Drugs, Behaviour and Society [3 ed.] 9781259273469, 1259273466

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THIRD CANADIAN EDITION Carl L. Hart Columbia University

Charles Ksir University of Wyoming

Andrea L. O. Hebb Saint Mary’s University

Robert W. Gilbert Dalhousie University

DRUGS, BEHAVIOUR, AND SOCIETY Third Canadian Edition Copyright © 2019, 2016, 2012 by McGraw-Hill Ryerson Limited. Copyright 2018, 2013, 2011, 2009, 2008, 2006, 2004, 2002, 1999, 1996, 1993, 1987, 1978, 1972 by McGraw-Hill Education LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of McGraw-Hill Ryerson Limited, or in the case of photocopying or other reprographic copying, a license from The Canadian Copyright Licensing Agency (Access Copyright). For an Access Copyright license, visit www.accesscopyright.ca or call toll free to 1-800-893-5777. The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does not indicate an endorsement by the authors or McGraw-Hill Ryerson, and McGraw-Hill Ryerson does not guarantee the accuracy of the information presented at these sites. ISBN-13: 978-1-25-927346-9 ISBN-10: 1-25-927346-6 1 2 3 4 5 6 7 8 9 10   TCP   22 21 20 19 Printed and bound in Canada. Care has been taken to trace ownership of copyright material contained in this text; however, the publisher will welcome any information that enables them to rectify any reference or credit for subsequent editions. Product Director: Rhondda McNabb Portfolio Manager: Alex Campbell Senior Marketing Manager: Patti Rozakos Portfolio Team Associate: Tatiana Sevciuc Content Developers: Tammy Mavroudi & Peter Gleason Supervising Editor: Jessica Barnoski Photo/Permissions Editor: Tracey Tanaka Copy Editor: Valerie Adams Plant Production Coordinator: Sarah Strynatka Manufacturing Production Coordinator: Jason Stubner Cover Design: Dianne Reynolds Interior Design: Michelle Losier Cover Image: aniaostudio/iStock/Getty Images Plus Page Layout: MPS Limited Printer: Transcontinental Printing Group

About the Authors Dr. Carl Hart is the chair of the Department of Psychology and Dirk Ziff Professor in Psychiatry at Columbia University. He has published extensively in the area of neuropsychopharmacology and continues to lecture on the topic of psychoactive drug use throughout the world. Dr. Charles Ksir is professor emeritus of psychology and neuroscience at the University of Wyoming. Now retired after 35 years of research and teaching, he has authored or coauthored Drugs, Society and Human Behavior since 1984. He continues to teach a class based on this text via the Internet. Dr. Andrea Lyn Olding Hebb earned her bachelor’s degree from Dalhousie University and her MSc and PhD in Neuroscience from Carleton University. She pursued postdoctoral training in neurobiology, biochemistry, and pharmacology at the University of Ottawa and Dalhousie University. Her research investigated putative therapeutic genetic targets for the diagnosis and treatment of neurobiological diseases. Dr. Hebb is the inventor on two patents and has published more than 20 papers and several major review papers and book chapters. Dr. Hebb is a research scientist with the Division of Neurosurgery at Dalhousie University and holds a faculty position at Saint Mary’s University, where she teaches undergraduate classes in child development, neuroscience, neurobiology, pharmacology, and addiction. Dr. Robert Gilbert is an associate professor in the Faculty of Health Professions at Dalhousie University. He received his MSc in medicine from Memorial University and a PhD in pharmacology and neurosciences from Dalhousie University. His research interests focus on the development of tools for assessing health care professionals’ knowledge of the principles of evidence-based medicine and skills essential to applying those principles. This interest in knowledge translation blends well with his applied research initiatives that have, through clinical trial, investigated purported outcomes of several popular treatment approaches in addictions. In recent years, Dr. Gilbert’s efforts have also focused on the development of educational resources and programs that support the development of members of Canada’s substance abuse workforce.



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Brief Contents Preface  xi

iv

SECTION ONE

Drug Use in Modern Society 

Chapter 1 Chapter 2 Chapter 3

Drug Use: An Overview  2 Drug Use as a Social Problem  24 Drug Policy  41

SECTION TWO

How Drugs Work 

Chapter 4 Chapter 5

The Nervous System  60 The Actions of Drugs  83

SECTION THREE

Uppers and Downers 

Chapter 6

Stimulants  114

Chapter 7 Chapter 8

Depressants and Inhalants  145 Psychotherapeutic Drugs: Medication for Mental Disorders  168

SECTION FOUR

Alcohol 

Chapter 9

Alcohol  210

SECTION FIVE

Familiar Drugs 

Chapter 10 Chapter 11 Chapter 12

Tobacco  248 Caffeine  277 Natural Health Products and Over-the-Counter Drugs  304

SECTION SIX

Restricted Drugs 

Chapter 13 Chapter 14 Chapter 15 Chapter 16

Opioids  322 Hallucinogens  349 Cannabis  381 Performance-Enhancing Drug Abuse  406

SECTION SEVEN

Prevention and Treatment 

Chapter 17 Chapter 18

Preventing Substance Abuse  424 Treating Substance-Related Disorders  441

1

59

113

209

247

321

423

Contents Preface  xi

Why We Try to Regulate Drugs  39 Summary  40

SECTION ONE

Drug Use in Modern Society  1

1

Drug Use: An Overview  2

The Drug Problem  3 Talking about Drug Use  3 Four Principles of Psychoactive Drugs  6

How Did We Get Here?  8 Have Things Really Changed?  8

Drugs and Drug Use Today  10 Extent of Drug Use  10 Trends in Drug Use  12

Correlates of Drug Use  17 Risk and Protective Factors  17 Gender, Socioeconomic Status, and Level of Education  18 Personality Variables  18 Genetics  19

Review Questions  40

3 Drug Policy  41 The History of Drug Regulations  41 The Opium Act of 1908  43 Patent Medicine Act of 1909  43 Narcotic Control Act of 1961  44 The Le Dain Commission  44 Canada’s Drug Strategies  44

Canada’s Controlled Drugs and Substances Act  45 Sentencing  47 Drug Paraphernalia Laws  47 Regulation of the Sale of Alcohol and Tobacco  47 Impaired Driving  47 Diversion to Treatment  47 International Conventions  47

Antecedents of Drug Use  19

Bill S-10: An Act to Amend the Controlled Drugs and Substances Act  48

Motives for Drug Use  20

Regulation of Pharmaceuticals  49

Summary  23

New-Drug Submission Processes  49

Review Questions  23

Provincial and Territorial Responsibilities  50

2 Drug Use as a Social Problem  24 Laissez-Faire  25 Toxicity  25 Categories of Toxicity  26

Compulsory Licences  50 Developing and Introducing a New Drug  51

The Pharmaceutical Industry in Canada  52 The Compendium of Pharmaceuticals and Specialties  52

Medicinal Marijuana Regulations  53

Determining the Toxicity of Drugs of Abuse and Misuse  26

Canadian Marihuana Medical Access Regulations (MMAR)  53

How Dangerous Is the Drug?  29

Marihuana for Medical Purposes Regulations (MMPR)  54

Intravenous Drug Use and the Spread of Blood-Borne Diseases  29

Access to Cannabis for Medical Purposes Regulations (ACMPR)  56

Substance Dependence: What Is It?  31

Natural Health Products  56

Three Basic Processes  31

Summary  57

Changing Views of Dependence  32

Review Questions 58

Which Is More Important: Physical Dependence or Psychological Dependence?  34

SECTION TWO

Broad Views of Substance Dependence  34 Is Dependence Caused by the Substance?  34

How Drugs Work 

59

Is Dependence Biological?  35

4 The Nervous System  60

Is There an “Addictive Personality”?  36

Homeostasis  60

Is Dependence a Family Disorder?  36

Components of the Nervous System  61

Is Substance Dependence a Disease?  36

Crime and Violence: Does Drug Use Cause Crime?  37

Glia  61 Neurons  63

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Contents

Neurotransmission  64 Action Potential  64

The Peripheral Nervous System  65

SECTION THREE

Uppers and Downers 

Somatic Nervous System  65

6 Stimulants  114

Autonomic Nervous System  66

Cocaine  114

Central Nervous System  67

The Brain  67

History  115 Coca Wine  115

Major Structures  67

Local Anaesthesia  115

Chemical Pathways  71

Early Psychiatric Uses  116

Drugs and the Brain  75 Life Cycle of a Neurotransmitter  75 Examples of Drug Actions  78

Chemical Theories of Behaviour  79 Brain Imaging Techniques  80 Summary  82 Review Questions  82

5 The Actions of Drugs  83 Sources and Names of Drugs  83 Names of Drugs  84

Categories of Drugs  85 Pharmacodynamics  88 Drug Effects  89 Nonspecific (Placebo) Effects  89 Dose–Response Relationships  94 Potency  97

Pharmacokinetics of Drug Action  98 Time-Dependent Factors in Drug Actions  98

Mechanisms of Drug Action: Getting the Drug to the Brain  100 A Little Chemistry  100 Routes of Administration  100 Drug Distribution and Transport in the Blood  103 More about the Blood–Brain Barrier  104

Mechanisms of Drug Actions  105

113

Legal Controls on Cocaine  117 Supplies of Illicit Cocaine in Canada  117 Pharmacology of Cocaine  118 Forms of Cocaine  119 Mechanism of Action  120 Absorption and Elimination  121 Medical Uses of Cocaine  121 Causes for Concern  122 Current Patterns of Cocaine Use  123 Cocaine’s Future  124

