LET'S INJECT SOME NEW THINKING

We've traditionally punished those who use illegal drugs. On World AIDS
Day, a Toronto lawyer suggests a different course of action

Canada is in the midst of a public-health crisis. Since the AIDs epidemic
began in the early 1980s, we have seen a steady climb in the number of HIV
cases attributed to injection drug use. If we are going to deal with the
spread of HIV, we must rethink the way we deal with those drug users.

In Canada, as in the United States, our approach to illicit drug use has
focused on compelling abstinence. We take a punitive approach to people who
consume illegal drugs. But it's not working. In fact, reliance on criminal
sanctions is exacerbating rather than eradicating many of the problems
associated with injection drug use.

By 1996, half of the new HIV infections in Canada were among injection-drug
users. Studies in Vancouver, Montreal, Toronto, and Ottawa have shown that
between 9 and 23 per cent of injection-drug users are HIV positive. The
rise in the number of HIV infections is also evident in small towns and
rural areas. Women, youths, aboriginal people and prisoners are
particularly at risk.

It's easy to see why. Because drug users fear long prison terms they
consume drugs by the quickest, most efficient way -- injection. People who
share needles and other drug equipment expose themselves to a high risk of
HIV and hepatitis C. The threat of criminal sanctions also pushes drug
users to the margins of society. This makes it difficult for health
officials to reach them with educational messages and to provide them with
access to medical services and treatment programs.

Health-care providers may also be subject to criminal liability in their
attempts to address drug use. Canada currently has more than 100 needle
exchange programs (NEPs) which seek to reduce the transmission of
blood-borne diseases such as HIV and hepatitis by providing injection drug
users with sterile syringes and needles. However, nurses and other staff
who work at NEPs and collect used needles which contain traces or residue
of illegal drugs may be criminally prosecuted for possession under the
Controlled Drugs and Substances Act.

There are other legal obstacles. Physicians who provide patients with
illegal drugs to treat their addictions may also be charged with possession
or trafficking. The maximum sentences for such offences range from six
months to life imprisonment. In the mid 1990s the Canadian Medical
Association testified at the Parliamentary hearings on the Controlled Drugs
and Substances Act that doctors should be permitted to treat drug-dependent
people with a greater number of options and without exposure to criminal
liability.

In Canada, methadone is the only opioid approved for long-term treatment of
drug dependence. Although methadone has many benefits, it is not
appropriate treatment for multiple addictions nor for people dependent on
cocaine, amphetamines or other non-opiate drugs. And it is intravenous use
of cocaine that is one of the growing problems among drug users in British
Columbia and Quebec.

Drugs other than methadone should be made available for treatment. In other
countries -- Switzerland, Britain, Australia, and the Netherlands -- health
workers have found that the prescription of heroin may achieve the same
objectives as methadone: it can prevent the spread of HIV and hepatitis,
reduce crime associated with drug use and improve the drug-user's overall
health.

Canada has been reluctant to prescribe drugs other than methadone to
drug-dependent persons. In addition the number of spots available for
methadone treatment is very low compared to other western countries.
Moreover these treatment centres are not well funded. Both drug users and
doctors are constrained by a vast array of rules and regulations. Doctors
are limited by the dosages of methadone that they can prescribe; drug-users
are generally not eligible to participate in such programs until they can
prove abstinence. Some programs even require that drug-users subject
themselves to the humiliation of giving urine samples under observation.

Canada must reassess its current orientation to the problem of injection
drug use and HIV/AIDS. Stakeholders must endorse a "harm reduction"
approach which views drug dependence as a public health problem. Such an
approach reduces the likelihood that drug users will contract or spread HIV
and other diseases. It lessens the possibility that they will overdose on
drugs of unknown purity or potency. A public health approach tries to stem
unsafe methods of injection, to decrease the rate of drug consumption, to
reduce experimentation with drugs most likely to cause medical problems,
and to help users to obtain treatment.

Such an approach, endorsed by Britain, the Netherlands, Australia, and
Switzerland, gives drug users access to different models of treatment --
not only ones that require abstinence. They can find comprehensive needle
exchange programs that also distribute condoms, provide counselling and
mental and medical health services. By contrast, Canada often does not even
offer HIV-positive drug-users a standard medical treatment for their
illness -- antiretroviral treatment, also known as ART, which has been
proven to reduce morbidity and mortality, and can significantly improve the
health and quality of life for HIV-positive people.

Canada's legislators must reassess the laws in this country and develop an
alternative approach to reduce the harms associated with drug use. In the
mean time, many actions can be taken immediately within the existing legal
framework.

Under the Controlled Drugs and Substances Act, the cabinet can change
regulations with regard to the provision, possession, and administration of
illegal substances. As well, the Minister of Health can exempt any person
or illegal drug from the Act if the purpose is medical or scientific or in
the public interest.

In addition provincial and territorial governments, pharmaceutical
companies, and colleges of physicians and surgeons can effect change
without waiting for new legislation.

The spread of HIV through needles is a urgent problem but one that can be
successfully addressed.

Ronda Bessner, a Toronto lawyer, prepared the report Injection Drug Use and
HIV/AIDS: Legal and Ethical Issues, released last week by the Canadian
HIV/AIDS Legal Network.