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HSCI 214 > Chapter 9 (Lecture) > Flashcards

Chapter 9 (Lecture) Flashcards

1
Q

harm from different substances

A

Key question for public policy: how serious is the risk of harm resulting from use of different substances?
- implicit assumption in policy - drugs that are more risky or harmful require more control and monitoring
- remember: the goal of making some drugs illegal is to protect health and make society safer

international drug control conventions are based expert committee recommendations regarding a drugs liability to abuse (constituting) a risk to public health
- regulation differentiated by degree of risk fro social and health problems/harms
UK - class A, B, C (more severe to less severe penalties

Numerous attempts by researchers to characterise substances in terms of relative potential for harm including consideration of modifying factors (route of administration, context of use) that may increase/decrease risk

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2
Q

One approach by Hall

A

Comparing severity of health effects for heavy users (regular, sustained use) of different substances in their most harmful common form
- alcohol has greatest potential for harm
- tobacco, heroin, and marijuana have fever direct adverse health effects
- dependence potential is one criteria in this, and represents a mental health harm/outcomes
- legal substances have significant health harms and dependence potential, cannabis less so

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3
Q

safety ratio and overdose potential

A

Another dimension is the likelihood of an overdose, based on estimates of a safety ratio - based on dose
- most toxic substances (e.g. Heroin, GHB): were determined to have a lethal dose less than ten times the dose most commonly used for non-medical purposes of different substances

Formula: BLANK times regular dose produces overdose (or acute effect), focus on pharmacological effects
- heroin via injection had a safety ratio of 5 (5 x regular dose)
- oral stimulants and for alcohol had a safety ratio of 10
- intranasal cocaine 15
- MDMA was 16
- cannabis via smoking was over 1000

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4
Q

Margin of Exposure (MoE) paradigm

A

ratio of the toxicological threshold (benchmark dose) and estimated human intake dosage

  • for tolerant users, daily alcohol use fell in the highest risk category of MoE < 10
  • only diazapem and THC were outside the medium risk category with MoE above 100
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5
Q

Dependence potential

A

Propensity of a substance to result in dependence
- expressed as a drugs capture ratio - the proportion of users who develop dependence on that substance
- Heroin and methamphetamine were rated to have the highest dependence potential
- followed by cocaine, pentobarbital, nicotine, and alcohol

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6
Q

capture ratio - rose and cherptiel 200

A

Capture ratio = % of consumers that become dependent

Highest is nicotine, followed by:
- heroin
- crack cocaine
- powder cocaine
- alcohol
- amphetamine
- prescription opioids
- cannabis
- psychedelics
- inhalants

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7
Q

relative addictiveness 1994

A

2 different sets of rating (Henningfield and benowitz)
- based on withdrawal, tolerance, reinforcement, dependence and intoxication
- 1 is most serious, 6 is least serious

Henningfield ratings:
- heroin 1.8
- alcohol 2.4
- cocaine and nicotine 3.0
- caffeine and cannabis 5.4

Benowitz ratings:
- heroin 2.0
- cocaine 2.2
- alcohol 2.6
- nicotine 3.6
- caffeine 4.4
- cannabis 5.4

Average of both researchers:
- heroin 1.9
- alcohol 2.5
- cocaine 2.6
- nicotine 3.3
- caffeine 4.9
- cannabis 5.3

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8
Q

Trajectories of substance use

A

curiosity/social pressure –> experimentation w drugs
leads to either dysphoria or euphoria (many people stop here)
the leads to problematic use (a cycle) tolerance/dependence + elevated doses, decreased euphoria and increased dysphoria, withdrawal, either recovery or relapse, elevated use, repeat

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9
Q

problematic use is affected by?

A
  • genetic and environmental factors
  • stress
  • conditioning
  • more
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10
Q

what is dysphoria?

A

A profound state of unease or dissatisfaction. It is the semantic opposite of euphoria. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation

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11
Q

Nutt and colleagues (2010) led a comprehensive attempt to estimate the harm associated with the full range of psychoactive substances based on expert ratings of 16 different harm criteria including:

A
  • physical damage
  • the tendency of the drug to induce dependence (harm to the individual)
  • the effect of drug use on families, communities, and society (harm to others)

Studies found (worst overall harm to least - top 6 + cannabis)
1. alcohol - more harm to others but still harm to self
2. heroin - lower harm to other high harm to self
3. crack cocaine - a little lower harm to others, higher harm to self
4. methampetamine - really little harm to other, high harm to self
5. cocaine - slightly higher harm to others than #4, a little less harm to self than #4
6. tobacco - higher harm to others than #5, lower harm to self than #5
- Cannabis is #7, equal ish to #6 in harm to others, lower harm to self than #6