Amphetamines  124 History  124 Supplies of Illicit Methamphetamine in Canada  129 Pharmacology of Amphetamines  130 Mechanism of Action  131 Absorption and Elimination  131 Medical Uses of Amphetamines  131 Causes for Concern  141

Summary  143 Review Questions  144

7 Depressants and Inhalants  145 History and Pharmacology  146 Before Barbiturates  146 Barbiturates  147 Meprobamate  147 Methaqualone  148

Effects on All Neurons  105

Benzodiazepines  149

Effects on Specific Neurotransmitter Systems  105

Nonbenzodiazepine Hypnotics  152

Drug Metabolism and Deactivation  105 Drug Half-Life  107

Mechanisms of Tolerance and Withdrawal Symptoms  108

Mechanism of Action of Benzodiazepines  152 Beneficial Uses of Depressants  153 Prescription Sedatives  153

Drug Disposition Tolerance  108

As Anxiolytics  153

Behavioural Tolerance  108

As Sleeping Pills  154

Pharmacodynamic Tolerance  108

As Anticonvulsants  156

Drug Classifications  110

Causes for Concern  157

Summary  111

Dependence Liability  157

Review Questions  112

Toxicity  157

Contents

Patterns of Abuse  157 Benzodiazepine Use in First Nations and Inuit Populations  158 Drugs Used to Facilitate Sexual Assault  159

Inhalants  163 Gaseous Anaesthetics  163 Nitrites  164 Volatile Solvents  164 Rates of Volatile Solvent Abuse in Canada  165

GHB (Gamma-Hydroxybutyric Acid)  165 Summary  167 Review Questions  167

8 Psychotherapeutic Drugs: Medication for Mental Disorders  168 Mental Illness  169 Concurrent Disorders  169 The Medical Model  170 Classification of Mental Disorders  172

Treatment of Mental Disorders  185 Before 1950  185 Antipsychotics  186 Antidepressants  193 Electroconvulsive Therapy  199 Mood Stabilizers  200

Consequences of Drug Treatments for Mental Illness  202 Summary  206 Review Questions  207 SECTION FOUR

Alcohol 

209

9 Alcohol  210

Canadian Alcohol and Drug Use Monitoring Survey (CADUMS)  218 Alcohol Use among Postsecondary Students  218 Regional Differences in Alcohol Use in Canada  219

Alcohol Pharmacology  223 Absorption  223 Distribution  223 Metabolism  224 Mechanism(s) of Action  225

Behavioural Effects  228 Time-Out and Alcohol Myopia  229 Driving under the Influence  229 Sexual Behaviour  231 Blackouts  232 Crime and Violence  232 Physiological Effects  233

Alcohol Toxicity  233 Hangover  234 Chronic Disease States  235 Brain Damage  235 Liver Disease  236 Heart Disease  237 Cancer  237 The Immune System  237 Canadian Recommended Guidelines for Low-Risk Drinking  237

Fetal Alcohol Syndrome  238 Alcohol Dependence  241 Withdrawal Syndrome  241 Dependent Behaviours  242

Summary  245 Review Questions  245

Alcoholic Beverages  210 Fermentation and Fermentation Products  210 Distilled Products  211 Beer  212 Wine  212 Distilled Spirits  213

Alcohol Use and “The Alcohol Problem”  214 The Temperance Movement  214 Prohibition  215 Prohibition Worked!  216 Prohibition Is Repealed  216 Regulation after 1933  217

Who Drinks? And Why?  217 Cultural Influences on Drinking  217 Prevalence and Patterns of Alcohol Use in Canada  218

SECTION FIVE

Familiar Drugs 

247

10 Tobacco  248 Tobacco History  248 Early Medical Uses  249 Chewing Tobacco  249 Cigars  250 Cigarettes  251

Tobacco under Attack  251 The Quest for “Safer” Cigarettes  252 Current Cigarette Use  255 Smokeless Tobacco  262 Are Cigars Back?  263

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Contents

Adverse Health Effects  264 Passive Smoking: The Danger of Second-Hand Smoke  265 Smoking and Pregnancy  267

Pharmacology of Nicotine  268

Regulation of Over-the-Counter Products  310 Improved Labelling of Over-the-Counter Drugs  310

Over-the-Counter versus Prescription Drugs  310 Behind-the-Counter Nonprescription Drugs  311

Absorption and Metabolism  268

Sleep Aids  311

Physiological Effects  268

Analgesics  312

Behavioural Effects  269

People and Pain  312

Nicotine Dependence  270

Aspirin  312

How to Stop Smoking  272

Acetaminophen  314

Summary  275

Ibuprofen and Other NSAIDs  315

Review Questions  276

Products Containing Codeine  315

Cold and Allergy Products  316

11 Caffeine  277

The All-Too-Common Cold  316

Caffeine: The World’s Most Common Psychostimulant  277

Allergy and Sinus Medications  318

Treatment of Cold Symptoms  317

Coffee  277

Choosing an OTC Product  318

Tea  282

Summary  320

Chocolate  286

Review Questions  320

Other Sources of Caffeine  289 Soft Drinks  289 “Energy” Drinks  290 Over-the-Counter Drugs  293

Caffeine Pharmacology  294 Time Course  294 Mechanism of Action  295 Physiological Effects  297 Behavioural Effects  298

Causes for Concern  299 Cancer  299 Pregnancy and Conception  299 Heart Disease  301 Caffeinism  302

Summary  302 Review Questions  303

12 Natural Health Products and Overthe-Counter Drugs  304 Natural Health Products  304 Some Natural Health Products Have Psychoactive Properties  306 St. John’s Wort  306 SAMe  306 Ginkgo Biloba  307 Caffeine  308 Weight-Control Products  308 Sleep Aids  309

Over-the-Counter Drugs  309

SECTION SIX

Restricted Drugs 

321

13 Opioids  322 History of Opioids  323 Opium  323 Morphine  325 Heroin  325

Opium and Heroin Supply, Distribution, and Trafficking in Canada  326 The Changing Profile of Opioid Users  327 Abuse of Prescription Opioids  328

Pharmacology of Opioids  331 Chemical Characteristics  331 Mechanism of Action  334

Beneficial Uses  335 Pain Relief  335 Intestinal Disorders  336 Cough Suppressants  336

Causes for Concern  336 Dependence Potential  336 Toxicity Potential  338 Patterns of Abuse  342

Research Studies and Pilots Addressing the Needs of Injection Drug Users in Canada  343 Insite: Vancouver’s Supervised Injection Facility  343 North American Opiate Medication Initiative (NAOMI)  345 Study to Assess Long-Term Opioid Maintenance Effectiveness (SALOME)  345

Contents

Summary  347 Review Questions  348

14 Hallucinogens  349 Animism and Religion  350

Causes for Concern  394 Abuse and Dependence  394 Toxicity Potential  395 Cannabis and Psychosis  399 Cannabidiol  403

Terminology and Types  350

Summary  403

Phantastica  351

Review Questions  405

Indole Hallucinogens  351 Catechol Hallucinogens  363

Deliriants  372

16 Performance-Enhancing Drug Abuse  406 Historical Use of Drugs in Athletics  407

PCP  373

Ancient Times  407

Anticholinergic Hallucinogens  375

Early Use of Stimulants  407

Amanita Muscaria  377

Amphetamines  408

Salvia Divinorum  378

International Drug Testing  408

Summary  379 Review Questions  380

15 Cannabis  381 Cannabis, the Plant  381 Cannabis Preparations  382 History of Cannabis  383 Early History  383 The Nineteenth Century: Romantic Literature and the New Science of Psychology  383 History of Cannabis Policy in Canada  383

Legalization of Cannabis in Canada  384 Marijuana Supply, Distribution, and Trafficking in Canada  384 Hashish and Hash Oil Supply, Distribution, and Trafficking in Canada  384

Prevalence Rates of Cannabis Use  385

North American Football  409 Steroids  409 The BALCO Scandal  410 The Battle over Testing  410

Stimulants as Performance Enhancers  412 Steroids  414 Mechanism of Action  415 Prevalence of Illicit Steroid Use in Canada  415 Psychological Effects of Steroids  416 Adverse Effects on the Body  416 Regulation  418

Other Hormonal Manipulations  418 Beta-2 Agonists  418 Blood Doping  419 Creatine  419 Getting “Cut”  419

What Canadian Youth Think about Cannabis  385

Summary  420

Worldwide Use of Cannabis  387

Review Questions  421

Pharmacology  387 Cannabinoid Chemicals  387 Absorption, Distribution, and Elimination  388 Mechanism of Action  388

SECTION SEVEN

Prevention and Treatment 

423

Physiological Effects  389

17 Preventing Substance Abuse  424

Behavioural Effects  389

Defining Goals and Evaluating Outcomes  425

Medical Uses of Cannabis in Canada  391 Nausea and Vomiting  392

Types of Prevention  426 Prevention Programs in Schools  427

Wasting Syndrome in AIDS and Cancer  392

Why Invest in Young People?  427

Multiple Sclerosis and Amyotrophic Lateral Sclerosis  392

The Knowledge-Attitudes-Behaviour Model  428

Epilepsy  393

Affective Education  429

Pain  393

Antidrug Norms  429

Psychiatric Disorders  393

Development of the Social Influence Model  431

Other Diseases and Symptoms  393

Prevention Programs That Work  432

Contraindications  394

School-Based Prevention Programs  433

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Project ALERT  433

Behavioural and Psychosocial Treatments  451

Drug Abuse Resistance Education (DARE)  434

Defining Treatment Goals  451

Life Skills Training  435

Motivational Enhancement Therapy  452

Programs That Target Peers, Parents, and the Community  435 Peer Programs  436

Contingency Management  452 Relapse Prevention  453

Parent and Family Programs  436

Transtheoretical Model (Stages of Change) and Substance Abuse Treatment  453

Strengthening Families for the Future  436

Harm Reduction  454

Community Programs  437

Substance Abuse in Canada: Concurrent Disorders  457

Prevention in the Workplace  437

Treatment and Rehabilitation: The Big Picture in Canada  458

What Should We Be Doing?  439 Summary  440 Review Questions  440

Is Treatment Effective?  458 Alcoholics Anonymous  459

A Systems Approach to Substance Use in Canada  459

18 Treating Substance-Related Disorders  441

Summary 461

The Social and Economic Costs of Alcohol and Other Drugs in Canada  442

Review Questions 462

Pharmacological Treatments  442 Detoxification (Withdrawal Management) and Maintenance Phase  442

