents be in both official languages, but I made an exception this morning. We're not dealing with national organizations here.
I get annoyed when organizations purporting to be national in scope and mandate come in here and tell us they don't have the resources to give us the document in the other language. But when we're dealing with individuals, I think as members of the committee we ought not restrict ourselves to a point that we can only hear witnesses who have the resources or the time to give us the document in both official languages.
I recognize that certain members of the committee were at a disadvantage in hearing Dr. Kalant in that they had a document that was in English only. The same would apply later when we hear from Dr. Lauzon.
I ask the clerk again, as I said to him privately, to encourage witnesses to give it to us in both languages or, alternatively, to give it to us in time so we can facilitate the translation for members of the committee.
Second, I say to witnesses that we have our own drug this morning, called coffee. Feel free to indulge.
I now invite Dr. Negrete to make his presentation.
Prof. Negrete: Continuing to cover the wide field of different psychoactive agents, which are the object of your survey and study, I will mention specifically opiates, the derivatives of opium. These are products that have been in circulation for a very long time. In fact, they're probably the oldest known psychoactive products, apart from alcohol. They are natural alkaloids, extracted from the poppy plant, called morphine and codeine.
Then there are semi-synthetic products in which the natural molecule has been altered, sometimes to improve its therapeutic efficiency or its effects. Entirely synthetic analogues have been produced along the way in laboratories to replicate the action of this natural product in the brain and other parts of the body.
The opiates are very potent and active drugs. They have an important effect, which has been recognized from the beginning and has of course justified its utilization in medicine. They control pain. In fact, since the 1700s this has been a very important element in modern medicine, utilized specifically for that purpose. They also produce sedation, relaxation and a general sensation of well-being. With that kind of effect, you can imagine that they are highly desirable as an experience for somebody who receives them.
.0950
And, of course, they are addictive - that is, the individual who experiences with these drugs tends to want to re-experience them. After repeated utilization, there is a growing desire, which sometimes implies a desire for larger doses to satisfy the need. Finally, there is the problem that if you cut down on the dose you normally or regularly use, or if you run out of the drug, you suffer the distress of withdrawal.
So the opiates have provided the model of what we describe clinically as an addiction: a strong desire to use the drug; a need to increase the dose to satisfy the expectations; suffering when the dose is cut down or arrested; and of course, feeling a sense of relief when the use resumes, the curative effect of further utilization. That was the medical model of addiction, which has now been altered a bit, but that had been in our nosology, in medical nosology, for many years.
Now, as far as the opiates in Canada are concerned at this time, there are three separate kinds of problems. I will start with what I see as a very important one, and perhaps the most frequent one, the abuse of pharmaceutical preparations of opiates, which include, of course, codeine, one of the very popular painkillers, analgesic drugs.
As you know, codeine in Canada is available without medical prescription at doses of 8 milligrams per pill, and it can be obtained over the counter in pharmacies. That has clearly resulted in Canada being one of the societies in the world that consume the highest amounts of codeine on average per year. This is very easy to compare with similar societies, such as the United States, for example, where codeine is not available as such.
Codeine is available over the counter in combination with other products, with other analgesics such as acetylsalicylic acid - aspirin - or with acetaminophen in the form of Tylenols. Tylenol 1 has 8 milligrams, Tylenol 2 has 15, and Tylenol 3 contains 30 milligrams of codeine.
The result is that people who are using codeine often have to buy it in combination with the other product, and they abuse both the codeine and the other product. In the case of preparations such as 222s, for example, the combination is not just with acetylsalicylic acid, but also with caffeine. So when you have a need for that drug, and since the dose per pill is so small, you take an enormous amount of pills.
In our treatment centres we see individuals come in who daily use over 100 pills of, let's say, Tylenol 1 or 222s. You can imagine then that they face a problem in relation to the associated components or the preparation as well.
The other situation we face with respect to the opiates is the illegal market, the street market, of very potent alkaloids and semi-synthetic preparations such as heroin.
.0955
The use of heroin derives from the fact that it has to be injected. It cannot be ingested. It can be absorbed through the nasal mucous membranes, and some people do that, but very few users of heroin do that. It is a waste of money, in fact, because it is not a very efficient way of procuring the effects of the drug.
It can also be smoked. It's an older oriental practice called ``chasing the dragon''. The heroin is burned and the smoke that is produced is inhaled quickly. It is also not as efficient as injecting it.
The most common practice, then, is to inject the drug intravenously. Because that is done, we have major associated health consequences from this practice: infections of all kinds, hepatitis being the most common and certainly most costly both in mortality and in morbidity, and infection with HIV. There are others indeed of a very serious medical nature, such as endocarditis.
