"Cannabis was the most prevalently used illegal drug.

"In 2017, the prevalence of past-year cannabis use was 15% (4.4 million), an increase compared to 2015 (12% or 3.6 million), and compared to 2013 (3.1 million). In 2017, past-year cannabis use was more prevalent among males (19% or 2.7 million) than females (11% or 1.7 million), which is consistent with previous cycles. The prevalence of past-year cannabis use among males increased from 2015 (15%), whereas for past-year cannabis use there was no change among females.

"Past-year use of cannabis was more prevalent among youth aged 15 to 19 (19% or 390,000) and young adults aged 20 to 24 (33% or 780,000) than among adults aged 25 years and older (13% or 3.2 million). Past-year use of cannabis among adults aged 25 years and older increased from 2015 (10%), whereas there was no change among youth aged 15 to 19 and young adults aged 20 to 24. The mean age of initiating use of cannabis was 18 years old for males, unchanged from 2015; and 19 years old for females, up from 18 years old in 2015.

"Among people who have used cannabis in the past year, 37% (or 1.6 million) reported using it for medical purposes, an increase from 24% (831,000) in 2015. The survey does not collect information on how people obtained the cannabis for medical purposes.

"Of the methods used to consume cannabis in the past 12 months, smoking was the most common. Ninety-one percent (91% or 4 million) of those who used cannabis in the past year smoked cannabis. Other common methods of consumption include mixing cannabis with tobacco (22% or 942,000), chasing (smoking a tobacco product right after smoking cannabis – 34% or 1.5 million), consuming cannabis in edibles (brownies, etc. – 38% or 1.6 million), and vaporizing (29% or 1.3 million). Those who reported using cannabis may have tried more than one method over the past 12 months.

"The majority (75% or 3.3 million) of those who reported using cannabis in the past year reported using cannabis in the past 3 months, an increase from 2015 (72% or 2.6 million). Of those who had used cannabis in the past 3 months, many reported consuming cannabis on a daily or almost daily basis (32% or 1 million, unchanged from 33% or 840,000 in 2015).

"Provincial prevalence of past-year cannabis use ranged from 11% (750,000) in Quebec to 23% (940,000) in British Columbia."

"The risk-mitigation prescribing guidelines were a harm reduction approach in response to the evolving risk environment during COVID-19—namely, continued drug market changes and increasing socioeconomic marginalization—that facilitated reliable access to opioids and stimulants of known contents and potency. Access to no-cost pharmaceutical alternatives enabled participants to exercise greater control over their drug use and reduced vulnerability to overdose. Participants emphasized that, although they had experienced more sporadic drug use patterns characterized by frequent periods of withdrawal and cravings at the outset of the pandemic because of supply shortages, rising prices, and reduced income, they remained uninterested in addiction treatment and yet wanted greater control over their drug use. This was often attributable to past negative experiences with medication-based treatment and recovery services. Prescription opioids and stimulants made available at no cost through the risk mitigation guidelines were positioned as a way to exercise greater agency over drug use and thereby avoid withdrawal and cravings amid deepening socioeconomic marginalization, drug market changes, and escalating overdose deaths."

"The rapid implementation of OPSs [Overdose Prevention Sites] in the province of British Columbia, Canada during a public health emergency provides an international example of an alternative to drawn-out, cumbersome sanctioning processes for SCSs [Supervised Consumption Services]. Unsanctioned SCSs provide alternative evidence to inform the implementation of SCSs that are more inclusive and responsive to PWUD [People Who Use Drugs]. Our research adds to this evidence. In particular, we found evidence that shifts in the outer context facilitated rapid implementation of a more user focused and driven intervention. We found innovation and inclusionary practices that typically define unsanctioned sites were possible within state-sanctioned OPSs. Community-driven processes of implementation involve centering PWUD in service design, implementation and delivery. Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned service and community-driven implementation. As described by those individuals implementing the services, OPSs effectively provide supervised injection services and overdose responses while addressing many of the documented limitations of existing sanctioned SCSs implementation processes and resultant service designs. However, OPSs lack permanency and ongoing funding due to enactment under a Ministerial Order that is limited to the duration of the public health emergency. Specific attention needs to be paid to the development maintenance of OPSs as primary points of contact and entry into the health system and as part of an ongoing system of substance use services."