Glossary  GL-1

Alcohol  443

Index  IN-1

References  RE-1

Nicotine  444 Opioids  446 Cocaine  448 Cannabis  449 Management of Problematic Substance Use in Pregnancy  449 Pharmacological Treatments for Adolescents with SubstanceRelated Disorders  449

Available Online: Appendix A: Drug Names  A-1 Appendix B: Resources for Information and Assistance  B-1

Preface to the Third Canadian Edition Today’s media-oriented college and university students are aware of many issues relating to drug use. Nearly every day we hear new concerns about the “opioid crisis,” legal pharmaceuticals, and the effects of tobacco and alcohol. Most of us have had some personal experience with these issues through family, friends, or coworkers. This course is one of the most exciting students will take because it will help them relate the latest information on drugs to their effects on Canadian society and human behaviour. Not only will students be in a better position to make decisions to enhance their own health and well-being, but they will also have a deeper understanding of the individual problems and social conflicts that arise when others misuse and abuse psychoactive substances. Much has changed in Canada over the years. Practices and patterns of psychoactive drug use, and their effects on human behaviour and Canadian society, are in a continual state of flux. The 1960s through 1970s was a period of widespread experimentation with marijuana and hallucinogens, while the 1980s brought increased concern about illegal drugs and conservatism, along with decreased use of alcohol and all illicit drugs. Not only did drug-using behaviour change, but so did attitudes and knowledge. And, of course, in each decade, including the 1990s, the particular drugs of immediate social concern changed: LSD gave way to heroin, then to cocaine and crack, and today to prescription medications.

Recent Trends The most alarming trend in recent years has been the increased misuse of  prescription opioid pain relievers such as fentanyl. This pharmaceutical has now joined cocaine, methamphetamine, and ecstasy as leading causes of concern about drug misuse and abuse. Methamphetamine, ecstasy, GHB, and the misuse of prescription opioids and performance enhancers are the big news items. Meanwhile, our old standbys, alcohol and tobacco, remain with us and continue to create serious health and social problems. Regulations undergo frequent changes, new scientific information becomes available, the legal status of certain drugs has changed (e.g., cannabis), and new approaches to prevention and treatment are being tested. But in spite of all these changes, the often grim realities of substance use and abuse always seem to be with us. This text approaches drugs and drug use from a variety of perspectives—behavioural, pharmacological, historical, social, legal, and clinical—and will help students connect the content to their own interests.

What’s New in the Third Canadian Edition In developing this edition, we considered the outlook and experiences of Canadian students. Throughout each chapter, we have included the latest Canadian statistics, and the “Drugs in the Media” feature has allowed us to include breaking news right up to press time. Additionally, we have introduced many timely topics and have highlighted cutting-edge research by and practices of Canadians. Collectively, these will pique students’ interest and stimulate class discussion. The following are just some of the new and updated topics in the Third Canadian Edition. Chapter 1: Broadened discussion of the fentanyl outbreak; updated tables, images, and source materials.  Chapter 2: Heavily contextualized to the Canadian perspective, DAWN data has been removed, and numerous tables updated with new material incorporated; most up-to-date criteria for the diagnosis of substance-related and addictive disorders (cannabis), as defined by the DSM-5. Chapter 3: Added information on medicinal marijuana and the recent legislative move to legalize marijuana in Canada in 2018. Chapters 4 and 5: Improved clarity for topics that are most challenging to students: biology, CNS, and neuroscience. Language revised to ensure content is easily understood by both novice students and those with more specialized backgrounds.  Chapter 5: New Drugs in the Media focus box on “Opioid Crisis in Canada.” Chapter 6: New Mind/Body Connection focus box on “Cocaine”; new Drugs in Depth box on methamphetamine addiction.  Chapter 7: Chapter title has changed to “Depressants and Inhalants”; revised “Causes for Concern” section; content more inclusive with greater discussion of Canada’s Indigenous communities. Chapter 8: New learning objective added for this chapter to reflect added coverage on the stigmas associated with mental illness and Canadian strategies to help address these issues. Chapter 9:  Updated CTADS survey data (to replace CADUMS data) on Canadian drug use; updated statistical data on CAUT-sponsored surveys of postsecondary institutions (conducted in 2013 and 2016).  xi

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Chapter 10:  Increased coverage of vaping and expanded discussion of neurophysiological effects of nicotine; updated Canadian statistics on cigarette use in Canada and in youth; new Mind/Body Connection focus box on “Smoking and Mental Illness.” Chapter 11: Updated DSM-5 boxes “Caffeine Intoxication” and “Caffeine Withdrawal Disorder”; new Mind/Body Connection box on “Caffeine: Canada’s Favourite Drug”; new Drugs in the Media box “Are Canadians Trading Their ‘Double-Doubles’ for Tea?” Chapter 12: Revised Drugs in Media box; updated Mind/Body Connection focus box. Heavily contextualized to the Canadian perspective and links to Web resources updated. Chapter 13:  Increased coverage of opioid crisis in Canada with a focus on fentanyl; new research and issues around addiction, health, and prevention of harms.  Chapter 14:  Updated Canadian statistics that define current trends in hallucinogen use with particular emphasis on youth. A closer look at ecstasy. Chapter 15: Expanded discussion on legalization of marijuana both in Canada and the United States, including the impact so far, benefits and risks currently in the United States (Colorado specifically), and concerns here in Canada.  Chapter 16: Updated information on the prevalence of substance misuse by Canadian youth and young adults for the purpose of enhancing performance. Chapter 17:  Revised prevalence data that defines Canada’s current substance misuse challenges. A consideration of recent Canadian efforts to better understand contributors to substance misuse. Updated discussions of the weaknesses of past prevention programs and information that supports readers in identifying prevention approaches with proven efficacy. Chapter 18: Updates on the findings of recent studies that evaluated the effectiveness of commonly used pharmacological and behavioural treatment approaches. An update on the measured successes of Insite, Canada’s first supervised injection facility. A subject index has also been added to the endmatter of this edition to provide readers with a concise listing of references to supplement their reading experience.

Focus Boxes Focus boxes are used in Drugs, Behaviour, and Society to explore a wide range of current topics in greater detail than is possible in the text itself. The boxes are organized around key themes.

Drugs in the Media Our world revolves around media of all types: TV, films, radio, print media, and the Web. To meet students on familiar ground, the Drugs in the Media boxes take an informative and critical look at these media sources of drug information. Students can build their critical thinking skills while reading about such topics as alcohol advertising, media coverage of prescription drugs, and the presentation of cigarette smoking in films. Chapter 3 Drug Policy 45 DRUGS IN THE MEDIA Canadian Police Chiefs Proposed Ticket System for Pot: Proposal Would Give Officer Discretion, Free Up Court Time, Chiefs Say In 2013 Canada’s police chiefs voted overwhelmingly in favour of reforming drug laws in the country. The Canadian Association of Chiefs of Police, meeting in Winnipeg, released a statement indicating that officers should have the ability to ticket people found with 30 grams of marijuana or less. Kentville, N.S., police Chief Mark Mander, chair of the association’s drug-abuse committee, noted that at that time officers had only two choices: turn a blind eye or lay down the law. Mander said officers could “either caution the offender or lay formal charges resulting in a lengthy, difficult process, which results in a criminal charge if and South American Shamanism. An important part of proven, a criminal conviction, and a criminal record.” its religious ceremony includes the drinking of a tea that Mander said ticketing the offender would be far less contains psychoactive harmala alkaloids. The use of these onerous and expensive. However, Peter MacKay, who alkaloids is restricted in Canada. To address this restricwas then the federal justice minister,  said there were no tion on their religious practice, the Santo Daime church plans in the works to legalize or decriminalize marijuana.  officials applied for an exemption to the Controlled Drugs “We don’t support legalization or decriminalizaand Substances Act. In 2006 they were granted an exemption,” Mander said. “Clearly there are circumstances tion in principle, under section 56 of the Act, thereby where a formal charge for simple possession is approallowing the importation and use of harmala alkaloids by priate. However, the large majority of simple possession the church’s members. In a related example the hallucinocases would be more effectively, efficiently dealt with

gen peyote (described in Chapter 14), which is listed as a Schedule III drug in the Controlled Drug and Substances Act, is exempt from restriction when used in religious ceremonies by members of the Native American Church and the supply of drugs through such activities as control and of Canada. enforcement, prevention, treatment and rehabilitation, and Psychoactive drugs have also played significant roles harm Furthermore, as part of the National in thereduction. economies of societies in the past.1987 Chapter 10 Drug Strategy, a committeeof was formedin to the draftearly new days legisladescribes the importance tobacco of 4 tion. Almost a decade and later,trade in 1996, thethe Controlled European exploration around globe, asDrugs well and Actin(Bill C-8) was votedof into law. colonies as itsSubstances importance the establishment English Canada’s Drug Strategy renewedthe in 2003. In the in North America; Chapter was 6 discusses significance renewal process focus waswhich placedcocaine on the reduction of harms of the coca plant (from is derived) in the associated theMayan use ofempire narcotics and controlled foundation with of the in South America; suband stances the abuse of alcohol and prescription It Chapterand 13 points out the importance of the opiumdrugs. trade in is important to note that opening China’s doors to the traderenewed with theStrategy West inrecognized the 1800s. underlying factors associated with substance-related disOne area in which enormous change has occurred orders. it is not surprising in additionand to over theTherefore, past 100-plus years is in thethat development enhanced measures the Strategy also supported marketingenforcement of legal pharmaceuticals. The introduction of education, and health promotion initiatives. In vaccines toprevention, eliminate smallpox, polio, and other communi2007, the Government introducedofitsantibiotics National cable diseases, followedofbyCanada the development Anti-Drug Strategy, whose some overarching goal is to reduce the that are capable of curing types of otherwise deadly supply andlaid demand for illicit for drugs. The Strategy encomillnesses, the foundation our current acceptance of passed three pillars: prevention, treatment, and enforcement. The prevention action pillar supported initiatives designed to prevent youth from using illicit drugs. The treatment action pillar supported initiatives aimed at enhancing the creation and delivery of evidence-based treatment and rehabilitation

