Canada

"What is legal as of October 17, 2018
"Subject to provincial or territorial restrictions, adults who are 18 years of age or older are legally able to:

"• possess up to 30 grams of legal cannabis, dried or equivalent in non-dried form in public
"• share up to 30 grams of legal cannabis with other adults
"• buy dried or fresh cannabis and cannabis oil from a provincially-licensed retailer in provinces and territories without a regulated retail framework, individuals are able to purchase cannabis online from federally-licensed producers
"• grow, from licensed seed or seedlings, up to 4 cannabis plants per residence for personal use
"• make cannabis products, such as food and drinks, at home as long as organic solvents are not used to create concentrated products
"As of October 17, 2019, cannabis edible products and concentrates are legal for sale.

"Possession limits for cannabis products
"The possession limits in the Cannabis Act are based on dried cannabis. Equivalents were developed for other cannabis products to identify what their possession limit would be.

"One (1) gram of dried cannabis is equal to:

"• 5 grams of fresh cannabis
"• 15 grams of edible product
"• 70 grams of liquid product
"• 0.25 grams of concentrates (solid or liquid)
"• 1 cannabis plant seed
"This means, for example, that an adult 18 years of age or older, can legally possess 150 grams of fresh cannabis.

"Cannabis for medical purposes
"The current regime for medical cannabis will continue to allow access to cannabis for people who have the authorization of their healthcare provider."

"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."

"In British Columbia, a new policy directive—termed “prescribed safer supply”—has recently been announced that will extend prescribing practices outlined in the risk mitigation guidelines beyond the pandemic,²⁹ although the original guidelines remain in effect and have since been revised with a more explicit focus on mitigating COVID-19 risk. However, although the recent policy directive has been broadened to include fentanyl patches and sublingual fentanyl, it does not presently support stimulant prescriptions and thus raises concerns for people who have been accessing stimulants. As the overdose crisis continues, it is imperative that safe supply be extended to all PWUD while being continuously modified to maximize access, efficacy, and equity.

"Finally, our findings draw attention to the tensions surrounding safe supply approaches primarily oriented toward managing withdrawal and drug cravings versus the desire of PWUD to experience enjoyment from drug use.³⁴ There is a need to account for pleasure in the design and implementation of safe supply approaches—something seldom examined in North American research and policy discussions on drug use. Better aligning safe supply approaches with the real-world experiences and desires of PWUD will likely necessitate expanding the options available to include regulated versions of criminalized drugs that they are accustomed to using, such as methamphetamine, cocaine, heroin, and even fentanyl. With growing support for drug decriminalization and strides being made in Oregon and elsewhere,^35,36 it is time that these discussions be broadened to also consider what a regulated drug market might look like in North America."

"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."

"Despite the relatively progressive policy landscapes of both Vancouver and Lisbon, the soft left hand of low-barrier harm reduction programs continues to be paired with the hard right hand of criminal sanctions and other forms of control in both settings [31]. In Vancouver and Lisbon, police are often tasked with identifying “problem” YPWUD [Young People Who Use Drugs] and making referrals to services [11]. While accessing these services is technically voluntary in Portugal, physically presenting oneself before the Commissions for the Dissuasion of Drug Addiction is mandatory for those who are caught using drugs (including cannabis), and accepting “invitations to treatment” can be enforced by fines and other kinds of sanctions. In fact, the last decade has seen a sharp increase in criminal sanctions targeted at people who use drugs in Portugal, despite decriminalization [11].4 In Vancouver, people who use drugs in the context of street involvement continue to be heavily criminalized, and as mentioned above, there have been growing calls for the decriminalization of substance use in this setting [15].

"Youth-dedicated drop-in centers and “one-stop-shop” service hubs that prioritize harm reduction are a better primary point of care for YPWUD than hospitals or criminal justice facilities. These kinds of centers and hubs do exist in Vancouver. They provide a range of harm reduction, drug use, mental health, and social services and are critical supports for YPWUD in this setting. In Portugal, harm reduction programs and centers are more explicitly targeted towards higher-income and older (> 18 years of age) YPWUD, such as those who use drugs at music festivals. In Lisbon, YPWUD in the context of street involvement have largely been left out of efforts to scale up harm reduction interventions, including in response to the COVID-19 pandemic [16]."

"In Vancouver and Lisbon, there are other critical gaps in harm reduction services and programs for YPWUD as well. In both settings, youth-dedicated safer injection, safer smoking, and overdose prevention sites do not exist. The COVID-19 pandemic prompted a scaling up of harm reduction initiatives in both Vancouver and Lisbon [9, 16]. And yet, in Lisbon, interventions such as a new shelter that includes access to a safer consumption space (via a mobile drug consumption room) was not designed to include youth. In Vancouver, even when YPWUD are allowed to use those safer consumption sites that do exist, they often don’t feel comfortable in these adult-oriented spaces.

"In our experience, adult-oriented safer consumption spaces can be intimidating for YPWUD, who don’t always feel like they can ask questions or get appropriate help in these places. In adult-oriented spaces, it can seem like everyone already knows what they are doing and what they want to be doing when it comes to their substance use, and many YPWUD feel like they have to imply that they are equally experienced and confident in their decisions about drugs when they are in these places. YPWUD may also worry that if they access adult-oriented safer consumption spaces, someone might report them to child protective services, or tell a family member, caregiver, provider, or worker that they were seen there. In Vancouver, we have seen YPWUD turned away from adult-oriented safer consumption spaces because they looked "too young" and “too healthy” to be using drugs intensively, or “didn’t have any track marks.” When YPWUD are uncomfortable or actively turned away, it can drive them even further away from life-saving care. It can also send the message that their lives are not worth saving.

"In Portugal, safer drug consumption spaces in general are not widely available (the first safer smoking and injecting sites were opened in 2021), and there are no youth-dedicated spaces. Drug checking is only available in Lisbon, and take-home naloxone kits and peer-to-peer overdose prevention (naloxone) programs are also not available despite ongoing advocacy. In both Vancouver and Lisbon, there has been a primary focus on connecting people who use drugs with OAT and sterile drug use paraphernalia. As others have argued, the focus is on mediating drug-related risks and harms (e.g., syringe sharing, blood borne infections), and treating substance use “disorders” via licit replacement therapies (e.g., methadone, buprenorphine-naloxone), rather than on making the use of substances such as heroin, fentanyl, crack, and meth safer via safe supply and harm reduction programs [11]. In both settings, a focus on substance use as either criminal or pathological undermines the self-determination of YPWUD in relation to their drug use, harm reduction, and care."