These ratings highlight limitations of conventional classification of drugs into high, medium, and low categories of harm sued as the basis for criminal penalties, policing, prevention, and treatment programs
Key inconsistencies:
- most harmful drug is legal and widely available
- some less harmful drugs are illegal or subject to strict penalites

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12
Q

Overall Harm of substances

A

divides into user and others

Users:
Physical - drug-specific and drug-related mortality and damage
Psychological - dependence, drug-specific and drug-related impairment of mental functioning
Social - loss of tangibles, loss of relationships

Others:
Physical and psychological - injury
Social - crime, environmental damage, family adversities, international damage, economic cost, community

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13
Q

Another examination (van Amsterdam 2015)

A

Based on an expert panel method assessed the harm of 20 drugs from an EU perspective
- used methods similar to Nutt 2010, but included specific information about local factors

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14
Q

Agreement between the different ranking (Nutt 2010 and van Amsterdam 2015)

A
  • heroin, cocaine, tobacco, and alcohol are rated to produce more harm
  • khat and betel nut (two plant-based stimulants) and cannabis are ranked to be less harmful
  • note: there are critiques of aggregate ratings of this type
  • these ratings do not compare the overall levels of harm from different drugs in a population, which relates to prevalence and volumes of use in the population
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15
Q

Population level dynamics and prevalence of use

A

Harm due to substance use has been calculated by epidemiologists according to the prevalence of use of a substance, as well as the relative risks associated with its use
- even substances with relatively lower risk to the average user can create considerable harm if they are used with higher prevalence
- although cannabis has a lower risk for dependence, because its use prevalence is much higher than cocaine in most countries, there are more people with cannabis dependence than with cocaine dependence

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16
Q

Drug Harms

A

Rating systems estimating risk or harm indicate that legal substances (alcohol, tobacco) are at least as dangerous as many illegal substances (perhaps more)
- risks associated with each substance vary according to the drugs health effects, safety ration, intoxicating effect, general toxicity, social dangerousness, dependence potential, environment/context of use, and social stigma

Its complex!
- chemical properties of a substance are only one factor among many that determines the potential for harm
- drug policy should reflect the social and pharmacological complexities of substances and the relative difference among them

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17
Q

TedTalk by Guy Felicella - WATCH IT

A

Giving people perspective from a lived experience that no matter what the odds are against an individual struggling in addiction, people do get better. People do get their lives and families back and do become productive members of society. When we remove the stigma of addiction and harm reduction and look at the individual with compassion, amazing things can happen!

Harm reduction: very broad, simply risk reduction in relation to a medical condition (blood pressure, diabetes …. everyone supports this)

Why is harm reduction for people who use drugs seen differently?
What was his example of a “mainstream” supervised consumption facility for society’s most popular accessible drug?
How does stigma influence the situation we see with the opioid crisis?
What model of addiction does he advocate for or subscribe to? How can you tell?
Why is OAT or methadone beneficial for people w opioid dependence or opioid use disorder?
What is he arguing for?

18
Q

Dr. Gabor Mate on addiction - WATCH THIS

A

What does he say is the cause of addiction, and what is the cure?
What model of addiction does he advocate for or draw on?
Does he take a constructivist or positivist view when considering addiction?

19
Q

Responses to addiction

A
  • internationally governments have largely applied a criminal justice approach to the problem of drug use, which may undermine medical or therapeutic approaches by marginalising, criminalising, and stigmatising people who use drugs (PWUD)
    The War on Drugs, attempted to end the international trade in drugs by directing military and police resources towards eliminating trade and consumption of drugs
  • although this has been a decades-long and expensive endeavour, there is little evidence that it has met its objectives: drug use remains widespread and drugs are available
  • extensive unintended consequences and harm stem from prohibition
20
Q

Criminalisation

A

Criminalisation of some psychoactive drugs and people who use drugs
- debate regarding how effectively this reduces illicit drug use

Produces many unintended consequences
- constrains opportunities for regulation measures due to prohibition and unregulated markets (key policy approaches we use with alcohol are not available)
- interferes with provision of risk-reduction efforts, including evidence-based HIV/AIDS prevention and treatment of BBV
- drives many harms stemming from illicit drugs, including transmission of HIV and other blood-borne viruses
- marginalisation and stigma reduce engagement with the healthcare system, leading to poor care experiences, and barriers to treatment