[by issuing a ticket],” he added, noting the move would free up court time. The president of the association and Vancouver police Chief Jim Chu said the plan offered a good compromise. “It’s a middle ground there, right? Nothing is nothing. All is a criminal record,” Chu said. Bill Vandegraaf, an advocate for marijuana use, said the ticket system amounts to decriminalization. “They are diminishing the seriousness of the offence,” said the former Winnipeg police officer, a Chapter 1 Drug Use: An Overview 9 member of the group Law Enforcement Against Prohibition, who is currently licensed to grow and use marijuana for medical purposes. “They are turning it into medicines as the cornerstone of our health care system. a common offence where they issue tickets on the Some of the scientific and medical discoveries, probstreet.” Vandergraaf called the proposal a good first lems, and laws associated with these changes are outlined step, but said it doesn’t go far enough. “If it’s going to in Chapter 3. The many kinds of legal pharmaceuticals be a common offence notice, they might as well end designed to influence mental and behavioural functioning prohibition altogether,” he said.

are discussed in Chapter 8. Another significant development in the past 100

Source: CBC LICENSING. Drugs in the Media: Canadian Police Chiefs years has been government efforts to limit to cerPropose Ticket System for Pot: Proposal Would Give Officeraccess Discretion, tainUp kinds drugs are deemed too dangerous Free Court of Time, Chiefsthat Say. Retrieved October 2018, from http:// or too www.cbc.ca/news/canada/manitoba/canadian-police-chiefs-propose likely to produce dependence to allow them to be used in -ticket-system-for-pot-1.1335493. Used with permission from the CBC.

an unregulated fashion. The enormous growth, both in illegal trade and in the number of controlled substances, has led many to refer to this development as a “war on drugs.” Canada’s National Anti-Drug Strategy outlines the systems and services. Finally, theonenforcement action pillar government’s heightened focus illicit drug law enforcesupported projects initiatives thatitaim to disrupt illicit ment. Critics of theand strategy cite that overlooks a critical drug operations and substance target criminal Howelement of Canada’s abuseorganizations. problem in that the ever a significant criticism of thisconsequences strategy was that did majority of our health and social stemitfrom not harm that reduction as a core pillar. These In response to the include use of drugs are legally produced. laws are ongoing criticism and the 3, emergence of the opioid also outlined in Chapter but we will trace theircrisis, effectthe on Government Canadathroughout announcedthe in 2016 the intention to different drugofclasses chapters. replace theboth National Anti-Drug Strategy with the Canadian With of these developments, the proportion of Drugs and Substances restoring harm as our economy devotedStrategy, to psychoactive drugs,reduction both legal aand core pillar and of Canada’s drug policy, alongside prevention, illegal, to their regulation, has also expanded contreatment, enforcement. Since 2007 the for government has siderably. and Drug use is an important topic us to under9 invested strategy projects.drug stand if $914 only 387 for 468 that in fact. In addition, use and its regulation are reflective of changes in our society and in how we as individuals interact with that society. Finally, LO2 drug problems and our attempts to solve them have in turn had major influences on us as individuals and on our perceptions of appropriate roles for government, education, and health care.

Taking Sides These boxes discuss a particular drug-related issue or problem and ask students to take a side in the debate. This thought-provoking material will help students apply what they have learned in the chapter to real-world situations. Taking Sides topics include potential medical uses of marCanada’s ijuana, current laws relating to drugControlled use, and Drugs the issue and of Act government funding for research onSubstances hallucinogens. TAKING SIDES

The Controlled Drugs and Substances Act (CDSA) was enacted into law in 1996. Provisions within this Act govern importation, production, distribution, and possession of various drugs and substances in Canada.10 This Act

Can We Predict or Control Trends in Drug Use? Looking at the overall trends in drug use, it is clear that significant changes have occurred in the number of people using marijuana, cocaine, alcohol, and tobacco. However, while it’s easy to describe the changes once they have happened, it’s much tougher to predict what will come next. Maybe even harder than predicting trends in drug use is knowing what social policies are effective in controlling these trends. The two main kinds of activities that we usually look to as methods to prevent or reduce drug use are legal controls and education (including advertising campaigns). How effective do you think laws have been in helping

prevent or reduce drug use? Be sure to consider in your analysis laws regulating sales of alcohol and tobacco to minors. What about the public advertising campaigns you are familiar with? How about schoolbased prevention programs? As you read this book, these questions will come up again, along with more information about specific laws, drugs, and prevention programs. For now, choose which side you would rather take in a debate on the following proposition: Broad changes in drug use reflect shifts in society and are not greatly influenced by drug-control laws, antidrug advertising, or drugprevention programs in schools.

Mind/Body Connection These  boxes highlight the interface between the psychological and the physiological aspects of substance use, abuse, and dependence. These boxes help students consider influences on their own attitudes toward drug use. Topics include religion and drug use, the social and emotional costs of smoking, and the nature of dependence.

Preface 48

xiii

Section 1 Drug Use in Modern Society

MIND/BODY CONNECTION Expanding Drug Treatment Courts in Canada A drug treatment court (DTC) provides judicially supervised treatment in lieu of prison time for individuals who have a substance use problem related to their criminal activities (e.g., drug-related offences, such as drug possession, use, or noncommercial trafficking or property offences committed to support their drug use, such as theft or shoplifting). The eligible accused must decide between the DTC program and customary criminal justice processing that ranges from fines to incarceration. Typically, formal admission into a DTC program requires the individual to plead guilty to the charges. If an individual fails to comply or participate in all aspects of the program, consequences range from an official reprimand or revocation of bail to 50 Section 1 Drug Use in Modern Society expulsion from the program. DTC participants are required to attend both individual and group counselling sessions and

comparison is usually done through comparative bioavailreceive appropriate medical attention (such as ability studies. treatment) If, post-approval, a manufacturer methadone and are subject to random would like drug to make change must to a previously tests.some Participants also appearapproved regularly product, in it must Supplemental NDSprogress (SNDS).and Product court,submit where aa judge reviews their changes requiring SNDSsanctions include or butprovide are notrewards limited to can then eitheran impose changes in the dosage, or strengthtoof the drug; the (ranging from verbal form, commendations a reduction formulation; the method ofDTC manufacture; the commulabelling; or in court appearances). staff work with the recommended of administration. nity partners toroute address participants’ other needs, If, upon completion a new-drug review, such as safe housing, of stable employment, andthe jobHPFB concludes thea participant benefits outweigh the stability risks and training.that Once gains social and that the risks can becontrol mitigated or managed, manufacturer can exhibit over their substancethe use problem, criminal charges either stayed (suspended receives a Notice ofare Compliance (NOC) and theorproduct postponed judgment) or the offender receives a nonis issued an eight-digit Drug Identification Number (DIN). sentence (restrictionstoother than jail, includThe custodial DIN allows the manufacturer sell the product in CanhouseDINs arrest). ada. ing Product must be present on the label of all prescription and nonprescription drug products sold in Canada.