"Respondents were asked about past-year use of illegal drugs including cocaine or crack, ecstasy, speed or methamphetamines, hallucinogens and heroin. This section excludes cannabis.

"Past-year use of at least one of five illegal drugs was 3% (987,000), an increase from 2% (678,000) compared to 2015, and 2% (458,000) compared to 2013. This increase is associated with an increase in the use of cocaine, compared to 2015 and 2013.

"Overall, prevalence of past-year use of these illegal drugs was higher among males (5% or 719,000) than females (2% or 268,000). There was an increase in past-year use of illegal drugs for both males and females, compared to 2015 (5% vs. 3% and 2% vs. 1% respectively).

"Past-year use of at least one of five illegal drugs was higher among youth aged 15 to 19 (4% or 81,000) and young adults aged 20 to 24 (10% or 241,000) than among adults aged 25 and older (3% or 665,000).

"While past-year illegal drug use remained low, there was an increase in the prevalence of use of cocaine; 2% (730,000) of Canadians reported using cocaine, an increase from 1% (353,000) compared to 2015, and 1% (259,000) compared to 2013. Cocaine use among adults aged 25 and older was 2% in 2017, an increase from 1% in 2015, and 1% in 2013. There was no change in the prevalence of use of hallucinogens (1% or 443,000), or ecstasy (1% or 271,000). The prevalence of heroin, speed/methamphetamine or salvia use was not reportable due to small sample size.

"Past-year use was more prevalent among males than females for cocaine (4% males vs. 1% females) and hallucinogens (2% males vs. 1% females)."

"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."

"Provincial prevalence of past-year cannabis use ranged from 8.5% in New Brunswick to 13.8% in British Columbia. There were no year-to-year changes in provincial rates of cannabis use. Each province’s past-year cannabis prevalence was compared with the average prevalence for the nine remaining provinces. Of these, only British Columbia shows higher than average prevalence."

"This research sought the perspectives of people involved in the unregulated drug market on how drug checking could be implemented as a market intervention within the current context of a highly unpredictable drug supply and unprecedented rates of overdose. Currently, drug checking is positioned as a public health intervention promoted to people who use drugs within supervised consumption sites while being averse to aiding people who sell or produce drugs. Drug checking does not need to be limited to an individual-level behavioral intervention targeted at the end user of a substance, but holds the potential to also function as a supply-side intervention within the drug market linked to overdose. However, careful consideration is needed to design and deliver appropriate drug checking services within the context of the criminalization of substances and the drug market. The demand for quality and product assurance within the illicit supply may operate as a potential driving force to facilitate drug checking and we identified several novel strategies to this end; however, there are also significant implementation challenges.

"We heard that criminalization was the most critical barrier to accessing drug checking services for those within the supply chain. While unsurprising, there are particular considerations and intervention design factors to be addressed to engage sellers and potentially function at a market level. Overall, the benefits of drug checking services need to ensure high-quality services that enable quality products, provided by knowledgeable peers and scientists, and establish trust and safety to outweigh the risks of arrest for accessing services. Promoting drug checking for marketing quality products may be more successful than relying on traditional health promotion messages. Safer settings within the context of criminalization are critical and yet not clearly defined and vary depending on the person and context. Trust was identified as central to successful implementation and may be enhanced through engaging peers and word of mouth."

"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."

Data from the Canadian Addiction Survey (CAS) and Canadian Alcohol and Drug Use Monitoring Survey (CADUMS).

Click here for the complete datatable of Estimated Prevalence of Use of Selected Drugs in Canada

"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)."

"Results from samples expected to be stimulants were divergent between testing groups. Crystal methamphetamine samples tested using take-home drug checking were reported as fentanyl positive more often than on-site samples (27.6% vs. 5.2%). The same pattern was seen for cocaine samples tested using take-home drug checking (17.2% vs. 1.1%). However, the study was underpowered to evaluate equivalence between these testing groups. A small portion of the test strips (3.8%) yielded an unclear or illegible response. It is unclear what the participants did in these cases, but the inclusion of multiple test strips would have allowed for repeat testing.

"Notably, when the results of take-home drug checking were stratified based on previous experience with fentanyl test strips, there was a trend towards a smaller difference between the results of take-home drug checking and on-site drug checking. For opioids, when only results from those who were using fentanyl test strips for the first time were included, there was a difference of 1.6% between take-home drug checking and on-site drug checking. This difference was reduced to 0.6% when only including samples from those who had self-reported prior experience with using fentanyl test strips. Similar results were seen for crystal methamphetamine (28.9% to 15.2%) and cocaine (28.3% to 7.8%)."

Data from the Canadian Addiction Survey (CAS) and Canadian Alcohol and Drug Use Monitoring Survey (CADUMS).

Click here for complete datatable of Trends in Age of Initiation of Cannabis and of Alcohol Use in Canada

"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)]."

"Based on our findings, distributed fentanyl test strips would be reliable for the testing of samples identified as opioids and should be more widely distributed. There is growing evidence that fentanyl test strips may help prevent overdose when included with other evidence-based strategies (Peiper, 2019). Other informal techniques such as visual inspection of a substance have been applied by PWUD, but may not be effective in substances that contain traces of fentanyl (Peiper et al., 2019). Our study situated fentanyl test strips within sites that provide naloxone kits, drug use supplies such as syringes, supervised consumption of substances, and drug checking using both test strips and more sophisticated technologies. In contrast to the potential for behaviour change from drug checking results, analysis of several cohort studies within Vancouver during the period of increasing fentanyl contamination in late 2016 showed that a majority of PWUD did not change their drug use behaviours nor translate the knowledge of a changing drug supply to an increased risk of overdose (Brar et al., 2020; Moallef et al., 2019). These findings indicate the need for targeted education and harm reduction interventions for those at risk. Distribution of testing supplies provides an opportunity for further engagement. In BC, an expansion of this pilot program, including continuation at sites included in this evaluation, has occurred to distribute fentanyl test strips labelled with instructions for use. Notably, the described positive behaviour changes rely on an individual possessing knowledge around safer ways to use substances, including knowledge around using a small amount (“test dosing”) and using with others or not alone to avoid overdose and allow for naloxone administration. Furthermore, participants identified using at an OPS/SCS as a potential behaviour, which necessitates that these services exist. Our findings around behaviour change in response to a positive fentanyl result underscore the need for comprehensive harm reduction services and education."