The use of illegal opiates is somewhat limited to a rather small proportion of the population. In the most recent surveys conducted by Health Canada the use of heroin falls within a category that is not really scored because it is below 1%, but we must say that being a Canadian survey, representing a national interest for all the country, it includes a pool of respondents which goes from Newfoundland to the Northwest Territories to Vancouver; all the way across, among all types of populations, rural, urban, in places where there's more exposure to the drug than others. So the 1% you get in the adult population - that is, the population of 15 years or more - is the result of that dilution of the prevalence over a very large number of people who are really not exposed to the drug.
If you look at the problem of heroin use, limiting yourself to high-risk areas such as the larger urban centres of Montreal, Toronto, Vancouver, and Calgary, the situation is different. Nonetheless it is still a minority, perhaps fewer than the cocaine users, much fewer than the cannabis users. I'm talking of illegal opiates; I'm not talking of codeine and other medicinal preparations.
Because it is a practice that affects only a small minority, then, those who engage in it are a more selective type of individuals within the population, perhaps more marginal, perhaps more deviant in both social and psychological terms, and therefore with more problems of psychosocial adjustment.
The use of codeine preparations, the abuse of them and addiction to them, follow more or less the pattern of other pharmaceutical products such as tranquillizers, sedatives, sleeping pills, and hypnotics. They are more often used by women than men, and in Canada they are more often used in Quebec than in other parts of the country. It follows the same trend as, let's say, benzodiazepines, which are tranquillizers with addictive potential.
.1000
The problem with opiate addiction is that once it starts it is very hard to stop, very much like nicotine. Because the individual is motivated to continue using, among other things, on the basis of the distress that he or she experienced with withdrawal, these are drugs that are used very frequently, and they lead to daily use patterns as opposed, for example, to cocaine, which could be used daily but is more likely when it is abused to be abused in binges. There is also binging on heroin, of course, but the real problem is that the individual cannot go a day without having it, and that of course leads to a total absorption with this practice and the surrendering of every other interest and activity. It is a full-time, very absorbing type of daily routine. The individual is completely enslaved to having to maintain that particular practice.
Contrary to other drugs, which you have heard about, cannabis or cocaine, heroin doesn't affect psychic function as much. Heroin and other opiates act through lower parts of the brain, not the higher-function cortical part of the brain, and individuals who use it regularly do not necessarily lose their mind or show a very serious and significant effect in their ability to think or to perform psychologically. Of course, that is when they are not under the effect of a heavy dosage, because they would be sedated. But normally they do not have psychiatric consequences or serious organic brain damage from the regular use of these products.
What makes the drug more of a problem is that compulsive obsession with repeating the intake, which becomes in fact the driving motivation in the life of these individuals, and therefore they move away from any other constructive or productive activity. The fact that these individuals seem to have tremendous difficulty in changing an addictive pattern once it has been established has led to the belief that some of them have found in heroin or other opiates something that they were in fact missing or lacking from the beginning and that they were unable to function without. This was the theory that justified or was behind the introduction of methadone substitution as a way of helping such individuals in the 1960s. It was to offer another opiate that was less hazardous, that comported lesser risk of complications than heroin because it was taken by mouth and it was not injected, because it has a long-lasting effect - the effects of a dose will last over 24 hours - and because then it could be administered within a medical treatment model and the individual would satisfy their needs through taking this particular substitute and therefore stop using heroin.
.1005
The results have been that indeed, as a group, individuals who receive methadone on a regular basis show decreased levels of many of the problems heroin users are expected to have. Their psychosocial function improves. Their level of medical complications is less. More particularly, in recent times their level of risk of contracting HIV is less, because they stop injecting or they inject less.
Dr. Lauzon is an expert in methadone programs and I will not go further into it. You could pose questions to him. Methadone substitution of course is a matter of social policy as well, because it is a particular approach to the management of an addictive disorder.
I think I'll leave it at that. We can have exchanges as you see the need for them.
The Chairman: Dr. Lauzon.
[Translation]
Dr. Lauzon: I will be presenting my brief in French.
I would like to thank the committee for having invited me to participate in his work. AsDr. Negrete mentioned, I am a general practitioner in Montreal and I have become particularly interested in treating heroin addicts using methadone. In fact, I founded the first clinic in Quebec in 1986. We currently treat 150 patients.
One of the approaches we've always advocated is to integrate the heroin addict population into regular health services that are available to the whole population. Therefore, contrary to American clinics and certain other clinics in Canada, our services are provided in public health institutions. Methadone is provided by community pharmacies.
This is an integration experience that has worked particularly well and that indicates to us that drug addicts can become integrated and receive health and psychosocial services in the same institutions that other people use.
I do not, however, restrict my presentation to methadone treatment, because treatment and its efficiency often depend on the general political context in which this treatment is provided. I would like to make a few comments on the drug policy that Canada has been following to date.