Provincial and Territorial Responsibilities LO3 Bill S-10: An Act

The first Canadian DTC was established in Toronto in 1998 as collaboration among the Centre for Addiction and Mental Health, the Provincial Court of Ontario, Justice Canada, the Toronto Police Service, and other community-based organizations. The DTC of Vancouver was opened in December 2001 to address the high rates of heroin use and cocaine and crack cocaine use in Vancouver. In 2003, the federal government underscored its support for the use of DTCs in Canada by dedicating monies to support the continued operation of the two existing Canadian DTCs and to facilitate the development, implementation, and operation of four additional sites in Ottawa, Winnipeg, Regina, and Edmonton. Today these DTCs are funded through the Drug Treatment Court Funding Program (DTCFP), which is administered by Justice Canada. The cost of funding Canada’s six DTCs is approxi⦁ Manage drug formularies mately $3.5 million per year. A responsibility of the Oversee the practiceand of medicine and pharmacy DTCFP ⦁is to collect information data on the effecthefor regulation of health professionals tiveness ofand DTCs the purpose of promoting best practices ongoing program development. formal ⦁ and Assess whether a brand-name drugAand its generic evaluationcompetitor of the programs’ outcomes was conducted are interchangeable. If they are, public in 2014. This evaluation found positive trends that sugreimbursements from government drug plans are gest DTCstypically are supporting in their reduclimitedparticipants to the lower-cost generic. tion of drug use, social stability (family relationships, Drug and benefit programs for certain client groups employment, housing), and avoidance of criminal within Canada are managed by the federal involvement.  Unfortunately, the presentation of thisgovernment. study’s methodology These include: and demonstrated approach to data analysis lacked methodological rigour. ⦁

Veterans

Source: Department of Justice. February 7, 2017. Drug Treatment Court ⦁ Members of the Canadian Forces Funding Program Evaluation. Accessed February 1, 2018, from http:// www.justice.gc.ca/eng/rp-pr/cp-pm/eval/rep-rap/2015/dtcfp-pfttt/p2.html. ⦁ Canada’s First Nations and Inuit peoples

⦁

Members of the Royal Canadian Mounted Police

⦁

Certain designated classes of migrant peoples

Inmates of federal penitentiaries and some former Bill S-10 received Royal Assent and became law durinmates on parole ing the 41st Parliament, which ended in September 2013. This law made jail time for serious drug offence convicCompulsory tions mandatory, andLicences where “aggravating factors” are present suchPatent as: Act was amended in 1969 to permit compulCanada’s sory licences to import medicines into Canada. This allowed ⦁ production; generic drug manufacturers to import a medicine’s active ⦁ trafficking; ingredients and process them for sale. Eighteen years later ⦁ possession for the purpose of trafficking Bill C-22 amended the Patent Act to guarantee patent ownexporting; and ers aorperiod of protection, 20 years from the date on which importing and exporting. a ⦁patent application was filed, from compulsory licences.15 2003 Trade-Related of Intellectual TheA amendments in Bill Aspects C-10 prescribed manda-Property Rights agreement permitted tory prison terms for offences related World to drugsTrade listedOrganiin zation (WTO) member countries to issue compulsory licences for patented pharmaceuticals. Compulsory licensing authorized the production and sale of generic drugs that are therapeutically equivalent to their patented, brandname counterparts, without the consent of patent holders. It was generally believed that by breaking the patent ⦁

Targeting Prevention Health Canada, through the HPFB, to Amend theis responsible for regulating the manufacture, sale, and import of therapeutic Controlled Drugsperspective and products. However, it is the offer responsibility of provincial/ These boxes and provoke thought regardterritorial governments to do the following: Substances Act ing which drug-related behaviours we, as a society, want Manage and deliver health care services Bill S-10, otherwise known as the “Safe Streets and ComPlan andwas evaluate the provision hospitalamendcare munities Act,” an omnibus Bill thatofincluded to reduce or prevent. Topics include syringe exchange proandCanada’s allied health care services ments to Controlled Drugs and Substances Act (CDSA). It was created Stephen Harper’s governProvide public drugbybenefit plans to certain segment and proposed minimum penalties for serious drug grams, criminal penalties for use of date-rape drugs, and ments of their population (e.g., all provinces and offences, such as provide dealing drugs for to organized crime purterritories coverage seniors and those poses or when a weapon or violence is involved. receiving social assistance) nondrug techniques for overcoming insomnia. These boxes Assess drug or medical device eligibility for includrug formularies (lists of drugs for which helpsion instudents better evaluate prevention strategies and public reimbursement from government drug plans is available), including consideration of the finanmessages. cial consequences ⦁ ⦁ ⦁

11,12

⦁

Prescribing Practices

the public. In fact, prior to the twentieth century government saw opium not as a health or safety issue, but as an opportunity for financial gain. Government received tax revenue from opium factories in the Chinese immigrant communities, and the federal government also received revenue through a $500 licensing fee obtained from these factories.1 Two factors are believed to have contributed to an escalation of the public’s fear and resentment of Asiatic immigrants and consequently the movement toward an era of drug regulation and antidrug policies.2 First, associations between certain elements of Euro-Canadian society (e.g., actors and gamblers) and Chinese immigrants began to develop. Respectable citizens viewed this mixing of races with disdain.3 Second, Chinese immigrant workers began to be perceived as an “economic threat” to Euro-Canadians. With a decline in the railroads and the

of the most common limitations is that the prescriptions may not be automatically refilled. In other words, the physician must write a new prescription if the patient wants to get more of the drug. Despite these rules, we are hearing more and more about people gold rush came fewer employment opportunities for all who develop dependence on prescription drugs. Do Canadians. The willingness of Chinese labourers to work you think the current limitations are effective? Could for lower wages made them more marketable and affected changes be made that would effectively reduce the overall wage rates. Euro-Canadian workers, with families chances of patients becoming dependent? 1

to support, could not compete with Chinese labourers. As economic conditions worsened, Chinese immigrants became a growing target for Euro-Canadian resentment and fear. Resentment turned to hostility, which subsequently was reflected in legislation designed to end Chinese immigration and drive the Chinese out of Canada’s economic mainstream. By 1904 the tax on Chinese immigrants had risen to $500 per person, which slowed Chinese immigration. However, between 1904 and 1907 Japanese immigration into British Columbia rose dramatically, fuelling an increase in Asiatic resentment and hostility.4 Subsequently, a major labour demonstration in 1907 (directed against Japanese immigrants) resulted in a riot and caused serious property damage in Vancouver’s Chinese community. The investigation of the event and recommendations that were made resulted in the passing of the Opium Act of 1908.

Drugs in Depth These boxes examine specific, often controversial, drugrelated issues, such as the growing number of people in prison for drug-related offences. Drugs in Depth boxes are a perfect starting point for class or group discussion. DRUGS IN DEPTH Opioid Contracts: Mandatory Drug Testing for Chronic Pain Patients. Who Benefits? In an article published in the Chronicle Herald, patients that are being seen at the Centre for Pain Management in Halifax are being asked to subject to a urinary toxicology screen to determine what, if any, drugs (illicit or legal) the patient is consuming. “Shelley Brown, a former patient at the Centre for Pain Management, said the requirement violates her rights. The Mahone Bay woman, who has a form of leukemia that causes severe pain, was upset at being told last week that she wouldn’t be treated unless she provided a sample” (McPhee, 2011). This mandatory drug test is being proposed necessary to determine whether or not patients receiving an opioid for pain, in conjunction with medications/drugs presently consumed, are at increased risk of harm both from an overdose and from an addiction perspective. Does the patient really benefit, or is it a means of discrimination? The result of this story was a buzz of information on social media, and there is reference to its utility on PubMed. A question emerges in light of this news story: “Is it ethical to subject patients to mandatory drug tests and what will be done with this information? In a quantitative design, what number of clients that receive opioids also test positive for other drugs, legal or illicit?

DSM-5 Post-Traumatic Stress Disorder (PTSD) ⦁ Note: The following criteria apply to adults, adoles-

cents, and children older than 6 years. A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse). ⦁ Note: Criterion A4 does not apply to exposure

through electronic media, television, movies, or pictures, unless this exposure is work related. B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). ⦁ Note: In children older than 6 years, repetitive

play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). ⦁ Note: in children, there may be frightening

dreams without recognizable content. 3. Dissociative reactions to (e.g. flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

TARGETING PREVENTION

Under Canada’s Controlled Drugs and Substances Act, scheduled drugs for medical treatment may 42 be legally Section 1 Drugonly Use with in Modern Society from a obtained a prescription licensed medical practitioner (including dental and veterinary practitioners). However, many of these to work for wages that were much lower than their Euroscheduled prescription medications (e.g., opioids, Canadian counterparts. These immigrants typically lived benzodiazepines, cannabis, amphetamines) have the in isolated communities where opium dens were known potential for patients to abuse them or to become but not perceived as harmful by either the government or dependent on them. Prescribing rules vary, but one

DSM-5 The Diagnostic and Statistical Manual of Mental Disorders (DSM), the handbook used by health care professionals as the authoritative guide to the diagnosis of mental disorders, has been updated. DSM-5 boxes and content throughout the text reflect current recommendations and concepts presentedChapter in the DSM-5.Drugs: Medication for Mental Disorders 179 8 Psychotherapeutic

What evidence exists that these ‘opioid contracts’ improve care and possess efficacy to reduce opioid addiction?” (Collen, 2009). These are all questions that may be answered by prospective clinical studies following patients being treated for chronic pain. In addition to gathering data, clinical measures need to be put in place by the interdisciplinary team for methods of treating pain other than with the administration of opioids. On the team would be a social worker/counsellor to talk with the client about population studies, a physician to be involved in establishing proper (non-judgmental) guidelines for the prescription of opioids, a nurse trained to recognize signs of addiction as well as pain, a psychologist to assess for depression or anxiety disorders that might exacerbate pain syndromes, a physiotherapist to initiate non-pharmacological strategies for pain (e.g., massage, heat), and a toxicologist trained in drug testing to rule out false positive and negative results. With well-controlled studies, the factors leading to addiction in these patients may be identified, the care of individuals with a higher risk for opioid misuse improved, and the costs and dangers of drug use could be greatly reduced. continued

⦁ Note: in children, trauma-specific reenactment

may occur in play. 4. Intense of prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest of participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g. inability to experience happiness, satisfaction, or loving feelings). E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. continued

Pedagogical Aids Although all the features of Drugs, Behaviour, and Society are designed to facilitate and improve learning, several specific learning aids have been incorporated into the text: Chapter Objectives Chapters begin with a list of numbered objectives that identify the major concepts and help guide students in their reading and review of the text. Definitions of Key Terms Key terms are set in boldface type in the running text and are defined in corresponding boxes. Other important terms in the text are set in italics for emphasis. Both approaches facilitate vocabulary comprehension. Chapter Summaries Each chapter concludes with a bulleted summary of key concepts. Students can use the chapter summaries to guide their reading and review of the chapters.

xiv

Preface

Review Questions A set of questions appears at the end of each chapter to aid students in their review and analysis of chapter content. Appendices The appendices include handy references on brand and generic names of drugs and on drug resources and organizations. These are available online in Connect. Drugs of Abuse: Uses and Effects A helpful chart of drug categories, uses, and effects appears on the front inside cover of the text.