"Among 995 participants who were interviewed in 2019–2021, 63 (6.3%) had their drugs seized by police at least once in the past 6 months. In multivariable analyses, factors significantly associated with drug seizure included: homelessness (adjusted odds ratio [AOR]: 1.98; 95% confidence interval [CI] 1.09–3.61), working in the unregulated drug market (AOR: 4.93; 95% CI 2.87–8.49), and naloxone administration (AOR: 2.15; 95% CI 1.23–3.76). In 2009–2012, 67.8% reported having obtained new drugs immediately after having their drugs seized by police. Odds of drug seizure were not significantly different between the two time periods (2019–2021 vs. 2009–2012) (AOR: 0.93; 95% CI: 0.64–1.35)."

"During the 16-month study period between June 2019 and November 2021 (June 2019–mid-March 2020 and June 2021–November 2021), 6% of our sample of people who used drugs daily in Vancouver reported having had their drugs seized by police without arrest at least once in the past 6 months. When examining the historical trends of annual prevalence, we found a declining trend in reports of drug seizure from 7% in 2009 to 3% in 2012, while the prevalence between June 2019 and mid-March 2020 and between June and November of 2021 (4–5%) remained essentially the same as the annual prevalence in 2011–2012. However, overall, the odds of drug seizure were not significantly different between the two time periods (2019–2021 vs. 2009–2012).

"The low documented numbers of recommended charges for simple possession by the VPD are often cited to indicate success of VPD’s de facto depenalization policy [24]. Certainly, recommended charges for simple possession and drug seizure without arrest are two distinct practices and not directly comparable; however, given that statistics regarding the former are almost the only data used to assess the extent of depenalization, it is worth examining the potential discrepancy between the two to deepen our understanding of street-level drug law enforcement activities. For example, in 2019, VPD recommended 36 charges for simple possession to Crown Counsel [7]. In contrast, in our study, participants reported experiencing at least 35 drug seizures by police during the 6 months prior to their interview date between June and December 2019. The number of unique events was much higher than 35 given that a substantial portion of participants (approx. 45% of those who reported the number of occurrences of police seizure of drugs) experienced having their drugs seized more than once during the same 6-month period. These findings corroborate previous anecdotal reports [8] and show that drug seizure without arrest occurs more frequently than the VPD’s recommended charges for simple possession.

"Some negative consequences of criminal justice involvement may be avoided by police not recommending charges for simple possession. However, we found that more than two-thirds of PWUD who were interviewed in 2009–2012 obtained more drugs immediately after police seized their drugs. These findings suggest that this policing practice may still lead to health and safety harms for PWUD. For example a previous qualitative study that interviewed PWUD in 2017 described that police seizure of drugs inadvertently promoted the creation of drug debts and increased the risk of drug market violence among PWUD [11]. Some PWUD were also forced to refill their drug supply hastily from an unknown unregulated drug market worker especially when experiencing withdrawal [11, 25]. Each time an individual has to return to the unregulated market, especially if accessing drugs from an unknown source, they are increasing their risk of fatal or non-fatal overdose. In this regard, drug seizure essentially ‘mimics the health and safety harms associated with criminalization’ [15], undermining the intended benefits of the VPD’s depenalization policy. Of concern, a previous qualitative study reported that some police officers in BC believed that seizure of drugs is ‘beneficial for preventing harms, including overdose’, though it was not made clear whether it referred to VPD officers or other officers in BC or both [26]."

"In 2006, the Vancouver Police Department (VPD), the police force within the city of Vancouver in British Columbia (BC), Canada, formalized its drug policy and endorsed harm reduction as a core pillar of its strategy, alongside prevention, treatment, and law enforcement [5]. The policy encouraged the de facto depenalization of simple possession by restricting enforcement to circumstances where people are engaged in public drug use or other behaviour that the VPD believed may harm others [5], which would notably sustain roles for policing in the lives of PWUD. Similarly, in August 2020, the Public Prosecution Service of Canada released guidelines that direct prosecutors to limit the criminal prosecution of simple possession offences to the most serious manifestations of the offence (e.g. where there is a safety risk to others) [6]. Although the VPD’s published data are limited, available data indeed indicate low and declining levels of enforcement between 2016 and 2019, with recommended charges for simple possession having decreased by 67% from 109 to 36 cases [7].

"Despite VPD’s depenalization policy regarding simple possession, officers are still afforded broad enforcement discretion, including with respect to drug possession [5]. For example officers may use their ‘professional judgement’ to enforce drug seizures with or without making an arrest [5]. While anecdotal reports suggest that the police practice of drug seizure is commonplace and a driver of harm among people who use drugs (PWUD) [8], such discretionary practice is not fully captured in the VPD’s published data [9], limiting our understanding of how VPD’s policy of depenalization has been implemented at the street level."

"The study’s findings emphasize that although some participants expect decriminalization to result in positive outcomes and felt as though the 2.5g threshold was appropriate, the majority of participants foresaw a number of significant limitations due to the defined threshold quantity. Our findings offer insights into what those limitations are. This is in line with the research and consultation process that was conducted by BC’s Ministry of Mental Health and Addiction to inform the exemption request, and by the many advocates who continue to recommend a higher threshold limit that more accurately reflects people who use drugs’ substance use profiles in BC [20]. Participants in our study proposed a number of factors that may undermine the effectiveness of the 2.5g threshold, such as continued need to purchase substances in smaller quantities, which has the potential to be “stomped” or contaminated with other substances, thus potentially increasing overdose risk. Additionally, with a threshold limit so low, it could create a market for substances to become more adulterated, which could make them increasingly dangerous for people to use. As research in other jurisdictions has shown, drug policy interventions that target drug markets can have severe impacts on the safety of the drug market and can increase overdose risk and other harms for people who rely on it [28–30]. People in our study who relied on purchasing drugs in bulk suggested that the threshold could result in additional financial costs and increased overdose risk. As well, police discretion to arrest and charge above the 2.5g threshold could result in the unintended consequence of increasing drug-related arrests, such as through targeted search and seizures and increased surveillance of drug trafficking.

"The implementation and enforcement of the policy, and particularly the 2.5g threshold, will likely be of utmost importance when evaluating whether the policy is meeting its proposed objectives, as the threshold will be used to delineate between those who will be criminalized versus those who will not. Currently, there is no publicly available information regarding what types of information police will take into consideration when deciding what amount above the 2.5g threshold will be considered possession for personal use versus for trafficking purposes, and whether a criminal or health response will be taken. This therefore has significant implications for law enforcement who are tasked with enforcing the policy. Data from Australia suggest that based on individual drug use patterns, even when there are clear threshold limits for personal possession/use versus trafficking, some people who use drugs are still at risk of being criminalized for possession and/or trafficking if their personal use exceeds current thresholds [16]. Recognizing this, it has been suggested that in BC, the threshold should be considered a ‘floor’ not a ‘ceiling’ [19], meaning that people who possess over the 2.5 g threshold should not automatically be considered as carrying for trafficking purposes and that law enforcement should be guided by explicit direction to avoid criminalizing people who use drugs. Such a broad interpretation would recognize that people who use drugs who have varying patterns of use might need to possess over the 2.5g limit but would not necessarily be doing so for trafficking purposes."