It should first be pointed out that this is a problem we share practically with all societies throughout the world. The approach that Canada has developed since the beginning of the century, as well as the approach adopted in several countries, has been mainly based on prohibition. Most of our resources have been used to reduce the supply of drugs on the Canadian market.
This prohibitionist's ideology is relatively recent in history. It started around 1915, whereas the substances have been around for thousands of years. Previously, societies dealt with this problem differently.
I would like to make a few comments about the results or effects this policy has had over the past 80 years. First, prohibition has used major amounts of public money as well as many very competent people. I think that it has been done competently. If it does not work, it is not because of a lack of human and financial resources; it is simply because it is probably an impossible task to carry out. It has not been achieved in Canada nor in any other country, except in those with totalitarian regimes. Therefore, in all those countries that have a Charter of human rights and that respect the rights of their citizens, prohibition has not been achieved.
The other negative effect that this prohibition has had is the establishment of criminal organizations. They are extremely powerful, they are multinational and they threaten political stability in some areas of the world and even democratic rights.
.1010
Obviously, the consumption of licit and illicit substances is something that happens within people's private life. The decision to consume alcohol or other substances is a choice that people in general consider to be a personal choice. It usually happens privately. Repression implies that people's privacy does not have to be invaded.
It should also be pointed out that the majority of users of substances in Canada use moderate amounts, for an extremely limited amount of time, during a period in their life. One could say that they consume responsibly, as do the majority of people who consume alcohol do so responsibly in Canada.
Relatively little is known about people who use drugs in a limited fashion. All our knowledge about drugs are based on studies carried out on people who have very strong addiction problems, strong enough for them to be using rehabilitation services, or for them to have been noticed because of an arrest.
Moderate users, in fact, are not well known at all. We really do not know what the risks of limited and moderate use are.
There's a small number of abusive and dependent users who probably represent less 10% of all users identified under public health investigations in Canada. This small number, which has been brought to our attention and has taken on importance, generate major social costs in terms of health care, legal treatment, incarceration, etc. There are also very high human costs for these people and their environment.
Another phenomenon, which is relatively recent, is HIV infection in the 1980s. This infection is established amongst Canadian addicts. We have a lower infection level than in other parts of the world, especially in the south of Europe and the northeast of the United States.
In most countries, the appearance of HIV was an opportunity to significantly change policy and approach dealing with illicit drugs.
In Canada, over the past few years, we have had a policy that has allowed us to develop new ways of treating and preventing, but most of all resources are still used for the purposes of prohibition.
Once addiction has been established, regardless of the nature of the substance, it is a relatively chronic condition that can require several interventions for the same individual at different times of his life. This is a condition that changes, with worse periods and with periods of remission. The treatment of this condition is efficient.
It is believed that people who are addicted will never change and that once they are addicted it is for the rest of their lives, but most studies show the treatment is very efficient and that addicts can change.
Incarceration in itself is not an efficient treatment for addiction. If no treatment measures accompany incarceration, whether that be during the period of incarceration or when the individual returns into his community, then one can expect incarceration to have very little effect on addiction.
Prison populations have much higher levels of dependency on alcohol and other drugs than in the rest of the Canadian population.
It has also been noted that it is probably in prison that there is less dependency treatment available, which is somewhat paradoxical. There are currently good indications that the treatment of the prison population is just as efficient as treatment for other dependents.
In terms of prevention, several strategies have been proven to be effective. There has to be a variety of strategies because the population we are dealing with is extremely heterogenous.
.1015
Strategies based merely on abstinence, such as the Just say no strategy are not effective for most people and the government must support other types of intervention that focus on moderate and responsible consumption and enlightened decision-making by the individual. These approaches are also been shown to be effective.
Finally, in several countries, such as Switzerland, the United Kingdom and the Netherlands, much more tolerant approaches have been developed, approaches that are based on the protection of life and health. I think that we should consider these approaches in our policies.
After having made those comments on the Canadian situation, I would now have the following recommendations to make to the committee.
First, the idea of a drug free Canada is not a realistic one for the near future. Eradication is probably impossible and we have to think of better ways of socially managing this phenomenon.
Changing the legal status of substances is a complex procedure which takes a long time. However, there are other possibilities, within the current legal context, that can reduce the criminalization of personal use or possession for personal use. In Canada, three quarters of drug convictions, are convictions for possession for personal use. The convictions entail major costs for society. Given that so many resources are spent on prohibition, this prevents us from using resources on other aspects such as treatment and prevention.
We could consider experiences outside Canada in this field, such as those of California or the Netherlands regarding the use of cannabis. Rather than prohibition, our policy should focus on public health, as other countries have done. The priority should be reduction of harmful effects linked to use, including reducing the spread of HIV infection, rather than advocating total abstinence for everyone.
Once this type of policy has been adopted, then it should be assessed and reviewed periodically, if it has had negative effects, then we should be correcting our drug use approach quickly.
