Issue #6 February 2020

Those of you who are more familiar with my work will recognize the title of this posting. I have used it frequently in publications and presentations to make an important point. For me, it is a clarion call for changing how we think about drug use and drug problems. At least as important is how we provide drug products to people. This includes for recreational and therapeutic purposes. These questions have profound implications for drug policy. But before we get into all that, let’s review the evidence for the provocative claim that we have three drug crises aligned with three legal, government-regulated, commercial drug industries: alcohol, tobacco, & pharma.

The lights really went on for me a quarter century ago when The Canadian Centre on Substance Abuse (CCSA) released its 1996 landmark report on the harms and costs of substance use in Canada. The first revelation to arise from this report was the extraordinarily high levels of morbidity, mortality, and costs to the economy that were associated with the use of alcohol, tobacco and illegal drugs. While this report was the first to provide cohesive documentation, more fragmented previous reports had suggested that high levels of harm had existed for many years earlier, probably for decades. The second and equally important revelation was that the harms and costs arising from our legal drugs (alcohol and tobacco) far exceeded those arising from illegal drugs.

Those findings might not seem so profound from the vantage of our 2020 vision. But when CCSA’s report was released, Canadian opinion and drug policy were still very much mired in a war on drugs ethos that was all about illegal drugs. The data showing that the preponderance of harm was attributable to our legal drugs was a game-changer. Or at least it should have been.

CCSA issued an update in 2006. The salient take-home messages were unchanged: substance misuse was a major public health and economic problem in Canada and our legal drugs accounted for the great majority of it.

With the force of longitudinal verification, drug policy organizations, academics, and advocates began to increasingly address the implications of the data for drug policy. The CCSA reports should have turned drug policy thinking among legislators on its head. But Canadian drug policy would remain frozen in the cold war on illegal drugs for years to come.

The most recent incarnation of the study was led by The Canadian Substance Use Costs and Harms Scientific Working Group, with a report released in 2018. Using data from 2007-2014, the report provided yet another confirmation of the same long-term picture in Canada.

In 2014, alcohol was responsible for 87,911 hospitalizations, 35,777 individuals absent from the workplace, and 14,827 premature deaths associated with 244,144 years of lost life. The total economic cost was $14.6 billion. All that in just one year.

In 2014, tobacco was responsible for 145,801 hospitalizations, 39,727 individuals absent from the workplace, and 47,562 premature deaths associated with 326,870 years of lost life. The cost to Canada’s economy was $12 billion. Again, just one year.

Alcohol and tobacco combined still accounted for the great majority of the drug-related harm and costs. This included 91.4% of drug-related hospitalizations, 85.9% of drug-related removals from the workplace, and 92.4% of drug-related premature deaths, accounting for 76.0% of drug-related years of lost life. Alcohol and tobacco also accounted for 69.3% of drug-related costs to the Canadian economy.

The report also provided the disturbing news that annual levels of harm and costs for alcohol and tobacco had been increasing between 2007 and 2014. What I find even more disturbing is that there is no reason to believe that these levels may have subsided since 2014. Nor is there any realistic cause for optimism that they will subside in the future.

The pharmaceutical industry is another legal, government-regulated, commercial drug industry. Federal Health Minister Patti Hajdu is the fourth consecutive Canadian Minister of Health to acknowledge that opioid overdose deaths constitute a public health crisis in this country.

A portion of this epidemic is attributed to the illegal trade in opioids. However, the crisis had its genesis in dishonest and illegal marketing campaigns launched from within the legal pharmaceutical industry. The epidemic worsened as a result of intensified marketing and reckless prescribing. Add the involvement of the illicit trade and of an ill-considered and inadequate regulatory response from government, and the carnage intensified.

Public Health Agency of Canada has reported escalating counts of annual opioid-related mortality and morbidity since the beginning of 2016, amounting to a total of 13,913 deaths and 17,050 hospitalizations through the end of June 2019. The count for the first half of 2019 shows little cause for optimism for a significant decline during the remainder of the year.

The opioid crisis is not restricted to Canada, having reached epidemic proportions in the US and parts of Europe as well. Nor is the problem restricted to opioid products. The US Centers for Disease Control and Prevention has declared the misuse of prescribed medications in general as “an epidemic” in that country.

So, 3 legal commercial drug industries and 3 public health crises.

Of course, these observations could be fairly described as correlational, not causative. Correlations are pesky creatures. They too often evoke unwarranted interpretations of causation. However, it is equally unwarranted to dismiss them as insignificant. In future posts, I will attempt to unravel these relationships and explore just how a drug industry’s practices and government regulation may play an important role in drug use and drug problems. Also, what are the implications for a relatively new legal commercial cannabis industry?

For these communications, I have elected to use a casual format that provides a quick read for interested but busy people. Accordingly, I avoid a formal structure using citations and references. However, should anyone find themselves curious or skeptical of any claim made, please do not hesitate to contact me. I will provide the sources that allow you to dig in.

And please consider making drug policy issues a focus for, or at least a part of, your next workplace, association, or network meeting. This is important stuff! I would be keen to work with you on design and delivery.

February 29 2020