Market Leading Technology Learn without Limits McGraw-Hill Connect® is an award-winning digital teaching and learning platform that gives students the means to better connect with their coursework, with their instructors, and with the important concepts that they will need to know for success now and in the future.With Connect, instructors can take advantage of McGrawHill’s trusted content to seamlessly deliver assignments, quizzes and tests online. McGraw-Hill Connect is a learning platform that continually adapts to each student, delivering precisely what they need, when they need it, so class time is more engaging and effective. Connect makes teaching and learning personal, easy, and proven.

Connect Key Features SmartBook® As the first and only adaptive reading experience, SmartBook is changing the way students read and learn. SmartBook creates a personalized reading experience by highlighting the most important concepts a student needs to learn at that moment in time. As a student engages with SmartBook, the reading experience continuously adapts by highlighting content based on what each student knows and doesn’t know. This ensures that he or she is focused on the content needed to close specific knowledge gaps, while it simultaneously promotes long-term learning. Connect Insight® Connect Insight is Connect’s new one-of-a-kind visual analytics dashboard—now available for instructors—that provides at-a-glance information regarding student performance, which is immediately actionable. By presenting assignment, assessment, and topical performance results together with a time metric that is easily visible for aggregate or individual results, Connect Insight gives instructors

the ability to take a just-in-time approach to teaching and learning, which was never before available. Connect Insight presents data that helps instructors improve class performance in a way that is efficient and effective. Simple Assignment Management With Connect, creating assignments is easier than ever, so instructors can spend more time teaching and less time managing. Assign SmartBook learning modules. Instructors can edit existing questions and create their own questions. Draw from a variety of text-specific questions, resources, and test bank material to assign online. Streamline lesson planning, student progress reporting, and assignment grading to make classroom management more efficient than ever. Smart Grading When it comes to studying, time is precious. Connect helps students learn more efficiently by providing feedback and practice material when they need it, where they need it. Automatically score assignments, giving students immediate feedback on their work and comparisons with correct answers. Access and review each response; manually change grades or leave comments for students to review. Track individual student performance—by question, assignment, or in relation to the class overall—with detailed grade reports. Reinforce classroom concepts with practice tests and instant quizzes. Integrate grade reports easily with Learning Management Systems including Blackboard, D2L, and Moodle. Mobile Access Connect makes it easy for students to read and learn using their smartphones and tablets. With the mobile app, students can study on the go—including reading and listening using the audio functionality—without constant need for Internet access. Instructor Library The Connect Instructor Library is a repository for additional resources to improve student engagement in and out of the class. It provides all the critical resources instructors need to build their course. Access instructor resources. View assignments and resources created for past sections. Post your own resources for students to use.

Preface

Instructor Resources The following instructor resources are available for download from Connect. To obtain a password to download these teaching tools, please contact your local sales representative. Instructor’s Manual Prepared by Dr. Robert Gilbert, Dalhousie University. Organized by chapter, the Instructor’s Manual includes chapter outlines, key points, suggested class discussion questions and activities, and video suggestions.  Computerized Test Bank Prepared by Anastasia Bake, University of Windsor and St. Clair College of Applied Arts and Sciences. The Test Bank has been revised to improve the quality of questions. Each question is ranked by level of difficulty, which allows greater flexibility in creating a test and also provides a rationale for the solution. Microsoft® PowerPoint® Slides Prepared by Dr. Andrea Lyn Olding Hebb, Saint Mary’s University. With figures and exhibits from the text, the PowerPoint slides include key lecture points and images from the text and other sources. 

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Image Bank Contains more than 200 full-colour figures and images from the text.

Additional Online Resources Appendix A: Drug Names Appendix B: Resources for Information and Assistance

Superior Learning Solutions and Support The McGraw-Hill Education team is ready to help instructors assess and integrate any of our products, technology, and services into your course for optimal teaching and learning performance. Whether it’s helping your students improve their grades, or putting your entire course online, the McGraw-Hill Education team is here to help you do it. Contact your Learning Solutions Consultant today to learn how to maximize all of McGraw-Hill Education’s resources. For more information, please visit us online: http://www.mheducation.ca/he/solutions

Acknowledgments It has been a pleasure to work with the team at McGraw-Hill Education Canada, and we appreciate their considerable patience and guidance throughout this process. To the editorial and production staff: Alex Campbell, Portfolio Manager; Tammy Mavroudi, Content Developer; and Jessica Barnoski, Supervising Editor. Without their support this project would have been insurmountable. Thank you for your efforts. We would also like to thank Valerie Adams  for the careful copyedit and proofread of the text and Tracey Tanaka, Permissions Editor, for her thorough work. Your contributions are greatly appreciated. We recognize the diverse backgrounds and levels of expertise of our readers and encourage you to send any comments or suggestions about this Third Canadian Edition to us at [email protected] (Robert Gilbert). Your input is essential to the development of future editions. Finally, we are extremely grateful to our colleagues from across Canada who reviewed the Second Canadian Edition, which helped lay the blueprint for this title. Their input and expertise have enhanced our knowledge and enriched the content of this book in a valuable way. We acknowledge these individuals in the list that follows. Thank you for your insightful suggestions. 

Mohammed Ali Al-Hamdani St. Mary’s University

Elizabeth MacGillivray Bow Valley College

Anastasia Bake St. Clair College & University of Windsor

Bruce McKay Wilfrid Laurier University

Suzanne Erb University of Toronto

Anna Rissanen Memorial University of Newfoundland

Kenneth Lomp Durham College

Mandana Salajegheh Simon Fraser University

Sincerely, Andrea L.O. Hebb & Robert W. Gilbert

xvi

Section 1 Chapter 1

Drug Use: An Overview Which drugs are being used and why? Chapter 2

Drug Use as a Social Problem Why does our society want to regulate drug use? Chapter 3

Drug Policy What are the regulations, and what is their effect?

Drug Use in Modern Society The interaction between drugs and behaviour can be approached from two general perspectives. Certain drugs, the ones we call psychoactive, have profound effects on behaviour. Part of what a book on this topic should do is describe the effects of these drugs on behaviour, and later chapters do that in some detail. Another perspective, however, views drug taking as behaviour. The psychologist sees drug-taking behaviours as interesting examples of human behaviour that are influenced by many psychological, social, and cultural variables. In the first section of this text, we focus on drug taking as behaviour that can be studied in the same way that other behaviours, such as aggression, learning, and human sexuality, can be studied. You will also be given information on the pharmacological and social aspects of recreational drugs so that you will be able to make informed choices on drug use.

Chapter 1

Drug Use: An Overview

Monkeybusinessimages/Getty Images

Drug use is on the rise among older adults in Canada. The use of multiple medications (polypharmacy) increases the risks of adverse drug events and interactions.

OBJECTIVES



LO4

When you have finished this chapter, you should be able to

Describe the concepts of dependence, tolerance, and withdrawal.



LO5

Explain correlates and antecedents of adolescent drug use.



LO6

Explain risk factors and protective factors for drug use.



LO7

Discuss motives that people may have for illicit or dangerous drug-using behaviour.



LO1

Develop an analytical framework for understanding any specific drug-use issue.



LO2

Apply four general principles of psychoactive drug use to any specific drug-use issue.



LO3

Explain the differences among misuse, abuse, and dependence.

Chapter 1  Drug Use: An Overview



LO1

LO2

LO3

LO4

The Drug Problem “Drug use on the rise” is a headline that has been seen quite regularly over the years. It gets our attention. At any given time, the unwanted use of some kind of drug can be found to be increasing, at least in some group of people. How big a problem does the current headline represent?

⦁⦁

Talking about Drug Use Before we can evaluate the extent of a drug problem or propose possible solutions, we need to be more specific about just what the problem is. It’s obvious that not all types of drug use demand our concern. If your Aunt Joan has a headache and takes two Tylenol tablets, that’s drug use, but most of us don’t see it as a problem. However, Uncle John’s continued need for pain medication even though his injury has healed, and your best friend Laura’s dependence on alcohol for social interactions at parties, may be viewed as problem drug use. Whether prescription or illicit, some drugs being used by some people in some situations are a problem our society must deal with. Let’s look at some of the factors that determine whether a particular kind of drug use is a problem that we should attend to. Journalism students are told that an informative news story must answer the questions who, what, when, where, why, and how. Let’s see how answering the same questions, and one more question—how much—can help us analyze problem drug use. ⦁⦁

⦁⦁

Who is taking the drug? The majority of Canadians perceive drug and alcohol abuse to be very or somewhat serious problems in Canada, their province or territory, and their community.1 However, we are more concerned about a 15-year-old girl drinking a beer than we are about a 21-year-old woman doing the same thing. We worry more about a 15-year-old boy smoking marijuana than we do about a 40-year-old man smoking it.  Images on YouTube of children as young as two years of age in other parts of the world smoking, whether real or not, are especially disturbing. And although we don’t like the idea of anyone taking heroin, we undoubtedly get more upset when we hear about the girl next door becoming a user. What drug are they taking? This question should be obvious, but often it is overlooked. A simple claim that a high percentage of students are “drug users” doesn’t tell us if there has been an epidemic of methamphetamine use or if the drug is alcohol