"Cannabis, which includes marijuana, hash and hash oil, has the highest prevalence of use after alcohol.

"In 2018-19, 18% of students in grades 7 to 12 (approximately 374,000) reported using cannabis in the year preceding the survey, unchanged from 2016-17. Past-12-month use of cannabis by both males and females was 18%, unchanged from the previous cycle. Students in grades 7 to 9 reported an increase in the use of cannabis (7%, approximately 73,000) compared to 6% in 2016-17, whereas cannabis use among students in grades 10-12 remained unchanged at 29%.

"The results of the 2018-19 survey showed that grade 7 to 12 students were on average 14.3 years old when they first used cannabis, unchanged from the previous cycle.

"Grade 7 to 12 students were asked about their methods of cannabis consumption. Among students who used cannabis, smoking (e.g., a joint, bong, etc.) was the most common method (76%, approximately 356,000), a decrease from 2016-17 (80%). The next most popular methods of cannabis consumption included consumption of edibles (an increase from 34% in 2016-17 to 45%, approximately 209,000), vaporizing/vaping (an increase from 30% to 42%, approximately 191,000), and dabbing (an increase from 22% to 28%, approximately 125,000). Drinking cannabis was the least reported method of consumption among students (15%, approximately 67,000), unchanged from 2016-17. Approximately 26% of students who used cannabis (approximately 115,000) also reported using another method, unchanged from 2016-17."

"Alcohol remains the substance with the highest prevalence of use by Canadian students in grades 7 to 12.

"After decreasing through successive cycles of the survey (from 53% in 2008-09), the prevalence of use of alcohol in the past 12 months by students in grades 7 to 12 remains at 44% (approximately 880,000), unchanged from 2016-17. Prevalence of past 12-month use of alcohol was 45% among females compared to 43% among males, also unchanged from 2016-17.

"On average, students tried their first alcoholic beverage at 13.4 years of age, unchanged compared to the previous cycle (2016-17). Females were slightly older when they tried their first drink than males (13.6 years versus 13.3 years).

"Less than one quarter of students (23%, approximately 481,000) reported high risk drinking behaviour (i.e., five or more drinks on one occasion) in the past 12 months, which was unchanged from 2016-17. Twenty-four percent of males and 23% of females reported drinking five or more drinks on one occasion in the past year, both unchanged from 2016-17."

"Eight of the nine provinces with student drug use surveys ask about daily or almost daily use of cannabis in the past month. Overall, 2.2–5.3% of students report smoking cannabis every day or almost every day in the past 30 days (Table 31 and Figure 31). In four of the eight provinces, the prevalence of daily or almost daily cannabis use was significantly greater among males than females (Table 32 and Figure 32). When examined by grade, the same pattern as noted in all previous indicators emerges. In Grade 7, very few students report daily use - so few that most estimates for Grade 7 students are suppressed. In Grade 12, however, 3.3–10.0% of students report using cannabis daily or almost every day (Table 33 and Figure 33)."

"The reported prevalence of drugs (other than alcohol and cannabis) such as cocaine or heroin among students is relatively rare. That said, provinces routinely measure use of these substances. British Columbia, Alberta, Manitoba, and Ontario estimates are for lifetime use. Atlantic provinces, Québec and the YSS [Youth Smoking Survey] ask about use in the past 12 months. Therefore, the two sets of prevalence estimates are presented separately in different tables. In addition to the different time frames used in the survey questions, there is also considerable variation in the terminology used in referring to these drugs as noted where appropriate in the tables below.
"All the surveys ask about ecstasy. Estimates for ecstasy use range from 3.4–7.2% reporting past-12-month use
and 4.4–7.1% reporting lifetime use (Tables 43 and 44). Following ecstasy, inhalants are second overall in reported
use with estimates ranging from 2.6–4.4% for past-year use and 2.2–3.8% for lifetime use. However, not all surveys ask about use of inhalants; some ask about ‘solvents’ or ‘glue’. These differences in terminology result in different prevalence estimates (Tables 45 and 46). Estimates for steroid use range from 1.4–1.7% for past-12-month use and 1.2–1.4% for lifetime use (Tables 47 and 48). Estimates for lifetime heroin use in British Columbia, Alberta, Manitoba and Ontario range from 0.8–1.3% (Table 49). Atlantic Canada does not ask students about heroin use. The YSS asks about past-12-month use of heroin [1.3% (1.0, 1.6)]."

