Despite the long-standing emphasis on drug law enforcement, the federal government has recently further prioritized this approach by developing legislation requiring mandatory minimum prison sentences for minor drug law offences.⁶ This article reviews the impact of conventional drug policies employed internationally and describes evidence-based steps to reduce the health and social costs attributable to drug policies in Canada.

Given its well-funded drug surveillance systems, the United States has generated excellent data for assessing the impact of drug law enforcement. Remarkably, despite an estimated US$1 trillion spent since former US president Richard Nixon first declared his country’s “war on drugs,” the effort to reduce drug supply and drive up drug prices through aggressive drug law enforcement appears to have been ineffective.^8-10 Instead, in recent decades, the prices of the more commonly used illegal drugs (e.g., cannabis and cocaine) have actually gone down, while potency has risen dramatically.^11,12 To highlight the limited ability of drug law enforcement to constrain cannabis supply, Figure 1 shows that the estimated potency of US cannabis (in terms of its active ingredient, tetrahydrocannabinol) has increased by more than 170%, from approximately 2.3% in 1981 to 6.3% in 2002, despite an increase in US federal anti-drug expenditures from US$1.5 billion in 1981 to more than US$18 billion in 2002.^8,13

Opponents of drug policy reform commonly argue that drug use would increase if health-based models were emphasized over drug law enforcement,¹⁴ but we are unaware of any research to support this position. In fact, a recent World Health Organization study demonstrated that international rates of drug use were unrelated to how vigorously drug laws were enforced, concluding that “countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones.”¹⁵ In addition, although reducing the availability of cannabis has been a central focus of drug law enforcement efforts, over the past 30 years of cannabis prohibition the drug has remained “almost universally available to American 12th graders,” according to US drug use surveillance systems funded by the US National Institutes of Health, with 80%–90% of survey respondents saying that the drug is “very easy” or “fairly easy” to obtain.¹⁶

Besides the fact that drug law enforcement is costly and ineffective, over-reliance on this approach has also resulted in a range of unintended consequences, which were recently summarized in the official conference declaration of the XVIII International AIDS Conference in Vienna, Austria (Box 1).¹⁷ The International AIDS conference has become the largest biennial public health conference in the world. The so-called Vienna Declaration has now been endorsed by thousands of individuals, including leaders in science and medicine, Nobel laureates and former heads of state. In Canada, the declaration has already been endorsed by the Canadian Public Health Association, and by the Urban Public Health Network, which represents the medical officers of health of Canada's 18 largest cities.

Conversely, a substantial research base points toward more effective models that have been proven to reduce health-related and community concerns attributable to drug use, as well as reducing the unintended effects of drug policies.^7,17,22-24 This substantial body of evidence leads to several observations, as outlined below.

Evidence-based drug treatment programs are cost effective, and significant benefits should be derived, at both individual and societal levels, through an increase in scale.²⁵ Consistent with the recent recommendations of the House of Commons Standing Committee on Public Safety and National Security,²⁶ this would include expanding access to existing evidence-based models of care such as medical and non-medical withdrawal programs, programs to manage concurrent mental health problems and addictions, ambulatory and residential treatment programs, and opioid substitution therapies.¹⁷ Similarly, given the substantial health (e.g., infectious disease, overdose death) and social (e.g., crime) concerns caused by heroin addiction in urban areas²⁷ and the potential for heroin by prescription to reduce these harms among those in whom conventional treatments fail, the prescription of heroin could be considered for selected patients with opioid addiction that is refractory to all other treatment modalities.^23,28,29

Various harm reduction strategies, such as needle exchange programs and methadone maintenance therapy, have also proven effective in reducing drug-related harm and have not been associated with unintended consequences.²² The joint recommendations recently released by several United Nations agencies, including the World Health Organization, provide a strong scientific basis for expanding harm reduction efforts.²² Beyond these recommendations, the recent consensus statement from Canada’s National Specialty Society for Community Medicine,³⁰ which endorses the scale-up of supervised consumption facilities, reflects the compelling national and international evidence to support the controlled expansion of these programs in urban areas with high concentrations of public drug use and related harms. Since 1986, more than 90 supervised drug consumption facilities have been set up in Switzerland, the Netherlands, Germany, Spain, Luxembourg, Norway, Canada and Australia, mainly in cities with large populations of street injection drug users.^29,31,32