"Our study also underscores the importance of recognizing the long history of uncertainty, punitive actions, and negative experiences with police among people who use drugs. Decriminalization in BC and implementation among police has important implications regarding building trust between people who use drugs, the community, and law enforcement. While there is the potential to reduce stigmatization and criminalization against people who use drugs, the discretionary power of law enforcement will play a large role in achieving these outcomes. Given the fear of police discretion and subsequent criminalization, the enforcement of the 2.5g threshold by police will be pivotal in reducing criminal penalties for people who use drugs in BC. Participants feared that some cities, particularly rural and remote or Northern and more isolated locations, would still experience criminalization for their drug use, and this was especially noted for marginalized and racialized populations and rural/remote communities. These sentiments have been noted in previous qualitative research on decriminalization where people who use drugs in Australia expressed concerns about how discretionary practices by police would impact the ways in which the policy is implemented, and called for clearly defined law enforcement measures to eliminate any discrepancies or grey areas in enforcement [31]. In Canada, previous reforms to drug policy, such as the Good Samaritan Drug Overdose Act, were ultimately undermined by a lack of knowledge and implementation among police, who continued to arrest individuals for possession despite the decriminalization of simple possession at overdose events [32, 33]. This policy had a number of shortcomings, such as ambiguity around police’s discretion when encountering people with drug paraphernalia on them or those who had outstanding warrants for their arrest, demonstrating the importance of recognizing the potential harms that shortsighted policies combined with continued use of police discretion may result in.

"Although study participants, people who use drugs and their allies have called for a more hands-off approach and an overall decentralization of police involvement in drug use, citing major concerns in relation to police use of discretion, as it stands, the policy and the 2.5g threshold will continue to be enforced by police [34]. Therefore, police knowledge on decriminalization and its goals, as well as training, will likely play a direct role in how police apply their discretion during enforcement of the policy. As part of the policy implementation plan, the BC MMHA have incorporated different phases of robust police training starting with Phase 1 in November 2022, and Phase 2 launching in Summer 2023 [35]. While the specifics of the training modules are not publicly available yet, the implementation paths allude to the importance and need for tailored and targeted police training measures. These training measures should incorporate awareness and education on different substance use practices and profiles that may criminalize people who use drugs who are polysubstance users, or who carry more than the allocated threshold because of location, tolerance, need, or accessibility. Frontline law enforcement officers must be made aware of established service pathways to be able to support people who use drugs, and adjunct health system improvements will need to be implemented to strengthen these connections and the capacity of services to provide support. Furthermore, under the MMHA plan, it is imperative that appropriate resources, training, and education are provided to inform police on how to engage with people who use drugs from different communities, guided by a public health and anti-stigma lens. If law enforcement officers are trained on how to identify different drugs, the ways in which drugs are commonly sold and packaged, and the various patterns of use among polysubstance users, then they may be able to exercise more appropriate discretion when applying the 2.5g threshold during an interaction with people who use drugs. As part of the policy, police will be mandated to provide resource cards with information on local health and social services to people who use drugs who request them, and provide referrals to these organizations upon request [35]. These connections will also be key to the policy’s objectives, and if done correctly and appropriately, can reduce stigma, and facilitate access to treatment or harm reduction services [36]. However, extant research suggests that even in situations where police have de-penalized simple possession, the ways in which this is enforced can vary and can result in significant inconsistencies, inequities, and harms, including net widening effects [37]."

"Among residents of a COVID-19 isolation hotel shelter for people experiencing homelessness, we found that an emergency, provisional safe supply program (i.e., prescribing pharmaceutical-grade medications and beverage-grade alcohol) was associated with low rates of adverse events and high rates of successful completion of the 14-day isolation period. No shelter residents experienced an overdose during their stay. We identified medication dosage ranges that generally fell within those recommended in “risk mitigation” prescribing guidelines, which were urgently produced in response to evolving risks of COVID-19."

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)."

"Regarding the potential for inconsistent application and enforcement of the 2.5g threshold, participants suggested that smaller, Northern, or isolated communities could be particularly vulnerable to police use of discretion, which could result in important jurisdictional disparities. For instance, many participants believed that police in rural and remote settings were more likely to criminalize and discriminate against people who use drugs. Additionally, participants suggested there may be stark differences in policing culture, ideologies, and practices between urban and rural police departments. Many participants proposed that police officers in larger, urban police departments, such as the Vancouver City Police Department (VPD), were more likely to ignore personal possession of small amounts of drugs compared to smaller or rural areas."

"Canada is in the midst of a devastating overdose crisis that has been further exacerbated by the COVID-19 pandemic and, in particular, the subsequent increased toxicity of the drug supply [1]. Between January 2016 and June 2022, close to 33,000 people died from an overdose in Canada, with the provinces of British Columbia, Ontario, and Alberta accounting for 88% of those deaths [2]. Fentanyl, and to a lesser extent fentanyl analogues, have contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses [2]. Between January and June 2022, fentanyl was detected in 76% of overdose deaths in Canada [2]. In Ontario, fentanyl is involved in 88% of fatal overdoses [3]. In Toronto, this number rises to 93% [3]."

"Scaling-up interventions such as naloxone distribution programs, supervised consumption services, and opioid agonist treatment have averted thousands of overdose-related deaths in Canada, but the persistent predominance of fentanyl in the unregulated drug supply continues to fuel overdose-related deaths [4]. To complement existing interventions, many have pointed out that providing an alternative to the unregulated toxic drug supply in the form of safer supply is critical to preventing overdose-related deaths and addressing the needs of people for whom current treatment models do not work or are not a good fit [5,6,7,8,9,10,11]. This approach builds on the premise that harms caused by the unregulated drug supply can be averted by providing access to a regulated drug supply [12].