Prices Per Gram, 2016

United States:
Black tar heroin: range from $17-$400
South American heroin: range from $45-500

Canada:
Heroin: range from $105.70-$452.80

UK, 2016:
Brown heroin: typical price $67.80, range from $54.20-$81.30
Opium: typical price $13.60, range from $13.60-$20.30

"The prescribing practices described in this evaluation – safe supply medications and managed alcohol, for unwitnessed consumption – are a recent development. While the relative safety of medications and alcohol dispensed for unwitnessed consumption has not been previously well-described in the literature, the practice is an extension of the evidence from witnessed consumption settings (Bonn et al., 2021; Brothers et al., 2022; Tyndall, 2020; Hales et al., 2020; Bonn et al., 2021). Witnessed injectable OAT (iOAT) with liquid hydromorphone or diacetylmorphine (Heroin) has a robust evidence-based and has been incorporated into Canadian clinical practice guidelines for opioid use disorder (Oviedo-Joekes et al., 2016; Fairbairn et al., 2019). Qualitative studies have evaluated the benefits of witnessed hydromorphone tablet consumption, which is more flexible and less resource-intensive than witnessed iOAT (Ivsins et al., 2021; Ivsins et al., 2020). A recent study from Ottawa, Canada, describes positive outcomes for people with severe opioid use disorder who are provided hydromorphone iOAT along with supported housing (Harris et al., 2021). Benefits of managed alcohol programs are also clearly established for people with severe alcohol use disorder, and particularly people who drink non-beverage alcohol (Stockwell et al., 2021; Stockwell et al., 2018; Crabtree et al., 2018). Some existing managed alcohol programs include once-daily alcohol dispensing and/or unwitnessed ingestion (Pauly et al., 2018)."

"The present study investigated treatment response and retention by gender in North America’s first randomized controlled trial of injectable diacetylmorphine [DAM]. DAM showed greater effectiveness than MMT with respect to treatment retention and response at 12 months for both men and women, although there were significant treatment differences in more sub-scores for men than women. There were no gender differences in overall clinical response and retention at 12 months in the DAM and MMT groups."

Crime, Courts, and Prison

"Unlike the Criminal Code violations discussed in previous sections, drug-related offences in Canada fall under the Controlled Drugs and Substances Act. In 2012, police reported more than 109,000 drug-related incidents, representing a rate of 314 incidents per 100,000 population (Table 6).
"Overall, fewer drug-related incidents were reported in 2012 than in 2011. The decline was due primarily to a decrease in cannabis-related incidents, which accounted for two-thirds of all drug-related incidents reported by police (Chart 14). In contrast, nearly all types of other drug offences increased. The largest increase in police-reported drug offences in 2012 was in cocaine possession (+5%), although over the previous 10-year period, the rate of possession of drugs other than cannabis and cocaine rose most, up 89%.
"British Columbia, which was the province reporting the highest overall rate of drug offences in recent years, had about 2,000 fewer cannabis-related incidents in 2012. On the other hand, the rate of cocaine-related offences in Saskatchewan has more than doubled over the past two years. As a result, Saskatchewan had the highest overall rate of police-reported drug offences in 2012, followed by British Columbia.
"Nevertheless, British Columbia continued to report the highest rates for some specific drugs, such as cannabis, heroin and ecstasy offences. It also had the second highest rate of methamphetamine (crystal meth) incidents, behind Quebec, but well above the other provinces. Overall, rates of drug-related offences were generally higher in the territories than in the provinces (Table 7)."

