Issue #14 March 2022
When I was an undergraduate psychology student at the University of Waterloo, I already had a keen interest in drug use and drug problems. I would often explore a related aspect in a term paper for any course that I took on the psychology specialties – comparative, social, developmental, psychopathology, cognition and perception, personality. While researching these papers, regardless of the focus, I would frequently encounter the name of Reginald Smart at the Addiction Research Foundation of Ontario. The man was prolific. Imagine my excitement when, shortly after graduate school, my first permanent job was with the Foundation. Shortly afterwards, I had the opportunity to meet Dr. Smart. He seemed a bit uncomfortable with my declared admiration of his work.
One of Dr. Smart’s many notable contributions to the addictions field was the creation, in 1977, of province wide surveys of student and adult drug use. These were unique and indispensable resources for program planning, public and professional education, and policy advocacy. More than four decades later, the surveys continue to provide general population surveillance of drug use and drug and mental health problems. The surveys also assess public knowledge and opinion related to drug and health issues. The latest results of the Ontario Student Drug Use (and Health) Survey were always a magnet for media coverage – providing much needed exposure for important issues.
The adult survey, now called The CAMH Monitor, issued a report in 2021 comparing results for 2019 (pre-COVID-19) and 2020 (during COVID-19). The survey included input from just over 3,000 Ontario respondents, age 18 and over.
Spoiler alert: overall, drug use and problems increased during the pandemic, in some cases dramatically. The changes I report below are based upon adjusted estimates related to use and problems in the past year. They are all statistically significant.
Alcohol consumption was up. More Ontario adults were drinking daily, more were drinking heavily on a single occasion, and people were consuming more drinks per week. More people were also drinking in ways that were hazardous or harmful and more reported symptoms of alcohol dependence.
More Ontarians were smoking traditional and electronic cigarettes, and more were smoking every day. There were more people using cannabis for strictly therapeutic use, and this was also true for cannabis use in general. More people also reported problems related to their cannabis use. There were more people using opioids – therapeutically or otherwise. More people reported use of antianxiety and antidepressant medications. More people reported using cocaine.
There was also an increase in reporting fair or poor general health. This included increases in reports of fair or poor mental health as well as moderate and serious psychological distress. There was also an increase in reporting suicidal ideation.
Most of the increases for all variables were observed among both men and women. However, men were more significantly inclined towards increased electronic cigarette use and suicidal ideation. Women were more significantly inclined towards increased cigarette use, daily smoking, therapeutic and non-specific cannabis use, and moderate to high risk of cannabis problems.
Among 18- to 29-year-olds, there were increases in alcohol dependence, moderate and serious psychological distress, reporting mental health as fair or poor, and suicidal ideation. Among those respondents 30 years and older, the percentage reporting substance use or mental health concerns rose significantly for almost all the variables showing increases in the general population.
Many of the increases reported are for use of various drugs. We know that most people who use a drug do not experience problems. And so, an increase in the number of people who use a drug is not necessarily an indication of an increased societal problem. But it can be.
Changes in aggregate use of a drug in a population have been correlated with changes in harm in that population. We might think of a portion of the general population (arguably 5-10%) as being susceptible to various pleasurable appetites (which include recreational drugs and other indulgences such as gambling, gaming, shopping, and sex). These are mostly benign (and enjoyable) activities for almost all people. But for that vulnerable portion of the population, the appetites are associated, to varying degrees, with the ruination of physical, mental, social, and financial well-being.
Thus, an increase in the number of people using a drug across a population is also likely to include an increase in the number of vulnerable people using the drug. The result will be more harm overall. This is the same explanation for why we should be concerned about an increase in the number of COVID-19 cases. Even though the great majority of cases do not develop into serious illness, there is a portion of cases (among the vulnerable) that do. Thus, even for a less toxic (but highly transmissible) variant such as Omicron, a large increase in cases will reach more of those who are vulnerable. That will increase the number of people experiencing serious illness.