21
Q

Global Drug Prohibition

A

Globally the primary response to drug use is prohibition and criminalisation (although this is shifting in some jurisdictions)
Predominance of prohibition and criminalisation is reflected in:
- international drug control treaties
- national approaches to drug use which make most drugs illegal and prescribe punishments for trafficking and possession: controlled drugs and substances act (CDSA) in Canada
- the relatively small number of countries that have pursued large scale decriminalisation and regulation (e.g., Portugal)

22
Q

Order - Public order-based response to drugs

A
  • possession of certain substances is a crime, people caught using drugs are arrested (on possession charges)

Assumptions:
- prohibition and drug law enforcement can reduce drug use through deterrence and punishment
- people who use drugs should be arrested and incarcerated to punish and prevent drug use

23
Q

Order - criminalisation of drugs and people who use drugs result in:

A
  • encounters with police (arrests, stop & frisk, crackdowns)
  • violence in drug markets and among PWUD/dealers due to lack of market regulations, and dispute resolution mechanisms
  • contaminated drug supply in unregulated market: drugs of unknown purity and composition are the norm (fentanyl poisoning)
  • extensive engagement in criminal justice system (repeated incarceration: “revolving door”)
  • marginalisation and stigmatisation: reduce engagement with healthcare system, and potential to access treatment
  • high levels of incarceration for non-violent drug offences
  • organised crime and profits related to illegal drugs, which generate no tax
24
Q

The dominant societal response to drug use is arrest and incarceration with limited emphasis on rehabilitation

This impacts people who inject drugs (PWID) particularly heavily

A
  • imprisonment is common among PWID
  • > 75% of PWID in Vancouver have ever been incarcerated
  • 60-90% in five European cities
  • 74% of men on MMT in NYC
  • 55.2% of PWID in Thailand within a treatment sample
25
Q

Incarceration

A

Assumption: incarceration will enforce abstinence, deter drug use, rehabilitate PWUD

Drug use continues behind bars:
- in prison drug use reported globally
- approx 12% of random urinalysis tests positive for opiates, cocaine, cannabis or alcohol in Canadian federal penitentiaries
- 11% of injectors reported injecting in custody in the past year in six Ontario prisons

Frequency and amount of use may be reduced, but there are greater risks due to lack of harm-reduction programs in most prisons

26
Q

Supply Control Interventions

A
  • key component of drug prohibition efforts

Goal: eliminate or reduce the availability of illicit substances by seizing drugs and disrupting supply chains and trafficking organisations

27
Q

The temporal relationship between drug supply indicators: an audit of international government surveillance systems

A

UN estimates global illegal drug trade is worth at least $350 billion USD annually

Most national drug control strategies prioritises law enforcement to reduce drug supply
- lack of evaluation of this approach
- need to systematically assess illegal drug supply over the long term

Longitudinal examination indicates a general pattern of:
- falling drug prices
- increasing drug purity and potency
- relatively consistent pattern of increasing seizures

These data highlight the need to re-examine the effectiveness of national and international drug policies emphasising supply reduction over evidence-based prevention and treatment

28
Q

What is harm reduction?

A

Policies, programmes and practices that aim primarily to reduce the adverse health, social, and economic consequences of the use of illegal psychoactive drugs without necessarily reducing drug consumption

29
Q

Other responses to addiction - harm reduction

A
  • the goal of harm reduction is to minimise the harmful effects of substance use without requiring abstinence from people with addiction
  • examples include: syringe exchange programs, safer injection facilities, managed alcohol programs, and overdose prevention kits (naloxone) - these programs are effective in reduction drug-related harm (HIV transmission, fatal overdoses) and connecting PWUD to care, services, and treatment
  • these programs are often controversial, as many prefer a punitive approach to addiction and drug use
  • proponents of the abstinence model and 12-step treatment are highly critical of harm reduction, stating it only perpetuates drug use
  • pragmatic interventions targeted at specific risks and harms in specific contexts
  • interventions take into account individual vulnerabilities (i.e., age, gender, homelessness, criminal status, etc.)
  • cost-effective; evidence-based; incremental
  • emphasis on dignity, compassion, and human rights
30
Q