"Over the past few years, there has been a rapid scale up of safer supply programs in Canada [13]. Ontario is home to a dozen safer supply programs where primary care physicians and/or nurse practitioners work with other health care and service providers to embed safer supply prescribing within a broader model of care and supports for clients with complex health and social needs [14]. At the time of the study, safer supply medications in this province consisted of take-home hydromorphone tablets and directly observed slow-release morphine tablets, dosed and titrated to meet clients’ needs. Some programs required both medications to be directly observed for high-risk clients, such as those who report high-volume alcohol consumption or benzodiazepine use. Early evidence suggests that clients enrolled in safer supply programs have significantly reduced emergency room visits and hospitalizations, improved health care engagement, fewer overdoses and overdose-related deaths, reduced drug-related harms, and improved health and social outcomes [14,15,16,17,18,19,20,21,22]."

"Safer supply programs are not designed or implemented with the explicit goal of changing injection practices. However, the experiences of clients and providers help us understand how a structural intervention, such as safer supply, can impact other aspects of IDU (e.g., frequency of injection) and its associated health risks (e.g., HIV, HCV, etc.). As Perlman and Jordan [37] point out, structural interventions are important because “structural factors contribute potently to creating the context that renders individuals and areas vulnerable to the syndemic of [overdose, HCV, and HIV]” (p.109). These interventions work upstream, to change the “risk environment” [38, 39], rather than solely focusing on mitigating the downstream consequences at the level of the individual. Our study findings suggest that changing the “risk environment,” by providing an alternative to the toxic drug supply, creates more opportunities for risk reduction. Changes in injection practices identified in this analysis offer a compelling example.

"Our findings suggest that clients enrolled in safer supply programs changed their injection practices in three intersecting ways: (1) they changed how often they injected, (2) they changed what they injected, and (3) they changed their mode of consumption (from injecting to swallowing or snorting). These findings add to existing research [16,17,18] by providing a more dynamic understanding of injection practices in the context of safer supply programs and further supporting the idea that safer supply can contribute to reducing injection-related health risks in addition to overdose risks [40]. We posit that safer supply programs have the potential to address disease prevention and health promotion gaps that other stand-alone downstream harm reduction interventions (e.g., needle and syringe programs) cannot address, by working upstream and providing a safer alternative to fentanyl. As Rhodes [38] reminds us, harm reduction interventions such as needle and syringe exchange programs are crucial, but their effectiveness at preventing injection-related health risks can be undermined by a particular “risk environment.” For example, if a particular shift in the drug supply results in people injecting more frequently, such is the case with fentanyl, an HIV outbreakFootnote1 could occur even in jurisdictions where needle and syringe exchange programs are available [38].

"It is important to note, however, that not all changes in injection practices could be attributed directly to safer supply programs. We identified several indirect factors, such as poor venous access and having to inject hydromorphone tablets not intended for intravenous administration (for more on this, see study by Ivsins and colleages [17] and guidance by the British Columbia Centre on Substance Use [42]), which shaped the decision to stop injecting. Having the option of taking safer supply medications orally made this decision possible, but it is unclear if all clients who stopped injecting would have done so if they had access to a range of injectable safer supply medications and/or had better venous access. Moreover, it is unclear to what extent clients continued to inject because the safer supply medications dosage/potency was not meeting their needs, as suggested by clients who spoke of the need to supplement with fentanyl, and/or because they wanted to continue injecting. Future research should aim at exploring these nuances because safer supply programs are not intended as interventions to stop clients from injecting. If clients want to inject, they should be able to do so and access injectable safer supply medications (including injectable hydromorphone) as well as sterile supplies and supervised safer consumption services—a priority echoed in a recent report on substance use patterns and safer supply preferences of PWUD in British Colombia [43]."

"Among those who used cannabis, 17.7% (representing about 420,000 Canadians or 1.6% of the Canadian population aged 15 years and older) reported doing so for medical purposes. Prevalence of use for medical purposes was similar between male and female cannabis users (17.3% versus 18.4%, respectively), while more than one in five (21.8%) cannabis users aged 25 years and older reported using it for medical purposes, representing 1.5% of all adults in this age group. The percentage of youth who used cannabis for medical purposes is not reportable.
"Half (49.7%) of those who used cannabis for medical purposes did so mainly for chronic pain caused by conditions such as arthritis, back pain and migraines, while the remaining 50.3% used cannabis primarily for one of a variety of conditions that included insomnia, depression and anxiety. These numbers do not in any way measure or reflect enrolment in the federal Medical Marijuana Access Program."

"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."

"In 2012, 78.4% of Canadians reported drinking alcohol in the past year, a rate similar to that reported in 2011 (78.0%). There was, however, a decrease in past-year alcohol use among youth 15 to 24 years of age compared to CAS in 2004, from 82.9% to 70.0% in 2012. Similar to previous years, in 2012, a higher percentage of males than females reported past-year alcohol use (82.7% versus 74.4%, respectively) while the prevalence of past-year drinking among adults aged 25 years and older (80.0%) was higher than among youth (70.0%).
"Provincial rates of current drinking ranged from 72.3% in Nova Scotia to 82.1% in Quebec. Each province’s past-year alcohol prevalence was compared with the average for the nine remaining provinces. Three provinces had lower than average prevalence (Nova Scotia, New Brunswick (73.8%) and Prince Edward Island (74.0%)) while the prevalence of past-year alcohol use in Quebec was higher than average. Prevalence of past-year alcohol use since 2011 was unchanged for all provinces."

"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."

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)."

"In 2009, Canadian law enforcement seized a total of 34,391 kilograms (kg) of marihuana and 1,845,734 marihuana plants. These figures, which have remained relatively unchanged from 2008 and coupled with steady street prices in 2009, indicated an apparently stable marihuana market. As in 2008, the majority of marihuana seized was domestically produced, yet the drug continued to be imported from Jamaica, the United States, the Netherlands, and Thailand."

"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."

"In 2009, an abundant supply of Canadian-produced MDMA continued to meet domestic consumption requirements, as well as provide significant quantities for international markets.⁴⁰ Domestic prices for MDMA remained at the record low levels from 2008, while purity levels of the drug remained high, or even may have increased. The nature or extent of MDMA production in Canada appeared to be unaffected by the significant shortage in the supply of MDP2P, that reportedly impacted European markets. In Europe, the shortage resulted in a decline in Ecstasy seizures and in the number of seizures of laboratories, storage, and dump sites related to large-scale MDMA production.
"Cross-border MDMA smuggling from Canada to the United States, the primary foreign market for Canadian-produced MDMA, significantly increased from 2008. As in previous years, smuggling activity at or between ports of entry (POEs) was reported in the provinces of British Columbia, Ontario, and Quebec.⁴¹ For example, a record amount of 2.6 million dosage unit equivalents confirmed as MDMA were seized in the Pacific region in 2009. However, there was also smuggling activity across the Canada-U.S. border in other provinces, such as Manitoba.⁴²"

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."