⦁⦁

⦁⦁

⦁⦁

3

(which is more likely). If someone begins to talk about a serious “drug problem” at the local high school, the first question should be, What drug or drugs? When and where is the drug being used? The situation in which the drug use occurs often makes all the difference. The clearest example is the drinking of alcohol; if it is confined to appropriate times and places, most people accept drinking as normal behaviour. When an individual begins to drink on the job, at school, or in the morning, that behaviour may be evidence of a drinking problem. Even subcultures that accept the use of illegal drugs might distinguish between acceptable and unacceptable situations; some university-age groups might accept marijuana smoking at a party but not just before going to a psychology class! Why a person takes a drug or does anything else is a tough question to answer. Nevertheless, it is important in some cases. If a person takes Vicodin because her doctor prescribed it for the knee injury she got while skiing, most of us would not be concerned. If, however, she takes that drug on her own, just because she likes the way it makes her feel, then we should begin to worry about possible abuse of the drug. The motives for drug use, as with motives for other behaviours, can be complex. Even the person taking the drug might not be aware of all the motives involved. One way a psychologist can try to answer why questions is to look for consistency in the situations in which the behaviour occurs (when and where). If a person drinks only with other people who are drinking, we may suspect social motives; if a person often drinks alone, we may suspect that the person is trying to deal with personal problems by drinking. How the drug is taken can often be critical. Indigenous South Americans who chew coca leaves absorb cocaine slowly over a long period. The same total amount of cocaine snorted into the nose produces a more rapid, more intense effect of shorter duration and probably leads to much stronger dependence. Smoking cocaine in the form of “crack” produces an even more rapid, intense, and brief effect, and dependence occurs very quickly. How much of the drug is being used? This isn’t one of the standard journalism questions, but it is important when describing drug use. Often the difference between what is considered normal use and what is considered abuse of, for example, alcohol or a prescription drug comes down to how much a person takes.

4

Section 1  Drug Use in Modern Society

Creatista/Shutterstock

Doug Menuez/Getty Images

Concern about the use of a substance often depends on who is using it, how much is being used, and when, where, and why it is being used.

DRUGS IN THE MEDIA Reporting on the “Drug du Jour” In 2000, newspaper and television stories about drugs were dominated by the so-called “club drugs,” such as ecstasy and GHB. Ecstasy grew to become the most popular designer drug in Canada, and its use extended beyond the rave culture and into schools, homes, and the streets. In a 2015 survey of students in Ontario, 5.4% of students in grades 9 through 12, some 24 200 students, self-reported using ecstasy in the previous 12 months. Fortunately, the use of ecstasy among Canadian youth has remained relatively stable and has not reached the prevalence rates of alcohol, tobacco, or cannabis. Before ecstasy, there was a wave of media reports about crystal meth and other forms of methamphetamine.  Before that, in the mid-1980s, it was crack cocaine. Recent media attention in Canada focused on the use of the psychoactive drug desomorphine (“krokodil”/“crocodile”). Whether such waves of media attention are true reflections of the extent or reality of drug use is sometimes debated. What is clear, however, is that when the news media jump on the latest drug du jour (drug of the day), they generally do so en masse. One question that we should continue to ask is, What role does media attention play in popularizing a current drug fad, perhaps making it spread farther and faster than it would without the publicity? Over 40 years ago, in a chapter titled “How to Create a Nationwide Drug Epidemic,” journalist E. M.

Brecher described a sequence of news stories that he believed were the key factor in spreading the practice of sniffing the glues sold to kids for assembling plastic models of cars and airplanes (see the section on volatile solvents in Chapter 7). He argued that, without the well-meaning attempts to warn people of the dangers of this practice, it would probably have remained isolated to a small group of youngsters in Pueblo, Colorado. Instead, sales of model glue skyrocketed across North America, leading to widespread restrictions on sales to minors. The 2015 Ontario Student Drug Use and Health Survey showed that 3% of males and 2.5% of females, grades 7–12, reported having used an inhalant (glue or solvents) in the past year. The highest rates of use were reported by students in grades 7 and 8 at 6.2% and 4% respectively. While seen in all ethnic groups in Canada, volatile solvent misuse (VSM), involving the inhalation of substances such as gasoline, glue, and cleaning products, has been reported to be prevalent among street youth, inner city youth, and some First Nations and Inuit youth in selected rural or remote areas of Canada. A 1994 survey carried out on reserves in Canada reported that most youth who had tried solvents did so by the time they were 11 years old. Most (43%) said they tried it only once, followed by social users (38%), and chronic users (19%). In 2003 a report commissioned by the Pauingassi First Nation continued

Chapter 1  Drug Use: An Overview



DRUGS IN THE MEDIA Reporting on the “Drug du Jour” continued in Manitoba determined that approximately half of the children in that community who were under 18 years of age engaged in VSM. Despite anecdotal reports of VSM as a continuing crisis, the true prevalence among Canada’s First Nations and Inuit youth population as a whole is not known. Furthermore, it is not clear if prior perceptions of widespread misuse were factual or were inflated though media reporting, particularly through repeated showings of 1993 and 2000 news clips of Innu youth in the communities of Davis Inlet and Sheshatshiu, Labrador, getting high on gasoline. Regardless of the true extent of the problem, the consequences are clear. Volatile substance misuse among First Nations and Inuit youth has been linked to

high rates of poverty, boredom, unemployment, family breakdown, loss of self-respect, and poor social and economic structures. These issues have been attributed to the impact of residential schooling, racism and discrimination, and multi-generational losses of land, language, and culture. Thinking about the kinds of things articles often say about the latest drug problem, are there components of those articles that you would include if you were writing an advertisement to promote use of the drug? Do you think such articles actually do more harm than good, as Brecher suggested? If so, does the important principle of a free press mean there is no way to reduce the impact of such journalism?

The Canadian Press/Ted Ostowski

Gas inhalation among children in Davis Inlet, 15 kilometres south of Natuashish, Labrador, attracted worldwide media attention in 1993 and 2000. Sources: 1. Boak, A., H.A. Hamilton, E.M. Adlaf, and R.E. Mann. 2015. Drug use among Ontario students, 1977–2015: Detailed OSDUHS findings (CAMH Research Document Series No. 41). Toronto, ON: Centre for Addiction and Mental Health. Retrieved December 10, 2017, from http://www.camh.ca/en/research/news_and_publications/ontario -student-drug-use-and-health-survey/Documents/2015%20OSDUHS %20Documents/2015OSDUHS_Detailed_DrugUseReport.pdf. 2. Health Canada. 2017. “Canadian Tobacco, Alcohol and Drugs Survey. Detailed Tables for 2015.” Ottawa: Controlled Substances and Tobacco Directorate, Retrieved 2017, from https://www.canada .ca/en/health-canada/services/canadian-tobacco-alcohol-drugs -survey/2015-summary.html. 3. Centre for Addiction and Mental Health. 2003. “Ecstasy Use Down, Cigarettes and LSD Continue to Decline, But Heavy Drinking Remains a Problem.” Retrieved October 31, 2011, from http://www .camh.net/News_events/News_releases_and_media_advisories _and_backgrounders/osdus2003_newsrelease.html.

4. Canadian Centre on Substance Abuse. 2013. CCENDU Bulletin, “No Confirmed Reports of Desomorphine (“Krocodil”/“Crocodile”) in Canada.” Retrieved December 30, 2013, from http://www.ccsa .ca/2013%20CCSA%20Documents/ccsa-CCENDU-Desomorphine -Bulletin-2013-en.pdf. 5. Manitoba Office of the Children’s Advocate. 2003. Pauingassi First Nation Report on Solvent Abuse. Sourced from Winnipeg Free Press, Wednesday, August 24, 2005. “Manitoba’s sniff crisis has given birth to a tragic trend… Babies that smell like gas”. D. O’Brien. pp. A1–A2. 6. Dell, C. 2007. “Youth Volatile Substance Abuse FAQs”. Canadian Center on Substance Abuse. Retrieved December 10, 2017, from  http://www.ccsa.ca/Resource%20Library/ccsa-011326-2006.pdf. 7. Canadian Public Health Association. 2005. “Parents Be Aware: Sniffing Kids.” Retrieved October 2018, from http://www.ccsa.ca /Resource%20Library/ccsa-011326-2006.pdf. 8. Health Canada and Kaweionnehta Human Resource Group. 1994. First Nations and Inuit Community Youth Solvent Abuse Survey and Study. Ottawa: Author.

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Svanhorn4245/Dreamstime.com

Representatives of Ontario’s Ministry of Health have repeatedly spoken about the issue of OxyContin abuse in that province.