In terms of public information, drugs are a topic that has been extremely present in the media. One could say that the way this issue has been presented in the media and politically, can contribute to maintaining this perception with respect to the consumption of these substances and to maintaining the public's intolerance with respect to users, with respect to a category of citizens that has been identified.
It is important that the public have access to quality information, and the state can play a supportive role in that area.
The other aspect I would like to cover concerns access to treatments using alternatives.Dr. Negrete talked about methadone treatments. This approach has been used for about 30 years and was in fact developed for the first time in Canada, in Vancouver. It is an approach that has been thoroughly evaluated, that is based on 30 years of scientific research and that is extremely effective.
However, in Canada, we are considerably behind in terms of access to this type of treatment. Probably less than 10% of all people who need it have access to this form of treatment.
Internationally, the use of methadone and other types of medication is an important part of several countries' policies in reducing the spread of HIV.
Another of my recommendations has to do with the treatment of the prison population. I think it is extremely important that prisoners have access to all of the treatments available to addicts within the community.
Finally, Canada can play an international role in drug policy. Peacekeeping is not the only area where Canada can be a leader. Canada could develop very progressive policies, based on public health, and could be a world leader in this area.
.1020
Thank you. I would now be pleased to answer your questions.
[English]
The Chairman: Thank you, gentlemen. Pierre.
[Translation]
Mr. de Savoye (Portneuf): Gentlemen, your presentations were extremely instructive. This morning we have had the pleasure of being given a course on the physiological, psychological and psychic effects of the use of drugs, and also on available treatments. I would like to thank you however, for not having included a laboratory session in your course.
That having been said, Mr. Kalant, I liked your presentation, which was well structured. I would like to ask you a few questions to clarify your statements and better understand them.
You talked about the respiratory system. You indicated that the effects of marijuana use can be chronic bronchitis, etc., but for regular heavy users.
What is a regular heavy user of marijuana? Are we talking about one joint a day, 10 joints a day, five joints a week? What is a regular heavy user?
Mr. Kalant: No definition hasn't been agreed upon by everyone, but in general, I would say that daily use is heavy use.
There are two aspects considered. First, the drug itself, THC, remains in the body and has a half-life of approximately 56 to 60 hours. That means that half the drug is still in the body two or three days after having been used.
Therefore, a daily user is almost always under the influence of a certain amount of that drug. That would obviously entail a higher risk of from the harmful effects.
Second, in terms of the respiratory system, it is the quantity of tar and other toxic substances that appear by a pyrolysis that remain in the lungs and... perhaps I should continue in English because I am not familiar with all the vocabulary in French.
[English]
Mr. de Savoye: By all means.
Prof. Kalant: The cells that clear debris from the lungs, the phagocytes, the cells responsible for clearing dust, toxic materials and so on, are themselves rather inhibited by the drug. Therefore, the deposition of smoke in the lungs, combined with a lesser efficiency of removal, means the daily user is exposed constantly. It has a permanent residual effect as long as the smoking continues.
That's why the effects of the irritants in the cannabis smoke appear after a shorter period, in fewer years, than the same changes that occur in the exclusive tobacco smoker. The changes that have been observed in the lungs of young daily cannabis users appear in the order of around five or six years, when it may take twenty years to produce them in an exclusive tobacco smoker.
[Translation]
Mr. de Savoye: Mr. Kalant, you said that on a mental and emotional level, there is a slowing down of memory and of the intellectual process. You also said these side effects improve or disappear when the user stops using cannabis. But you say that does not always happen, and now I am concerned about the American President who only remembers having -
.1025
Some members: Ah, ah!
Mr. de Savoye: But that is what he remembers.
Some members: Ah, ah!
[English]
Mr. de Savoye: Dr. Kalant, when you say it usually but not always improves when cannabis use stops, what percentage is ``not always''?
Prof. Kalant: It's difficult to give a precise percentage. It's a small percentage. The ones who are left with residual effects are sufficiently few that it's a matter of interest for case reports in the literature when it happens. I would say probably less than 5% or 10% of heavy regular users would remain with permanent changes if they stopped.
[Translation]
Mr. de Savoye: You also said that young school children, whose mother used cannabis at times before her delivery had suffered from effects on their ability to express themselves verbally.
You also indicated that effects on their academic progress have not been proven. Could you tell us more about that in terms of percentage, probability, levels of difficulty that the child may have to deal with?
Mr. Kalant: It would be very dangerous to provide any figures, because the period of observation has not yet been long enough. It started recently, over the past two years, I believe.
[English]
It will take a period of years of observation in order to be able to say what percentage of the children in the group experience long-lasting and serious difficulty.
At the present time, what we can say is that the group of children, as a group, have a significant difference in verbal learning and verbal memory from the whole group of the children of mothers who did not smoke cannabis during pregnancy. But that doesn't break it down into different degrees of severity in different individuals. Probably it's going to take following that group through their whole school program to be able to come up with the kind of figures you've asked for.