This mechanism, as applied to drug use and harm, is supported by the survey data from CAMH. Increases in use and in harm were observed for both alcohol and cannabis.
As mentioned earlier, some of the changes were dramatically higher for a single year. Among current drinkers, prevalence of binge drinking (5+ drinks per occasion) doubled from 7% to 14.6% and hazardous or harmful drinking almost doubled from 15.6% to 27.5%. Among the total sample, alcohol dependence doubled from 7.1% to 14.2%. Non-medical use of opioids more than tripled from 5.3% to 17.9%. Reports of moderate and serious psychological distress, fair or poor mental health, and suicidal ideation also more than doubled in prevalence.
I have been using the ARF/CAMH surveys in my work for more than four decades. Longitudinal patterns of drug use and harm, if they change at all, tend to change gradually over several years, especially for the adult population. Sudden, dramatic changes are relatively rare. The breadth and degree of the changes observed by the CAMH Monitor, between 2019 and 2020, are unprecedented.
COVID-19 has created many challenges for individuals, families, employers, communities, and governments – challenges that, for most of us, are also unprecedented. But COVID-19 has also shone a spotlight on pre-existing, even long-standing, problems. Society’s vulnerability to the use of drugs to manage stress and isolation is a telling example, as were government decisions to designate alcohol and cannabis businesses as essential services during the pandemic. There is something disquieting about that, but maybe they really have become essential services for more of us than we are inclined to acknowledge.
Future dispatches from me will continue to shine a spotlight on the supply side aspects of our pandemics of drug harm. The establishment and enabling of legal, commercial drug industries not only allows us to use those products; it also encourages us to use them. That is probably not a good thing.
There is increasing optimism that the worst of COVID-19 is behind us. With many jurisdictions now relaxing restrictions, this spring and early summer will be a critical test. Some policy and public health organizations are beginning to consider the possibility of in-person meetings. So far, I have had requests for online presentations only for this spring. With some regret, I respect the caution. But I remain hopeful to see many of you in person again when it feels like the right thing to do for all of us.
I want to close with an announcement that before my next dispatch near the beginning of June, there will be a new resource available on cannabis legalization in Canada from The University of British Columbia Press. The book is entitled The High North: Cannabis in Canada – edited by Andrew D. Hathaway and Clayton James Smith McCann. It contains chapters written by a selection of accomplished and provocative authors. On the provocative side is my chapter “Cannabis Legalization: Déjà Vu All Over Again?”.
On January 9 2018, I delivered a presentation at the inaugural “Innovations in the Science of Cannabis” Conference at McMaster University. That presentation was entitled “Cannabis Legalization: Lessons from Alcohol, Tobacco and Pharmaceutical Industries”. I described examples from the long history of regulatory non-compliance, criminal conduct, and disregard for public health by those industries. I closed the presentation by identifying some flags that suggested that the new cannabis industry might be adopting the same playbook. During the Q&A segment of the session, Dr. Mark Ware stood up in the crowded auditorium and thanked me for my description of the other drug industries. He then went on to assure all of us in attendance that the cannabis industry would strike a more noble path. Most of you probably know of Dr. Ware from his career as an academic and cannabis researcher, the vice-chair of the Canadian Government’s Task Force on Cannabis Legalization and Regulation, and now the chief medical officer at Canopy Growth Corporation, one of Canada’s longest standing and largest licensed cannabis producers. In deference to Dr. Ware’s prominence in the field, my short (and restrained) response that day was that I hoped he was right. My chapter “Cannabis Legalization: Déjà Vu All Over Again?” provides the longer (and much less restrained) response. The High North: Cannabis in Canada has a release date of May 1 2022. I hope you will consider adding it to your library.
Please feel free to forward this dispatch to any colleagues that you think might enjoy it. If they send me an email, I will be happy to add them to the distribution list.
Hamilton Ontario Canada
March 3 2022.