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."

"Seventeen percent (17%) of inmates reported recently injecting drugs. A substantial proportion of these inmates increased their risk of acquiring a blood-borne infection (BBI) by using someone else’s used injecting equipment (see Table 4 for gender-specific estimates). Of those who recently injected drugs, 37% of inmates reported sharing a needle with a person with a positive or unknown BBI status and 42% reported using someone else’s works after they had used them. Additionally, men were more likely than women to report using someone else’s used needle, 55% vs. 41%, ?2 (1, n=438) = 6.22, p < 0.05 and sharing works with a person with a positive or unknown BBI status, 33% vs. 23%, ?2 (1, n=397) = 4.40, p < 0.05."

CONCLUSIONS
"1. Heroin-assisted therapy proved to be a safe and highly effective treatment for people with chronic, treatment-refractory heroin addiction. Marked improvements were observed including decreased use of illicit “street” heroin, decreased criminal activity, decreased money spent on drugs, and improved physical and psychological health.
"2. The NAOMI trial attracted the most chronic and marginalized heroin users who were outside the treatment system and continued to use heroin despite numerous previous treatment attempts. Both heroin-assisted therapy and optimized methadone maintenance treatment achieved high retention rates and remarkable response rates in this difficult-to-treat group.
"3. Contrary to pre-existing concerns, the treatment clinics appeared to have no negative impacts on the surrounding neighbourhoods.
"4. Participants on hydromorphone did not distinguish this drug from heroin. Moreover, hydromorphone appeared to be equally effective as heroin although the study was not designed to test this conclusively. If this were proven to be true, hydromorphone-assisted therapy could offer legal, political and logistical advantages over heroin and could be made more widely available."

"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%)."

"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."

"Overall, 87% of inmates who recently injected drugs in a penitentiary reported opiates as one of their three most used drugs. Although the number of inmates who reported injecting only non-opiate drugs was small, comparisons between this group and opiate users suggests that injecting opiates may be associated with the use of someone else’s used equipment (see Table 9). Inmates who recently injected opiates were more likely, than those who recently injected non-opiates, to use someone else’s used needle, 81% vs. 48%, ?2 (1, n=251) = 13.92, p < 0.05, and works, 59% vs. 36%, ?2 (1, n=236) = 3.98, p < 0.05."

"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%)."

"Although estimates of the number of new HIV infections are uncertain, the number of new infections in 2011 was estimated at 3,175 (range between 2,250 and 4,100) which was about the same as or slightly fewer than the estimate in 2008 (3,335; range of 2,370 to 4,300) (Table 2, Figure 2). In terms of exposure category, MSM continued to comprise the greatest proportion (46.6%) of new infections in 2011, which was slightly higher than the proportion they comprised in 2008 (44.1%). In 2011, the proportion of new infections among IDU was lower than in 2008 (13.7% compared to 16.9%). The proportion of new infections attributed to the heterosexual/non-endemic and heterosexual/endemic exposure categories were about the same in 2011 compared to 2008 (20.3% vs 20.1% and 16.9% vs 16.2%, respectively) (Figure 3)."

"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."

"We detected no reduction in druguse frequency or drug price in response to a large-scale police crackdown on drug users in Vancouver's DTES. The evidence that drugs became more difficult to obtain was consistent with reports of displacement of drug dealers and was supported by the significantly higher rates of reporting that police presence had affected where drugs were used, including changes in neighbourhood and increases in use in public places. These observations were validated by examination of needle-exchange statistics.

"Our findings are consistent with those showing that demand for illicit drugs enables the illicit drug market to adapt to and overcome enforcement-related constraints. Although evidence suggested that police presence made it more difficult to obtain drugs, this appeared to be explained by displacement of drug dealers."

"Diacetylmorphine was found to be a dominant strategy over methadone maintenance treatment in each time horizon studied (Table 2). Over a lifetime horizon, people in the methadone cohort lived 14.54 years on average following entry into the model, spending 8.79 years (60% of their remaining life) in treatment and 5.52 years in relapse. They accumulated 7.46 discounted QALYs and generated a societal cost of $1.14 million. People in the diacetylmorphine cohort lived 15.45 years on average, spending 10.41 years (67% of their remaining life) in treatment (2.34 years of which was in post-diacetylmorphine methadone treatment) and 4.05 years in relapse. They accumulated 7.92 discounted QALYs and generated a societal cost of $1.10 million. Based on these findings in the baseline model, over a lifetime horizon the provision of diacetylmorphine in the hypothetical cohort provided greater incremental health benefits and reduced the total costs to society compared with methadone maintenance treatment."

"The present study determined participants’ satisfaction with received treatments in the first North American RCT [Randomized Controlled Trial] to provide injectable diacetylmorphine or hydromorphone compared to oral methadone for the treatment of long-term, treatment resistant, opioiddependency. At 3 and 12 months, participants were satisfied with the treatment received during the study period, although satisfaction was greater for those randomized to receive injectable treatments. At 3 months, participants who reported that the program met their needs were more likely to be retained at 12 months. To our knowledge this is the first study to assess treatment satisfaction among participants receiving supervised injectable diacetylmorphine or hydromorphone.

"Regardless of the outcome of the randomization, participants in the trial were highly satisfied with the treatment received. This follows previous studies which have consistently found that patients tend to report high levels of treatment satisfaction, including community health services [45], services for mental health [13], addiction [46], and opioid dependence [20]."

Harm Reduction

"At the time of the survey, 7% of all inmates reported being on MMTP. An additional 9% of all inmates reported not being on the program but previously trying to get on it at CSC. The remaining 84% of inmates reported never trying to join the program (63%), never using drugs (20%), and no longer needing the program (<1%).
"Participation in MMTP was associated with drug use in penitentiaries. Of inmates who were on MMTP, 60% reported not using opiates recently in a penitentiary; however, 40% did (see Table 10). Similarly, of those who were not on CSC’s MMTP but had tried to get on the program, almost equal proportions reported no drug use in a penitentiary (45%) and recent opiate use a penitentiary (44%). Conversely, the majority of inmates who never tried to get on MMTP at CSC reported no recent opiate use in a penitentiary (87%) and a minority (12%) reported recent opiate use in a penitentiary."

"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."