[Translation]
Mr. de Savoye: I presume, and let me know if I have understood or not, that these five-year-old children who are suffering from the effects of their mother's long-term marijuana consumption, have mothers who smoke regularly and not occasionally. Can you comment on that?
[English]
Prof. Kalant: Yes. These are mothers who have smoked more or less regularly throughout the pregnancy.
As for the children, it isn't so much a question of a disability that develops five years after; it only becomes evident five years after. The same difficulty has presumably been there, but it's put to the test only when they reach school.
[Translation]
Mr. de Savoye: Doctor, I apologize for not putting questions to our other witnesses, but you have all presented fairly in-depth material and I will give my colleagues the pleasure of dealing with the other subjects.
I have one last question, Dr. Kalant. You say, when you compare other drugs:
[English]
- If level of use increased by easy availability, low price, social acceptance, problems will also
increase, possibly to same level as with alcohol.
This leads me to two questions. I know that in Quebec, access to alcoholic products is more liberal - in its good sense - than elsewhere in Canada. However, our per capita alcohol consumption is no higher than in the rest of Canada. Therefore, there is no direct correlation between access to, or availability of the product, and its consumption.
.1030
Second, you say that problems could possibly reach the same level as problems with alcohol. However, unless I am wrong, according to what I heard from other witnesses when we were discussing Bill C-7 and C-8, the types of behaviour amongst cannabis users are not the same as those amongst people who consume too much alcohol. Consequently, how can the problems be compared? What is your view?
[English]
Prof. Kalant: In terms of your first question, the question of ease of availability obviously is not the only determinant of the level of use. The level of use of any drug within a society is determined by a number of different things, including the place of that particular drug within the culture, within the traditions, the practices and the norms of the society. Social controls on level of use are just as important as the other factors I mentioned.
But given that, within the same society at any given time, the easier the drug is to obtain, the cheaper it is, the more its use is accepted and the more its consequences are tolerated, the more it will be used and, as a result, the more effects it will have.
For example, if you look at Canada as a whole...or I can speak of Ontario better, probably, because the figures I'm going to mention relate to Ontario.
The population of Ontario is obviously different in many significant ways from the population of Quebec. I won't try to compare Ontario with Quebec. But within Ontario, given the same population, given the same attitudes - and these are gradually changing over time; nonetheless, there's a given pattern of social acceptance - toward alcohol and manners of use, when the Depression occurred and the cost of alcohol went up relative to the available income, there was a sharp drop in the level of use. Together with that there was a sharp drop in the number of deaths from alcohol, such as cirrhosis of the liver.
When the war came and there was full employment and price controls, the average disposable income started to climb again, and the consumption of alcohol went up with it. After the war there was full employment, wages went ahead rapidly, there was a large gain in available income, and the consumption of alcohol rose rapidly and steadily. It reached its highest point probably since the 19th century, when there was much more use than in the 20th, and displaced by a few years the length of time it takes to produce a new case of cirrhosis by heavy drinking. The death rate from cirrhosis went up in parallel with the per capita consumption of alcohol.
In the 1980s, when uncertainty about the economic situation became more or less important, before there was even a definite downturn but when worry about it began, consumption levelled off and then began to drop. Within a few years of that, the frequency of the consequences also dropped.
The point I'm making is that for a drug that has been legal and well studied, and for which excellent statistics are available, we know that ease of availability, price, convenience and social norms all influence the level of use. Together with the level of use, they influence the frequency of the adverse health effects.
There's no a priori reason to doubt that the same will apply to cannabis or any other drug. After all, you have to pay for the drug, which competes with the money you have to spend on other things. There is also the question of whether the society as a whole approves or doesn't approve of use. People say the law does not deter use, yet the experience of prohibition on the consumption of alcohol and on the death rate from alcohol, such as from cirrhosis, demonstrates that it does. The point is, the law works only if it is in harmony with the society.
Mr. de Savoye: My second question?
Prof. Kalant: Your second question was -
Mr. de Savoye: Comparing alcohol -
[Translation]
The Chairman: You have already used 15 minutes.
[English]
Mr. de Savoye: I'm very sorry.
.1035
The Chairman: Paul.
Mr. Szabo (Mississauga South): Mr. Kalant, on the material you took us through, outlining the effects of cannabis...and as I deal with cannabis it seems to be the starting point for most discussions on drug policy as it relates to illicit drugs.
A hypothetical question: if cannabis were to become a legal consumer product - here it comes - would you recommend a health warning label be placed on the product?
The Chairman: And should Paul's picture be on the label?
Some hon. members: Oh, oh!