"The amount of marihuana produced in Canada exceeded domestic demand. Reportedly, there were OC [Organized Crime] groups producing this drug specifically for export to foreign markets, the largest of which is the United States. According to the U.S. National Drug Intelligence Center (NDIC), while seizures of Canadian marihuana have declined13 at the Canada-U.S. border, Canada continued to be a source country for high-grade marihuana destined for U.S. illicit drug markets.v The reported decline was believed to be due, in part, to Canadian-based Asian OC groups using their expertise to establish cannabis cultivation sites within the United States, thereby avoiding the cost of transporting drugs across the border and the risk of detection.
"Shipments of marihuana destined for Canada were smuggled through air cargo or passenger flights, and arrived primarily at Toronto Pearson International Airport. Canada Border Services Agency (CBSA) reported the seizure of approximately 1.15 tonnes of marihuana in 2009, with 60 percent of the total originating from Jamaica. Jamaican marihuana was primarily supplying a small market in Ontario and Quebec."

Problem Drug Use and Its Correlates

"The number of Canadians reporting use of an injectable drug at some point in their life increased from 1.7 million in 1994 (7.4% overall: 10% of males, 4.9% of females) to a little more than 4.1 million in 2004 (16.1% overall: 20.8% males, 11.7% females). Of those who used an injectable drug at least once in their life-time, 7.7% (132,000) reported past-year use by injection in 1994 compared with 6.5% (269,000) in 2004. The numbers of individuals having used drugs by injection in the past year are too small to allow any analysis."

"Infectious disease management can be a challenge in correctional settings due to the high rates of BBIs, and risky behaviours such as injection drug use (IDU), tattooing and piercing among people entering the correctional system (PHAC, 2008b). While jurisdictions prohibit IDU, tattooing and piercing within their facilities some inmates continue to engage in these activities with escalated risk of infection due to the need to share equipment. For example, among Canadian studies, the reported level of IDU ranges from 5% to 28% in federal institutions and 1% to 8% in provincial correctional centres (Alary, Godin & Lambert, 2005; Calzavara & Burchell, 1999; Calzavara et al., 2003; Calzavara, Myers, Millson, Schlossbert, & Burchell, 1997; Dufour et al., 1996; Ford, 1999; Ford et al., 2000; Martin, Gold & Murphy, 2005; PASAN, 2003; Poulin et al., 2007; Price Waterhouse, 1996; Rehman, 2004; Small et al., 2005). These rates are higher when capturing ever injecting in prison (8% to 28%) compared to shorter periods of time such as the past 12 months (1% to 11%)."

"HIV/AIDS remains an issue of concern for Canada. The number of people living with HIV (including AIDS) continues to rise, from an estimated 64,000 in 2008 to 71,300 in 2011 (an 11.4% increase) (Table 1, Figure 1). The increase in the number of people living with HIV is due to the fact that new infections continue at a not insignificant rate which is greater than HIV-related deaths, as new treatments have improved survival. The estimated prevalence rate in Canada in 2011 was 208.0 per 100,000 population (range: 171.0–245.1 per 100,000 population). Nearly half (46.7%) of those living with HIV were men who have sex with men (MSM). Those who acquired their infection through heterosexual contact and were not from an HIV-endemic region comprised the next largest group (17.6%), followed by those who acquired their infection through injection drug use (IDU) (16.9%) and those exposed through heterosexual contact and were also from an HIV-endemic region (14.9%)."

"The most commonly reported drug-related harm involves physical health, reported by 30.3% of lifetime and 23.9% of past-year users of illicit drugs excluding cannabis, and 15.1% of lifetime and 10% of past-year users of any illicit drug . Following physical health, a cluster of harms, represented somewhat equally, includes harms to one’s friendships and social life (22.3% and 16.4% of users excluding cannabis, 10.7% and 6.0% of any illicit users), home and marriage (18.9% and 14.1% excluding cannabis, 8.7% and 5.1% of any illicit users), work (18.9% and 14.2% excluding cannabis, 9.2% and 5.1% of any illicit users) and financial position (19.6% and 18.9% excluding cannabis, 8.4% and 6.5% of any illicit users)."