"In the present analysis we found that overdose events were not uncommon at the Vancouver safer injection facility. During an 18-month period, 285 individuals accounted for 336 overdose events, yielding an overdose rate of 1.33 (95% CI: 0.0–3.6) overdoses per 1000 injections. Heroin was involved in approximately 70% of all overdoses, and opiates considered together were involved in 88%of overdoses. It is notable, however, that approximately one-third of overdoses involved stimulants. The most common indicators of overdose were depressed respiration, limp body, face turning blue, and a failure to respond to pain stimulus. The majority of overdoses were successfully managed in the SIF, with the most common overdose interventions undertaken by SIF staff involving the administration of oxygen, a call for ambulance support, and the administration of naloxone hydrochloride via injection. Among a randomly selected sample of SIF users, factors associated with time to overdose at the SIF included fewer years injecting, daily heroin use, and having a history of overdose. None of the overdose events occurring at the SIF resulted in a fatality."

"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."

"Among IDU [Injection Drug Users] who attended Vancouver’s supervised injecting facility, regular use of the SIF and having contact with counselors at the SIF were associated with entry into addiction treatment, and enrollment in addiction treatment programs was positively associated with injection cessation. Although SIF in other settings have been evaluated based on wide range of outcomes (Dolan et al., 2000; Kimber et al., 2003; MSIC Evaluation Committee, 2003), our study is the first to consider the potential role of SIF in supporting injection cessation. While our study is unique, our findings build on previous international analyses demonstrating a link between SIF attendance and entry into detoxification programs (Wood et al., 2006; Wood et al., 2007a; Kimber et al., 2008).

"A postulated benefit of SIF is that, by providing a sanctioned space for illicit drug use, a hidden population of IDU can be drawn into a healthcare setting so that service delivery can be improved. The present study provides additional evidence that SIF appear to promote utilization of addiction services and builds on past evaluations to demonstrate that, through this mechanism, they may also lead to increased injecting cessation. While these findings are encouraging, it is concerning that Aboriginal participants were less likely to enter addiction treatment. This finding is consistent with prior reports (Wood et al., 2005a; Wood et al., 2007b), and highlights the need for innovative and culturally appropriate addiction treatment services developed with full consultation with Aboriginal people who use drugs."

"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)."

Economics

"Measured in terms of the burden on services such as health care and law enforcement, and the loss of productivity in the workplace or at home resulting from premature death and disability, the overall social cost of substance abuse in Canada in 2002 was estimated to be $39.8 billion. This estimate is broken down into four major categories in Figure 1. This overall estimate represents a cost of $1,267 to every man, woman and child in Canada, as indicated according to substance in Figure 2.
"Tobacco accounted for about $17 billion or 42.7% of that total estimate, alcohol accounted for about $14.6 billion (36.6%) and illegal drugs for about $8.2 billion (20.7%) (see Table 2).
"Productivity losses amounted to $24.3 billion or 61% of the total, while health care costs were $8.8 billion (22.1%). The third highest contributor to total substance-related costs was law enforcement with a cost of $5.4 billion or 13.6% of the total."

"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)."

Laws & Policies

"The National Anti-Drug Strategy is a horizontal initiative of 12 federal departments and agencies, led by the Department of Justice, with new and reoriented funding4 covering activities over a five-year period from 2007/08 to 2011/12. The goal of the Strategy is to contribute to safer and healthier communities through coordinated efforts to prevent use, treat dependency, and reduce production and distribution of illicit drugs. Illicit drugs are defined in the Controlled Drugs and Substances Act (CDSA) to include opiates, cocaine and cannabis-related substances (including marihuana) as well as synthetic drugs such as ecstasy and methamphetamine. The Strategy encompasses three action plans: Prevention, Treatment and Enforcement:
"• The objectives of the Prevention Action Plan are to prevent youth from using illicit drugs by enhancing their awareness and understanding of the harmful social and health effects of illicit drug use; and to develop and implement community-based interventions and initiatives to prevent illicit drug use.
"• The objective of the Treatment Action Plan is to support effective treatment and rehabilitation systems and services by developing and implementing innovative and collaborative approaches.
"• The objective of the Enforcement Action Plan is to contribute to the disruption of illicit drug operations in a safe manner, particularly targeting criminal organizations.
"The Strategy‘s action plans are expected to contribute to a reduction in the supply of, and demand for, illicit drugs, which ultimately contributes to safer and healthier communities."

"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)."

"Our analyses suggest that public perceptions of the relative seriousness of substance abuse problems are incongruent with the actual costs they impose on Canadian society. In particular, the total social costs associated with alcohol are more than twice those for all other illicit drugs in 2002, yet the public consistently rated the overall seriousness of illicit drugs as higher at the national, provincial and local levels in the Canadian Addiction Survey (2004). Interpreting these findings it is possible to suggest that perceptions of the seriousness of illicit drugs are relatively amplified while perceptions of the seriousness of problems associated with alcohol are relatively attenuated in Canadian society."

"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."

The Canadian government in 2001 established regulations to expand the use of marijuana as a medicine. According to an editorial in the Canadian Medical Association Journal, "The new regulations promise more transparency in the review of applications to grow or possess medicinal marijuana, a broader definition of medical necessity, and greater latitude for physicians in determining the needs of individual patients."

"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."

"In 2006, the province of Alberta passed the Drug Endangered Child Act,¹⁷ which authorized the state (child welfare authorities or the police) to seize children from drugproducing homes, even if based on suspicion alone.¹⁸ Often these children, and even the parents, might not know about the drugs. More troubling is that there may not even be illicit substances present, but rather the chemicals used to create such substances, and this may be deemed sufficient for apprehension of the children. To add to the equation, the Motherisk Laboratory at the Hospital for Sick Children receives hair samples to be analyzed for drugs of abuse from thousands of parents implicated in child-protection matters each year from across the country, and they are analyzed for drugs of abuse. Based on consultations with child protection workers or the respective authorities, children are rarely removed from drug-using parents’ care until substantial evidence of child safety issues is built. Among our cohort of children presented here, however, the majority of the parents were not known to be using illicit substances themselves and, on the basis of our clinical assessments, appear to be able to parent their children adequately. It is not likely that the production of drugs, particularly marijuana, hinders effective parenting much more than actual drug use, yet the differences in the ways these cases are handled suggest that police and child protection agencies perceive the former to be of greater concern with respect to child safety than the latter."

"Heroin prescription is consistent with a number of state responsibilities under international human rights instruments. The Universal Declaration of Human Rights states that 'everyone has the right to a standard of living adequate for the health and wellbeing of himself … including … medical care and necessary social services.'²⁴ Similarly, the International Convention on Economic, Social and Cultural Rights (ICESCR) recognizes the 'right of everyone to the highest attainable standard of physical and mental health.'²⁵ The UNAIDS/OHCHR International Guidelines on HIV/AIDS and Human Rights recommend that states ensure the 'widespread availability of qualitative prevention measures and services, adequate HIV prevention and care information' in order to protect the human rights of people living with HIV/AIDS and stem the spread of the virus." [Note: Ellipses used in source document.]