Prof. Kalant: Using the same logic as with tobacco, or in the States with alcohol, I would say yes, obviously. The whole point is whether society considers that, as Dr. Lauzon said, a more lenient and more protection-oriented - that is, harm-reduction-oriented - approach is better or whether it is better to retain illegality in order to express the general disapproval of society of its use while avoiding the worst of the excesses the illegal status carries, such as I think quite unwarranted prison sentences for simple possession and things of that kind.
Mr. Szabo: I raise it only because I think in looking at some of the reasons here - impairment of ability to reason or make decisions and, particularly of interest to me, the impact on pregnant women or the fetus, which seems to me to be very similar to the effects of FAS, for instance -
Prof. Kalant: They're not really that similar. No one has shown actual production of birth defects from cannabis.
Mr. Szabo: But there was growth retardation, for instance.
Prof. Kalant: That was temporary. As I said, by six months the children had outgrown it and had returned to normal levels.
Mr. Szabo: That's helpful, because the Addiction Research Foundation did appear before us during consideration of Bill C-222 on health warning labels and in fact did recommend health warning labels for alcoholic beverages, similar to what was in the States.
My last question is directed at Dr. Lauzon on this whole aspect of harm reduction. Really, I think it is a very fundamental discussion point for the whole area of illicit drugs.
You stressed that we have to focus on public health. I assume you include all Canadians in terms of public health, not just those who are presently users. I would pose this to you. What would you expect - and I'm not sure if there are ways to draw on experience in terms of strategy for dealing with problems for young people - if we were to change the policy and say that cannabis was no longer a prohibited substance and that it was available for use? What would you think would be the impact on the number of users of cannabis, given that change in policy?
Dr. Lauzon: We can look at the whole experience in the Netherlands. There are cafes where you can buy it. There are areas of tolerance that are accessible to adults, even though cannabis is still a prohibited substance. But they say they have no more use of this substance than do other countries in Europe.
Mr. Szabo: Let's say it's not a prohibited substance but a legal substance. What would you expect would happen to the number of people who are users?
Dr. Lauzon: If it's not prohibited any more, of course it's going to be for adults, 18 years and over. It will have to be dealt with the same way we deal with tobacco and alcohol.
Mr. Szabo: Which is just for people 18 years and over, right?
Dr. Lauzon: That's exactly how we deal with alcohol and tobacco. We know very well that a lot of parents in Canada allow their youngsters to smoke and drink much earlier than that and will even help them get the product, buy it.
.1040
Mr. Szabo: So the irony here, to me, is that a harm reduction philosophy is almost a reverse psychology approach. If you back off and don't say it's going to harm you, there's somehow going to be a better environment in which to educate people who are already doing it on why they shouldn't do it. It's almost like dealing with the problem after you have the problem rather than preventing it beforehand.
Dr. Lauzon: It's a matter of seeing people as able to make responsible decisions for themselves. People can make responsible decisions by getting married, driving a car and doing things like that. Why would they not be able to make responsible decisions concerning cannabis?
Mr. Szabo: I have one last question. Do you think all the various kinds of educational approaches can be implemented or augmented to the extent that they already exist under the current drug policy as effectively as they could if there was a liberalization of rules on illicit drugs?
Dr. Lauzon: I think it's even easier to implement prevention in a more liberal context, because that's exactly what we're doing with alcohol and tobacco. It's a legal substance, but there's a lot of prevention in schools and other places where young people go to help them make responsible decisions with tobacco and alcohol. As a matter of fact, 85% of Canadians drink currently, but only a very small number abuse alcohol and experience problems with it.
We can expect that if cannabis is legalized, maybe more people will use it but the number of abusers will probably stay very small. Prevention should be aimed at moderate and responsible use, as we do with alcohol.
Mr. Szabo: I can only assume that Mr. Kalant will disagree with you on the basis that -
The Chairman: I'm going to give him an opportunity to respond right now.
Mr. Szabo: Mr. Chairman, that ends my questions.
Prof. Kalant: One has to be careful with the statistics from the Netherlands, which are cited as an example. It is true that the level of use has not gone up dramatically in the Netherlands, but it stayed level or went up slightly at the same time that in the surrounding countries in Europe it went down rather dramatically. Therefore, I don't think it is fair to conclude that this policy had no effect on the level of use.
The question Dr. Lauzon raises I think goes to the heart of the matter, that what one is dealing with here is not a matter of science but one of philosophy. If you feel that the function of a democratic society is to maximize personal freedom and responsibility as much as possible, and you live with the consequences, that's one thing. On the other hand, no society has perfect, total freedom. You cannot have a society together with total individual freedom. That's a contradiction in terms. Living in a society means accepting certain restrictions for the sake of the common good.
The question is, which better achieves the protection of health, a more liberal attitude with greater emphasis on preventive education and so on or a combination of legal restriction and education? I think we have to give more weight than we have done to the importance of education and society's norms, but we mustn't drop the idea that the law has no protective value at all.