"Our results probably explain reports of increased injection drug use, drug-related crime and other public-order concerns in neighbourhoods where activities related to illicit drug use and the sex trade emerged or intensified in the wake of the crackdown. Such displacement has profound public-health implications if it 'normalizes' injection drug use among previously unexposed at-risk youth. Furthermore, since difficulty in obtaining syringes has been shown to be a significant factor in promoting syringe sharing among IDUs in Vancouver, displacement away from sources of sterile syringes may increase the rates of bloodborne diseases. Escalated police presence may also explain the observed reduction in willingness to use a safer injection facility.³³ It is unlikely that the lack of benefit of the crackdown was due to insufficient police resources. Larger crackdowns in the United States, which often involved helicopters to supplement foot and car patrols, have not had measurable benefits and have instead been associated with substantial health and social harms."

"Our results on the cost-effectiveness of diacetylmorphine are consistent with those of an economic analysis based on data from two Dutch heroin-assisted treatment trials,²¹ despite differences in the design of the Dutch trials and the North American Opiate Medication Initiative, and the time horizon and analytic design of the economic analyses.

"The Dutch trials compared methadone maintenance treatment with a combination of methadone and diacetylmorphine (prescribed concurrently), which changed the profiles of health utility and health resource use. Furthermore, participants in the Dutch trials were recruited from methadone maintenance programs, whereas participants in the North American Opiate Medication Initiative had to have been out of treatment for at least six months before trial entry. We considered a range of time horizons, using external parameters where necessary to extrapolate results to longer time horizons. The other economic analysis used trial data exclusively and focused only on a 12-month study period. The consistency in results between our analysis and the analysis of the Dutch trials appears to be due primarily to the advantages diacetylmorphine provides in retaining individuals in treatment.

"We believe a lifetime horizon is the most appropriate period for evaluating treatments of chronic, recurrent diseases such as opioid dependence, because treatment is available indefinitely in practice and will have a long-term impact. The key outcomes, such as progressing to a drug-free state or death, would likely not be realized within the 12-month period of the North American Opiate Medication Initiative."

"Among long-term chronic opioid injectors participating in a randomized clinical trial prescribing injectable diacetylmorphine or hydromorphone and oral methadone, those receiving injectable medications were more satisfied with treatment. Independent of treatment group, treatment satisfaction was also an indicator of retention in treatment, as well as treatment response, including a reduction in substance use. As the first study in North America to provide injectable OST, these findings have valuable implications for future RCTs, which should continue to measure satisfaction in order to identify areas of improvement. These findings also provide evidence-based knowledge for good clinical practice guidelines in the treatment of chronic opioid dependence in Canada as they highlight the association between treatment satisfaction and improved treatment outcomes, particularly for those receiving more innovative treatment medications."

"Urine, hair, and meconium samples are sensitive biological markers of substance use. Urine drug screening can detect only recent substance exposure, while neonatal hair and meconium testing can document intrauterine use because meconium and hair form in the second and third trimester, respectively.^38–41 By itself, a single positive test result cannot be used to diagnose substance dependence. Although child protection agencies sometimes request hair analyses, neither hair nor meconium is appropriate for routine clinical use because of the high costs and propensity for false positive results."

"The rate of overdose observed at the Vancouver SIF is within the range of rates observed in an international review of SIF which estimated the rates of overdose typically to be between 0.01 and 3.6 per 1000 injections (Kimber et al., 2005). However, the rate observed in Vancouver is lower than rates observed recently in Munster, Germany (6.4 per 1000 injections) and Sydney, Australia (7.2 per 1000 injections) (Kimber et al., 2003). This may reflect differences in threshold for coding and intervention by staff, and differences in drug consumption patterns across cities, especially as it pertains to the use of opioids and other central nervous system depressants."