"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."

"Public health oriented regulation has much potential to reduce the health, social and fiscal harms associated with all psychoactive substances.
"In addition, public health oriented regulation is supportive of Canadians human rights as established by the pre-eminence of the Charter of Rights and Freedoms 7 i.e. the “right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.” (section 7), “subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society” (section 1)."

"... 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."

"Our analysis showed that the implementation of a province-wide centralized prescription network was associated with large, immediate and sustained reductions in filled prescriptions for opioid analgesics and benzodiazepines deemed inappropriate by our definition. These findings provide empirical evidence that centralized prescription networks can reduce inappropriate prescribing and dispensing of prescriptions by offering health care professionals real-time access to prescription data. Physicians did not have access to PharmaNet when it was first introduced; consequently, the reductions observed in our study likely reflect the availability of real-time prescription information to front-line pharmacists."

"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."

"The North American Opiate Medication Initiative (NAOMI) is a carefully controlled (clinical trial) that will test whether medically prescribed heroin can successfully attract and retain street-heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs.

"The NAOMI study will enroll 470 participants at three sites in Vancouver, Montreal and Toronto. The Toronto and Montreal sites are expected to begin recruitment this spring.

"Each site will enroll about 157 participants. About half of these volunteers will be assigned to receive pharmaceutical-grade heroin (the experimental group) and half will receive methadone (the control group). The prescribed heroin will be self-administered under careful medical supervision within a specially designed clinic. Those in the heroin group will be treated for 12 months then transitioned, over three months, into either methadone-maintenance therapy or another treatment program. The researchers expect a 6-9 month recruitment period, so that the total time to complete the study will be 21 to 24 months."

"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 Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) is a clinical study that tests alternative treatments for people with chronic heroin addiction who are not benefiting sufficiently from available treatments such as oral methadone.

"SALOME compared two medications – diacetylmorphine, the active ingredient of heroin, and hydromorphone (HDM), a legal, licensed pain medication.

"Studies in Canada and Europe have demonstrated that treatment with diacetylmorphine is more effective than oral methadone for some of the most vulnerable heroin users. HDM has now been shown to be as good as diacetylmorphine and should now become an alternative for those currently not benefitting from methadone and other treatments, and be integrated in the treatment continuum available through licensed doctors."

"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."

"Since its inception, Insite has been subject to an independent review by a team of physicians and scientists put in place to provide an 'arm’s length' evaluation of the program. The results of this scientific evaluation have been published in peer-reviewed academic journals and have indicated that Insite has reduced unsafe injection practices, public disorder, overdose deaths and HIV/Hepatitis while increasing uptake of addiction services and detox [8]. To date, there have been over three-dozen peer-reviewed papers evaluating Insite published making it one of the most evaluated healthcare programs in the history of Canada [9-38]. In light of the evidence, the program has garnered widespread support from Canadian physicians, scientists and healthcare professionals."

"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."

"The British Columbia Centre for Excellence in HIV/AIDS was commissioned to evaluate Insite. A study published in 2006 showed that there was an increase in uptake of detoxification services and addiction treatment.¹³ Another study published that year showed that Insite did not result in increased relapse among former drug users, nor was it a negative influence on those seeking to stop drug use.¹⁴ Results of studies using mathematical modelling showed that about one death from overdose was averted per year by Insite.¹ A subsequent study estimated 2–12 deaths averted per year.¹⁵ Although these studies did not have sufficient power to detect any difference in incidence of blood-borne infections, Kerr and colleagues did find that Insite users were 70% less likely to report needle-sharing than those who did not use the facility.¹⁶ Before the opening of Insite, those same individuals reported needle-sharing that was on par with cohort averages. As for public order, Wood and colleagues found that there was no increase in crime following the opening of the facility.¹⁷ In fact, there had been statistically significant decreases in vehicle break-ins and theft, as well as decreases in injecting in public places and injection-related litter."

(Reduced Overdose Mortality) "In this population-based analysis, we showed that overdose mortality was reduced after the opening of a SIF [supervised injecting facility]. Reductions in overdose rates were most evident within the close vicinity of the facility—a 35% reduction in mortality was noted within 500 m of the facility after its opening. By contrast, overdose deaths in other areas of the city during the same period declined by only 9%. Consistent with earlier evidence showing that SIFs are not associated with increased drug injecting (panel),38,39 these findings indicate that such facilities are safe and e!ective public-health interventions, and should therefore be considered in settings with a high burden of overdose related to injection drug use."

"The present study demonstrates that the opening of the Vancouver SIF was associated with a greater than 30% increase in the rate of detoxification service use among SIF users in comparison to the year prior to the SIF's opening. Subsequent analyses demonstrated that detoxification service use was associated with increased use of methadone and other forms of addiction treatment, as well as reduced injecting at the 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."

"In this population-based analysis, we showed that overdose mortality was reduced after the opening of a SIF. Reductions in overdose rates were most evident within the close vicinity of the facility—a 35% reduction in mortality was noted within 500 m of the facility after its opening. By contrast, overdose deaths in other areas of the city during the same period declined by only 9%. Consistent with earlier evidence showing that SIFs are not associated with increased drug injecting (panel),^38,39 these findings indicate that such facilities are safe and effective public-health interventions, and should therefore be considered in settings with a high burden of overdose related to injection drug use.

"In both the primary and sensitivity analyses, we saw no significant reductions in overdose mortality further than 500 m from the SIF. This finding is not surprising, since over 70% of frequent SIF users reported living within four blocks of the facility. Although the facility operates at capacity with over 500 supervised injections per day on average,²³ it is a pilot programme with only 12 injection seats in a neighbourhood with about 5000 injection drug users.⁴⁰ Therefore, and since previous studies have shown that waiting times and travel distance to the facility are barriers to SIF use,⁴¹ larger reductions in community overdose mortality would probably require an expansion of SIF coverage."

"Although there was a substantial increase in the number of participants who started smoking crack cocaine, it is unlikely that the facility, which does not allow smoking in the facility, prompted this change. These findings are relevant to a recent review of supervised injection facilities by the European Monitoring Centre on Drugs and Drug Addiction, which highlighted concerns that these facilities could potentially 'encourage increased levels of drug use' and 'make drug use more acceptable and comfortable, thus delaying initiation into treatment.'"