As far as alcohol is concerned, it's true that about 85% of adult Canadians use alcohol. But whether you call the percentage who use it heavily enough to run into problems very small, asDr. Lauzon did, or very large, depending on what your attitude is, shouldn't obscure the fact that this percentage is somewhere between 5% and 10% of users.
If you say that's small compared with the total number who use, then you have to define your meaning of small. But if you say that those 5% to 10% of users produce a huge cost in health, in social costs, in accidents, in personal relations, problems and so on, then you would not call it a very small percentage. You have to use the same type of logic in judging what is likely to happen if cannabis becomes legal and readily available.
.1045
The Chairman: Dr. Negrete.
Prof. Negrete: I'd like to introduce, if I may, a clinical view on this policy issue. I do agree with Pierre Lauzon that people can make mature, rational decisions about what they would do with these products if they were available, but I do not think every product gives the individual the same chance of being free to decide. I believe there are differences between them in how fast or how strongly the product starts controlling the behaviour of the individual.
For example, cocaine, if available for regular use, will produce more people who lose their ability to decide rationally and maturely what they do with it than, for example, marijuana. Simply, it is more addictive. It has been demonstrated clearly in the laboratory. For example, just about every animal in the laboratory that has been given cocaine takes it - from mouse to rat to monkey to dog - and of course man. Others, such as alcohol, are not readily taken by every animal. You have to find those that are more genetically predisposed toward taking it to use for models of intoxication and in studies.
If you put difficulties in front of the animal to self-administer cocaine, they will go to a very great extent to continue doing it. For example, if they were to receive a dose after pressing the bar seventy times, which is very extreme, rather than two or three times, they will do it. It is more addictive. It is something they like to have the feeling of. It is more rewarding and it is more addictive.
Clinically, then, individuals exposed to this product progressively may lose their ability to act rationally about it. I think that is something that has to enter the equation, has to be seen as such. Because the more people are exposed to them, the more there will be those who become slaves to it and whose behaviour is determined by that enslavement. That degree of enslavement is not produced in the same measure by every product. There is a difference between them.
So we cannot say that if we liberated every drug and made them available for people to experience they all would be used in the same way.
The Chairman: Okay.
We have a time problem. This entire exercise had to be within a two-hour timeframe, of which ten minutes remain. Witnesses took an hour and ten minutes to make their presentations, which left less time for questions. That's why we're up against the clock here.
I have Andy and Harb, and Pierre if there's time, but we're fast running out of time. I'd ask the questioners and the witnesses to be brief and to the point.
Mr. Scott (Fredericton - York - Sunbury): Thank you, Mr. Chair.
Further to the most recent discussion about prohibition as against education and a combination thereof, would it be helpful to distinguish between types of what are now considered illicit drugs in terms of that balance and that trade-off in the context of the comments made by Dr. Negrete, that sometimes you don't get to make the rational choices, that your behaviour is affected by the introduction of that activity in your life?
I think we all understand the nature of addiction to some extent. Would it not be helpful to perhaps distinguish between types and impacts of certain drugs in terms of finding the appropriate place to find that balance?
.1050
Right now I think we have a tendency to deal with these things generically, as if they're all the same. Therefore we're imposing a prohibitive practice that I think most Canadians would support in certain instances and fewer Canadians would support in other instances. In terms of trying to convince people that certain things are harmful when we deal with illicit drugs generically, as we have, what impact does that have on our credibility when everyone in the country knows aboutMr. Clinton?
What Mr. de Savoye doesn't understand is that Mr. Clinton knows about him - not with regard to this issue.
Mr. de Savoye: How do you know that?
Some hon. members: Oh, oh!
Mr. Scott: So that would be the first question: would it not be helpful perhaps to distinguish in terms of public policy between types of drugs and not to deal with them generically, as we seem to?
The second question - and this will be brief, Mr. Chair - has to do with the public health effects mentioned by Dr. Negrete, that a lot of the problems related to injection of heroin are because of the fact that it is prohibited in the way it is. A lot of use would be different, perhaps, if it were not. I'd like to have some sense of the relative public health damage.
How much of the public health damage done by heroin is the effect of the drug specifically, that would be there regardless, and how much of the public health damage is done by virtue of hepatitis and infections and activities probably more related to the nature of the prohibition - if that's a fair comment - than the drug?
Prof. Kalant: To whom are your questions directed?
Mr. Scott: I have no idea. The last conversation involved Drs. Lauzon, Kalant and Negrete in terms of the balance, whether it's prohibition or education. I'm not sure who would like to answer first.