"The model used here [18], predicted the number of new HIV and HCV cases prevented based on the needle sharing rate. This included the impact of behavioral changes in injection activities outside of the SIF. The behavioral change, according to Table 2 and Table 3, was only considered twice (once for the first SIF and later for the second SIF)—this modeling decision is apparent in the marginal number of new HIV cases averted in Tables 3, 4 and 5. This calculation of behavioral impact is based on a conservative odds-ratio that falls within the limit specified by Kerr et al. (2005) [40].

"As expected, the results presented in Table 2 and Table 3 show that increasing the scope of SIFs through site expansion would result in a decrease of HIV infection cases. The model predicts: 14–53 fewer HIV cases and 84–327 fewer HCV cases annually, with the marginal range being much smaller: 5–14 fewer HIV cases and 33–84 fewer HCV cases annually.

"This range disparity, as outlined in Table 2 and Table 3, translates into substantial differences between the economic evaluation of SIFs with respect to the cumulative versus marginal estimates: the total effect of establishing SIFs and the effect of establishing each subsequent SIF, respectively.

"For example, according to Table 3, the cumulative annual estimates of new HIV cases averted, translates into a cost savings for society ranging from $0.764 million (benefit) for the first SIF to -$4.1 million (loss) for the seventh SIF. Benefit-cost ratios range from 1.35 to 0.73, and cost-effectiveness values range from $155,914 to $288,294 (cost per lifetime treatment). The cumulative annual estimates of new HCV cases averted translate into a cumulative cost savings that range from $0.769 million (benefit) for the first SIF to -$3.7 million (loss) for the seventh SIF. Benefit-cost ratios range from 1.35 to 0.73, and incremental cost-effectiveness values range from $25,986 to $46,727 (cost per lifetime treatment).

"In contrast, the marginal estimates of Montreal’s SIF expansion translate into a much smaller return. This is particularly true with respect to its benefit-cost and cost-effectiveness ratios. For instance, the marginal benefit-cost ratio varies from 1.35 to 0.77 for HIV and 1.35 to 0.76 for HCV. The marginal cost-effectiveness value for HIV ranges from $155,914 to $436,560 (cost per life- time treatment). The HCV marginal cost-effectiveness value ranges from $25,986 to $66,145 (cost per lifetime treatment)."

"In 2006 a team of researchers published estimates of the social costs of substance abuse in Canada across several domains based on 2002 data (Rehm et al., 2006). Total costs of substance abuse for all substances (including tobacco) were estimated to be $39.8 billion in 2002, which translates into $1,267 per capita. Of this, approximately 39% are direct costs to the economy associated with health care, enforcement, prevention/research and 'other costs'⁶, and 61% are indirect costs associated mainly with productivity losses resulting from premature death and disability. Figure 2 depicts the estimated direct social costs associated with alcohol, illicit drugs and cannabis in 2002.
"Important findings from Figure 2 include the fact that (1) total direct social costs associated with alcohol ($7,427.5 million) are more than double those for all illicit drugs combined ($3,565.5 million); (2) direct alcohol-related health care costs ($3,306.2 million) are nearly three times as high as for all illicit drugs, excluding cannabis ($1,061.6 million), and over 45 times higher than the direct health care costs of cannabis ($73 million); and (3) annual direct costs for health care ($4,440.7 million) are 31 times higher, and annual direct costs for enforcement ($5,407.7 million) are 36 times higher than annual costs for prevention and research ($147.6 million)."