The criminalization of people who use drugs continues to prove ineffective in reducing rates of drug use and has instead contributed to substantial health-related harms (Box 1).⁷ Portugal, which decriminalized all drug use in 2001, has seen no increases in drug-related harms. Instead, a published review of the effects of decriminalization noted that this change was followed by “reductions in problematic use, drug-related harms and criminal justice overcrowding,” with rates of drug use remaining among the lowest in the European Union.²⁴

Accordingly, Canadian society would greatly benefit from a reorienting of its drug policies on addiction—that is, with consideration of addiction as a health issue, rather than primarily a criminal justice issue. In this context, evidence-based community diversion programs for non-violent drug offenders could be expanded and evaluated to replace more costly and less effective incarceration efforts.^33,34 In the states of New York, Michigan, Massachusetts and Connecticut, for instance, mandatory minimum legislation for non-violent drug offences is being repealed, with several other US jurisdictions set to follow suit.

Finally, in light of the simple reality that drug prohibition has not effectively reduced the availability of most illegal drugs and has instead contributed to a vast criminal enterprise and related violence,⁴ among other harms, alternatives should be prioritized for urgent evaluation.¹² In addition, controlled regulation of illegal drugs may offer several advantages over the unregulated market currently controlled by organized crime groups, and there is substantial evidence from research on illicit drugs, tobacco and alcohol regarding how regulatory tools can more safely control drug availability while having the potential to positively influence cultural norms related to drug use (Table 1).^35-37 For instance, comparisons of cannabis use between the United States and Holland, where cannabis is sold to adults for recreational use through government-sanctioned “coffee shops,” have revealed that rates of use are higher in the United States, and researchers have concluded that “Drug policies may have less impact on cannabis use than is currently thought.”³⁸ Similarly, evaluations of cannabis use by US youth have demonstrated that rates of use have not increased in states where medical marijuana has been legalized.³⁹

In this context, several Canadian bodies, including the Canadian Public Health Association⁴⁰ and the Health Officers Council of British Columbia,⁴¹ have recently endorsed the evaluation of a regulated market for all currently illegal drugs. Although a full description of regulatory models is outside the scope of this paper, it is important to stress that regulatory tools would need to be closely evaluated and should be tailored to each specific substance. Examples of regulatory tools that have been described for cannabis are presented in Table 1.³⁶

Advocating for drug policy reform has traditionally been politically unpopular, but a recent Angus Reid poll estimated that 50% of Canadians already support legalization of cannabis.⁴² In this context, it is noteworthy that, although cannabis is not free from harms, recent reviews have suggested that it is less harmful than many currently legal drugs, including alcohol and tobacco, as well as several commonly used pharmaceutical drugs.⁴³ A recent study based on a 16-level matrix of harm, spanning individual physical and social harms, demonstrated the relative safety of cannabis over alcohol (Figure 2).⁴⁴ In light of the persistently widespread availability and relative safety of cannabis in comparison to existing legal drugs, as well as the crime and violence that exist secondary to prohibition of this drug,⁴ there is a need for discussion about the optimal regulatory strategy to reduce the harms of cannabis use while also reducing unintended policy-attributable consequences (e.g., the organized crime that has emerged under prohibition).^8,38

In 2007, however, the federal government abandoned this framework in favour of a new anti-drug strategy, which removed support for the evidence-based harm reduction programs recommended by the World Health Organization. The new strategy has also supported various drug-use prevention measures that have proven ineffective and potentially harmful elsewhere.^18,20,21 Lastly, as described above, more recent plans to enact costly mandatory minimum sentences for drug law violations highlight a complete departure from evidence-based policy-making.³³