Dr. Lauzon: As far as opiates are concerned, they can be made available through medical prescription. This would not be the case for cannabis, for instance, which probably could be made available the way alcohol and tobacco are. We could prescribe much more than we do now to people addicted to heroin without having to change the law, actually. We could even consider prescribing heroin for the portion of addicts who would not come for methadone treatment. We know we can attract a maximum of maybe 40% of heroin addicts with methadone replacement. We have to consider what we do for the other portion of the heroin addicts.
A few countries are experimenting now with heroin prescriptions for limited numbers of addicts. This could be a way to make the drug available under medical control.
Prof. Negrete: The problem with heroin is that it's short-acting. The administration of it has to be repeated as you build up tolerance. Therefore, you may want more and more injections along the way. It may not be obtained only from normally operating medical outlets.
That is exactly what happened in England in the sixties, when there was in fact legal administration of heroin, prescribed by practitioners who registered their patients. What happened is that they kept control on some of them, giving them doses that they thought were sufficient. These patients did comply with the protocol, but many couldn't comply. They would inject in addition to that or would search out other drug experiences at the same time.
So that program, which was quite well known, faded away in favour of methadone. It's now being revived in Meyerside, but the truth is, while there would be those who would be orderly enough to limit themselves to what would be the prescription, there would be a large number who wouldn't.
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The infections I was talking about come about through very anarchic practices. For example, they can inject it just an hour ago, later be with somebody else in some other place who has another dose, and they will take it. They will take it from the same needle and so on. That's what happens.
So there is a question of compulsive behaviour in these addictions, and we cannot ignore that. They do not have total control over what they do.
Prof. Kalant: With respect to your other question, I think you could make a good argument that there should be a differentiation, that society has in fact made a differentiation between alcohol and tobacco on the one hand and cocaine and heroin on the other. The question in doubt is where we put cannabis.
I think you could make a good argument that it is much more like alcohol than it is like cocaine or heroin. The question as to how you deal with it, though, really rests on a broader philosophical question: how much drug use in general does society want to countenance or to encourage by explicit acceptance? You can make an argument that cannabis is no riskier than alcohol, possibly even a little less risky, and therefore should be treated in the same way alcohol is treated by society - legally, and relying on social controls.
You can make a counter-argument that it's not been part of our tradition, whereas alcohol has since long before history. It wasn't common practice here until 20 to 25 years ago. We don't need it. We survived without it for centuries. We can continue to survive without it. The majority of Canadians don't use it. There has never been, to my knowledge, a survey that has shown a majority in favour of legalization. The question is, can you retain the benefits of illegal status in expressing and codifying the attitudes of the public while avoiding the harm the law does in terms of overzealous enforcement?
The Chairman: Harb, if you have a burning question, make it fast.
Mr. Dhaliwal (Vancouver South): I have two quick questions. One, for someone who is addicted to daily use of heroin, what is the cost to that person to fulfil that addiction? Second, let's say someone comes in and tells you they have a heroin problem and want to be cured of it. What is the success rate, and how long does it take?
Prof. Negrete: Pierre deals with heroin addicts on a daily basis, and I think he should give you the answer. I can tell you about our clinic. We have seen people spending more than $1,000 per day. That is an extreme. There are people spending, on average, $100 to $200 per day. Nonetheless, a sizeable amount of money has to be procured on a daily basis.
The success rate - by that I mean people arresting the use - is certainly less than with other products, less than with alcohol. It's not much less than with nicotine, but a large number of people have stopped using through drug-free programs. An even larger number have benefited from substitutions. That is one of the programs that has shown very clear advantages.
How you define success, of course, is varied. For example, Pierre could give you figures from his own clinic, where he has more than 200 heroin addicts in treatment. He can tell you what he observes.
Dr. Lauzon: Methadone treatment is quite effective with heroin use. After a year of treatment we can say that the use is cut down by about 95%, and 75% of patients will stay in treatment at least one year. We have much better figures with methadone treatment than with drug-free treatment, specifically with this addiction.
Of course, they don't come with only heroin addiction. They may also be addicted to cocaine, alcohol, and tranquillizers. We have to work on that. We don't have specific pharmacological intervention for cocaine or alcohol addiction, but we have the same success rate with those addictions as we can have with other alcoholics or other cocaine addicts.
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There's a huge reduction in arrest and criminality during methadone treatment. During the first year of treatment the arrest rate in males is decreased by half, and in females by four. If we treat them for a longer period it continues to decrease.
The cost-benefit of this intervention is very important. It's been evaluated in the United States that every $1 you put in methadone treatment will save you $10 in mainly incarceration and health care. For example, if someone gets AIDS, it's a very expensive disease to treat. So the cost-benefit is very good for this type of intervention.
The Chairman: We are out of time. There is another committee due here at 11 a.m. My apologies to Pierre for not getting back to him.
I thank the witnesses for their participation this morning. We hope we can be in touch with you again as the study progresses. We may need to get your views and observations further.
Members, you might want to talk individually with witnesses after the meeting, if there is time.
We are adjourned.