"The role of the federal government is described in key legislation and international conventions and protocols in areas relevant to the Strategy‘s activities. The federal government role in the Strategy is grounded in its authorities under the Constitution Act (1867) as well as key legislation, including CDSA; Criminal Code of Canada; Canada Health Act; Proceeds of Crime (Money Laundering) and Terrorist Financing Act; and Youth Criminal Justice Act. Departmental legislative authorities of relevance include Canada Revenue Agency Act; Canada Border Services Agency Act; Corrections and Conditional Release Act; Department of Foreign Affairs and International Trade Act; Department of Health Act; Department of Justice Act; Department of Public Safety and Emergency Preparedness Act; Department of Public Works and Government Services Act; Director of Public Prosecutions Act; and Royal Canadian Mounted Police Act. International conventions and protocols of relevance include the United Nations Narcotic Drug Conventions and other multilateral processes such as the OAS, the G8, the Paris Pact, and the Dublin Group.
"The federal government plays a critical role in addressing illicit drug issues at the broad policy level. For example, the Department of Justice led on introducing Bill C-10, which included mandatory minimum penalties for serious drug crime, and received royal assent on March 13, 2012. HC [Health Canada] is responsible for amendments under the CDSA to control the movement of certain substances in and out of Canada. This is particularly relevant for controlling and preventing the movement of illicit drugs as well as precursor chemicals which are used to make synthetic drugs (e.g. methamphetamine)."

"RECOMMENDATIONS
"1. The severity of punishment for a cannabis possession charge should be reduced. Specifically, cannabis possession should be converted to a civil violation under the Contraventions Act.
"The current law involves considerable enforcement and other criminal justice costs, as well as adverse consequences to individual drug offenders, with little evidence of a substantial deterrent impact on cannabis use, and at best marginal benefits to the public health and safety of Canadians. As a minimal measure, jail should be removed as a sentencing option for cannabis possession. The available evidence indicates that removal of jail as a sentencing option would lead to considerable cost savings without leading to increases in rates of cannabis use. Punishing cannabis possession with a fine only would be consistent with current practices and prevailing public opinion."

"Ensuring that offenders have access to interventions that address their substance abuse issues allows the Correctional Service of Canada (CSC) to support the safe reintegration of offenders into society. The treatment needs of offenders with opioid dependence are met through CSC’s Methadone Maintenance Treatment (MMT) Program.¹
Some of the objectives of CSC’s MMT program include reducing relapse to opioid drug use and the incidence of drug-related criminal activity; improving the offender’s general health and quality of life; and assisting and motivating offenders to gradually desist from all illicit drug use."

"Through successful binational fora such as the Cross-Border Crime Forum (CBCF) and Project North Star, the United States and Canada have increased intelligence-sharing and joint training opportunities for law enforcement officials. Investigative cooperation has also been expanded, through the establishment of new Integrated Border Enforcement Teams and notable enforcement initiatives such as Operation Sweet Tooth/Project O’Skillet and Operation Triple Play/Project O’Slider. The result: greater success in seizing illicit drugs crossing the U.S.-Canada border and apprehending those that traffic them.
"Despite our best efforts, drug trafficking still occurs in significant quantities in both directions across the border. The principal illicit substances smuggled across our shared border are MDMA (Ecstasy), cocaine, and marijuana."

"... the Government of Canada amend the Controlled Drugs and Substances Act to create a criminal exemption scheme. This legislation should stipulate the conditions for obtaining licenses as well as for producing and selling cannabis; criminal penalties for illegal trafficking and export; and the preservation of criminal penalties for all activities falling outside the scope of the exemption scheme."

"In summary, we documented significant reductions in the number of IDUs injecting in public, publicly discarded syringes and injection-related litter after the opening of the medically supervised safer injecting facility. These reductions appeared to be independent of several potential confounders, and our findings were supported by external data sources. Although the overall health impacts of the facility will take several years to evaluate, the findings from this study should be valuable to other cities that are contemplating similar evaluations and should have substantial relevance to many urban areas where public injection drug use has been associated with substantial public health risks and adverse community impacts."

18. What was NAOMI?
"NAOMI was North America’s first-ever clinical trial of prescribed heroin that took place from 2005 to 2008.
"It was led by researchers from PHC and UBC, and tested whether medically prescribed heroin (diacetylmorphine) was more effective than methadone therapy for individuals with chronic heroin addiction who were not benefiting from other conventional treatments.
"19. Who participated in the NAOMI study?
"NAOMI enrolled 251 chronic, heroin dependent participants (192 in Vancouver and 59 in Montreal)."