The outcomes of our current system - Canada

A
  1. Organised crime and illegal, unregulated markets
    - prohibiting access to drugs encourages the creation of lucrative illegal, unregulated markets controlled by organised crime
  2. Toxic Drugs
    - Since there are no formal rules governing the production and distribution of drugs, there is no quality control to ensure the substances available on the streets are safe
    - “iron law of prohibition” is a term describing how increased law enforcement results in more potent illegal drugs. B/c drug traffickers are at risk of arrest they have a strong incentive to deal in stronger, smaller quantities of drugs that can be more easily hidden and imported
  3. Criminalization
    - police maintain that enforcement is directed at stopping high-level production and selling of criminalised drugs, but stats show that youth, poor, and marginalised people are most vulnerable to arrest
    - Indigenous people account for 26.4% of the federal prison population, despite representing only 4.3% of all Canadians
  4. Community Violence
    - Can’t resolve disputes in a normal way like courts, because they are engaging in illegal activities therefore increasing violence
  5. Wasted resources
    - pouring millions of dollars in tax revenue into a criminal justice response that prioritises enforcing drug laws also diverts money that could be spent on more important areas such as housing and healthcare, or more effective programs addressing the social factors driving substance use. Instead money continues to be funnelled to criminal justice measures that have proven ineffective at ending substance use and preventing the catastrophic loss of life currently witnessed in North America

Ultimately, the system is BROKEN!

31
Q

Inspector Bill Spearn: Police officer calling for change - WATCH THIS

A
  • started in 1996 and saw the emergence of the first overdose crisis
  • did he originally support harm reduction?
  • how did his view change?
  • what does he say about criminalisation as the cornerstone of drug policy?
  • what does he advocate for?
32
Q

MYTH: harm reduction, supervised consumption sites, and policies like decriminalisation will “enable” drug use

What is reality?

A

23% of people who were interviewed for one study related to Insite, North America’s first sanctioned supervised injection site, stopping injecting, and another 57% entered addiction treatment

Harm reduction connects people to social and health care services that help them find stability and support

33
Q

Other responses to addiction - decriminalization

A
  • Portugal and Switzerland have both implement some form of decriminalisation with overall positive public health and economic results

In Portugal, where drug use was decriminalised in 2001:
- levels of drug use are below the European average
- drug use has declined among people aged 15-24, the population most at risk of initiating drug use
- rates of past year and past month drug use among the general population - which are seen as the best indicators of evolving drug use trends decreased
- rates of dependent drug use and injecting drug use decreased

34
Q

Myth: we’re wasting taxpayer money allowing people to use drugs when we support harm reduction and decriminalisation

What is reality?

A
  • in 2017 Canada spent $4.8 billion on policing costs for illegal drugs which includes policing, courts, and correctional services. (despite this massive spending, the overdose crisis continues unabated - this is the money being wasted)
  • Insite, North America’s first sanctioned supervised consumption site, saves the taxpayer system in access of $6 million per year by preventing HIV infection and death
  • Insite has saved taxpayers $18 million over 10 years by reducing disease transmission, needle sharing, and encouraging safer drug use practices
35
Q

How we spend the money

A
  • we spend more than 750x on punitive drug control than we do on life-saving harm reduction services for people who use drugs
  • US $100 billion is spent on global drug law enforcement every year but just US $131 million is spent on harm reduction
36
Q

BC overdose crisis

A
  • On April 14, 2016, BC declared a public health emergency in response to the rise in drug overdoses and deaths

BC death toll:
- COVID: 4,145
- Overdose: 10,164

  • fentanyl has had a rise and is the number reason for overdose deaths
37
Q

Factors contributing to a worsening of the overdose crisis

A
  • increasingly toxic drug supply
  • increased feelings of isolation
  • stress and anxiety
  • limited availability and accessibility of services for people who use drugs
38
Q

Fentanyl’s impact

A
  • 87% of accidental apparent opioid toxicity deaths involved fentanyl in 2021 (Jan to March)
  • 90% of accidental apparent opioid toxicity deaths from Jan to March 2021 involved a non-pharmaceutical opioid
39
Q

Understanding evolving patterns of substances in the unregulated drug supply

A
  1. the drug supply is evolving rapidly
    - fentanyl has become ubiquitous and potency is increasing
    - COVID has been associated with increasing variability
  2. Benzodiazepines and other psychoactive adulterants are becoming increasingly common and are implicated in rising numbers of overdoses
40
Q

Public health emergency in BC

A
  • lots of people using opioids throughout bC
  • illegal drug market is toxic
  • most people dying are using drugs alone
  • harm reduction keeps people alive
41
Q

goal of treatment for opioid use disorder is to reduce harm (health and social)

A
  • overdose/death
    infections:
  • HIV
  • Hep C
  • Osteomyelitis/Infective endocarditis (soft tissue and heart infections)
  • crime
  • social consequence
  • mental health issues
  • reduce health care costs
42
Q

Medication treatment

A
  1. Methadone
  2. Suboxone (buprenorphine/naloxone)
    - decrease overdose and death
    - reduce HIV (infection and medication adherence)
    - reduce Hep C transmission
    - decrease illicit drug use
    - reduce crime
    - improve mood / social functioning
    - reduce health care costs

HSCI 214 (14 decks)

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