"24. What did NAOMI find?
"The NAOMI Trial results, published in the prestigious medical publication the New England Journal of Medicine, showed that participants treated with diacetylmorphine reported improved physical and mental health, were 62 per cent more likely to remain in addiction treatment and 40 per cent less likely to take illegal drugs and commit crimes to support their habit than were those treated with methadone.
"After a year, 88 per cent of those treated with diacetylmorphine remained in treatment, compared with 54 per cent in the methadone group.
"Data from NAOMI and other long-term studies with medically prescribed heroin show that many of the patients of these studies also transition from injection to oral treatments, detox programs and abstinence."

"25. What happened to the NAOMI participants after they completed the study?
"Doctors were unable to secure approval from the federal government to give patients diacetylmorphine.
"All participants who received injection medication were encouraged to switch to methadone.
"Providence agreed to provide interim funding for the continued operations of a methadone program at the clinic site. SALOME was designed to continue the work of NAOMI."

"Our study had two primary findings. First, we found that most study participants were motivated for treatment, despite not accessing it in at least the past 6 months (as per trial entry criteria). This may be the result of a lack of accessible or attractive treatment options available to them. Second, we found that baseline motivation for treatment did not predict retention in either HAT [heroin assisted treatment] or MMT [methadone maintenance treatment], however motivated patients receiving HAT were more likely to achieve response than unmotivated patients. While HAT is likely to retain patients regardless of motivational status, success in treatment, in terms of decreases in illicit drug use and crime, is more likely among motivated patients, as measured in our study. Further, HAT was statistically significantly more effective than MMT on each of the outcomes assessed."

"The NAOMI study provided injectable HDM to a small group of participants. An unexpected finding was that many participants couldn’t tell the difference between the effects of diacetylmorphine and HDM.

"However, the small number of participants receiving HDM did not permit researchers to draw any definite and scientifically valid conclusions as to the efficacy of HDM as a treatment option.

"Therefore, the SALOME investigators designed a study to test this hypothesis.

"SALOME aimed to determine alternative treatments for people with chronic heroin addiction not benefitting sufficiently from available treatments such as oral methadone."

"Insite opened on 21 September of 2003 under an exemption granting it status as a scientific pilot study until 12 September 2006. The primary goals of the program are: (1) to reach a marginalized group of IDUs with healthcare and supports who would otherwise be forced to use drugs in less safe settings (2) to reduce dangerous injection practices (syringe sharing) thereby reducing the risk of infectious diseases like HIV and HCV; and (3) to reduce fatal overdoses in the population of people that use the facility. The program also aims to provide referrals to treatment and detoxification, reduce public disorder (public injection) and validate the personhood of a deeply stigmatized target population."

"Lifetime HIV-related medical care costs are approximately $210,555 in 2008 Canadian dollars (Pinkerton, 2010). Consequently, by preventing 5–6 HIV infections per year, the Insite SIF averts more than $1,000,000 in future HIV-related medical care costs. Andresen and Boyd (2010) estimate that the SIF generates $660,000 in additional cost savings by preventing 1.08 overdose deaths per year. The total savings due to averted HIV-related medical care costs and prevented overdose deaths (approximately $1.7 to $1.9 million per year), in and of itself, is just slightly greater than the estimated $1.5 million annual operating cost of the Insite SIF."

"In summary, the present study demonstrates that the SIF was associated with increased use of detoxification service use and that residential detoxification was associated with increased rates of methadone use and other forms of addiction treatment. Given the known role of methadone and other forms of addiction treatment in reducing levels of injection drug use, and given that detoxification programme use was associated with reduced injecting at the SIF, our findings imply that the SIF has probably helped to reduce rates of injection drug use among users of the facility."

"Evaluation of the Vancouver facility has shown that its opening has been associated with reductions in public drug use and publicly discarded syringes and reductions in syringe sharing among local injecting drug users. Our study suggests that these benefits have not been offset by negative changes in community drug use."