Four Principles of Psychoactive Drugs Now that we’ve seen how helpful it can be to be specific when talking about drug use, let’s look for some organizing principles. Can any general statements be made about psychoactive drugs— psychoactive:  having effects on those compounds that alter conthoughts, emotions, sciousness and affect mood? Four or behaviour. basic principles seem to apply to all these drugs. 1. Drugs, per se, are not good or bad. There are no “bad drugs.” When drug abuse, drug dependence, and risky drug use are talked about, it is the behaviour, the way the drug is being used, that is being referred to. This statement sounds controversial and has angered some prominent political figures and drug educators. It therefore requires some defence. For a pharmacologist, it is difficult to view the drug, the chemical substance itself, as somehow possessing evil intent. It sits there in its bottle and does nothing until we put it into a living system. From the perspective of a psychologist who treats drug users, it is difficult to imagine what good there might be in heroin or cocaine. However, heroin is a perfectly good painkiller, at least as effective as morphine, and it is used medically in many countries. Cocaine is a good local anaesthetic and is still used for medical procedures, even in Canada and the United States. Each of these drugs can also produce bad effects when people abuse them. In the cases of heroin and cocaine, our society has weighed its perception of the risks of bad consequences against the potential benefits and decided that we should severely restrict the availability of these substances. It is wrong, though, to place all the blame for these bad consequences on the drugs themselves and to conclude that they are simply “bad” drugs. Many people tend to view some of these substances as possessing an almost magical power to produce evil. When we blame the substance itself, our efforts to correct drug-related problems tend to

focus exclusively on eliminating the substance, perhaps ignoring all the factors that led to the abuse of the drug. 2. Every drug has multiple effects. Although a user might focus on a single aspect of a drug’s effect, we do not yet have compounds that alter only one aspect of consciousness. All psychoactive drugs act on more than one place in the brain, so we might expect them to produce complex psychological effects. Also, virtually every drug that acts in the brain also has effects on the rest of the body, influencing blood pressure, intestinal activity, or other functions. 3. Both the size and the quality of a drug’s effect depend on the amount the individual has taken. The relationship between dose and effect works in two ways. An increase in the dose usually causes an increase in the same effects noticed at lower drug levels. Also, at different dose levels there is often a change in the kind of effect, an alteration in the character of the experience. 4. The effect of any psychoactive drug depends on the individual’s history and expectations. Because these drugs alter consciousness and thought processes, the effect they have on an individual depends on what was there initially. An individual’s attitude can have a major effect on his or her perception of the drug experience. The fact that relatively inexperienced users can experience a high when smoking oregano and dry oak tree leaves— thinking it’s good marijuana—should come as no surprise to anyone who while at a particularly fun party and felt a “buzz” after one drink rather than the usual two or three. It is not possible, marijuana:  also then, to talk about many of the spelled “marihuana.” effects of these drugs indepenDried leaves of the dent of the user’s history and Cannabis plant. 2 attitude and the setting.

Brand X Pictures/Getty Images

The setting and the expectations of the user influence the effects of drugs.

Chapter 1  Drug Use: An Overview



DRUGS IN DEPTH Important Definitions—and a Caution! Some terms that are commonly used in discussing drugs and drug use are difficult to define with precision, partly because they are so widely used for many different purposes. Therefore, any definition we offer should be viewed with caution because each represents a compromise between leaving out something important and including so much that the defined term is watered down. The word drug will be defined as any substance, natural or artificial, other than food, which by its chemical nature alters structure or function in the living organism. A drug may be loosely defined as any chemical substance that has an effect on a living organism. If you accept that broad definition, can you think of other substances that you may now classify as a drug? What about food? One obvious difficulty is that we haven’t defined food, and how we draw that line can sometimes be arbitrary. Alcoholic beverages, such as wine and beer, may be seen as drug, food, or both. Are we discussing how much sherry wine to include in beef Stroganoff, or are we discussing how much wine can be consumed before becoming intoxicated? Since this is not a cookbook but, rather, a book on the use of psychoactive chemicals, we will view all alcoholic beverages as drugs. Psychoactive drugs have their effect on the central nervous system, the brain in particular, with their resultant expression in behaviour. Illicit drug is a term used to refer to a drug that is unlawful to possess or use. Many of these drugs are available by prescription, but when they are manufactured or sold illegally, they are illicit. Traditionally, alcohol and tobacco have not been considered illicit substances even when used by minors, probably because of their widespread legal availability to adults. Common household chemicals, such as glues and paints, take on some characteristics of illicit substances when people inhale them to get high. Harm reduction is an initiative of Canada’s Drugs and Substances Strategy to use public education programs to significantly reduce the damage associated with alcohol and other drugs. The term harm reduction has become controversial in part because some people equate it with advocating for legalization of all drugs. The most commonly accepted definition of harm reduction is “measures taken to address drug problems that are open to outcomes other than abstinence or cessation of use.”

Measures may include programs, policies, or interventions that seek to reduce or minimize the negative social, health and economic consequences of problematic drug and substance use. Examples of harm reduction measures applied to injection drug use in Canada include safe injection sites, syringe exchange programs, easy access to naloxone, and methadone maintenance therapy for heroin intravenous drug users. As applied to alcohol use, harm reduction measures include introduction of earlier opening hours for a liquor outlet in downtown Edmonton to reduce the use of Lysol and other nonbeverage alcohol, changes to space and the padding of furniture in licensed establishments to minimize the harm that may result from fights, and designated driver and alternative transportation programs for drinkers. Harm reduction focuses on lowering the risk and severity of adverse consequences arising from drinking without necessarily trying to reduce consumption. The key message in population-based approaches is that drinking less is better; the key message in harm reduction is to avoid problems when you drink. An elaborated discussion of the principles that guide harm reduction initiatives in Canada is provided in the document “Harm Reduction: What’s in a Name?” published by the Canadian Centre on Substance Use and Addiction and available at www.ccdus.ca. Drug misuse generally refers to the use of prescribed drugs in greater amounts than, or for purposes other than, those prescribed by a physician or dentist. For nonprescription drugs or chemicals, such as paints, glues, or solvents, misuse might mean any use other than the use intended by the manufacturer. Abuse consists of the use of a substance in a manner, amounts, or situations such that the drug use causes problems or greatly increases the chances of problems occurring. The problems may be social (including legal), occupational, psychological, or physical. Once again, this definition gives us a good idea of what we’re talking about, but it isn’t precise. For example, some would consider any use of an illicit drug to be abuse because of the possibility of legal problems, but many people who have tried marijuana would argue that they had no problems and therefore didn’t abuse it. Also, the use of almost any drug, even under the orders of a physician, has at least some potential to cause problems. The question might come down to how great the risk is and whether the user continued

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DRUGS IN DEPTH Important Definitions—and a Caution! continued is recklessly disregarding the risk. How does cigarette smoking fit this definition? Should all cigarette smoking be considered drug abuse? For someone to receive a diagnosis of having a substance use disorder (see the DSM-5 feature in Chapter 2), the use must be recurrent, and the problems must lead to significant impairment or distress. Addiction is a chronic relapsing condition characterized by compulsive drug seeking and abuse and by long-lasting chemical changes in the brain. Addiction is the same irrespective of whether the drug is alcohol, amphetamines, cocaine, heroin, marijuana, or nicotine. Every addictive substance induces pleasant states or relieves distress. Continued use of the addictive substance induces adaptive changes in the brain that lead to tolerance, physical dependence, uncontrollable craving, and, all too often, relapse. Addiction is a controversial and complex term that has different meanings for different people. Because the term is so widely used in everyday conversation, it is risky for us to try to give it a precise, scientific definition, and then have our readers use their own long-held perspectives whenever we use the term. Therefore, we have avoided using this term where possible, instead relying on more precisely defined terms, such as dependence. Drug dependence refers to a state in which the individual uses the drug so frequently and consistently

How Did We Get Here? Drug use is not new. Humans have been using alcohol and plant-derived drugs for thousands of years—as far as we know, since Homo sapiens first appeared on the planet. A truly “drug-free society” has probably never existed, and might never exist. Psychoactive drugs were used in rituals that we might classify today as religious in nature and where their use was believed to enhance spiritual experiences. A common belief in many early cultures was that illness results from invasion by evil spirits, so in that context it makes sense that psychoactive drugs were often used as part of a purification ritual to rid the body of those spirits. In these early cultures, the use of drugs to treat illness likely was intertwined with spiritual use so that the roles of the priest and that of the shaman (medicine man) often were not separate. In fact, the earliest uses of many

that it appears it would be difficult for the person to get along without using the drug. Stopping is very difficult and may cause severe physical and psychological withdrawal. Some drugs and some users have clear withdrawal signs when the drug is not taken, implying a physiological dependence. Dependence can take other forms, as shown in the DSM-5 feature in Chapter 2. If a great deal of the individual’s time and effort is devoted to getting and using the drug, if the person often winds up taking more of the substance than he or she intended, and if the person has tried several times without success to cut down or control the use, then the person meets the criteria for dependence. Tolerance is a condition that may follow repeated ingestion of a drug. Drug tolerance occurs when a person’s reaction to a psychopharmaceutical drug (such as a painkiller or an intoxicant) decreases so that larger doses are required to achieve the same effect. Drug tolerance can involve both psychological and physiological factors. The resulting pattern of uncontrolled escalating doses may lead to drug overdose and death. Withdrawal symptoms are abnormal physical or psychological effects that occur after stopping a drug. They may include sweating, tremors, vomiting, anxiety, insomnia, and muscle aches and pains. Source: Canadian Centre on Substance Abuse. 2008. Harm Reduction Overview. Retrieved October 31, 2011, from http://www.ccsa.ca /Eng/Topics/HarmReduction/Pages/HarmReductionOverview.aspx.

of the drugs that we now consider to be primarily recreational drugs or drugs of abuse (nicotine, caffeine, alcohol, cocaine, and marijuana) were as treatments for various illnesses. Today many such drugs are either restricted or tightly regulated through the Controlled Drugs and Substances Act.

Have Things Really Changed? What happens when the regulation or restriction of a drug conflicts with religious practices and freedoms? One example can be seen in the actions of the Santo Daime church in Quebec. Santo Daime is a syncretic spiritual practice founded in the 1930s in Brazil and now practised worldwide. Syncretism combines different systems of philosophical or religious belief or practice, in this case, Folk Catholicism, Kardecist Spiritism, African animism,

Chapter 1  Drug Use: An Overview



and South American Shamanism. An important part of its religious ceremony includes the drinking of a tea that contains psychoactive harmala alkaloids. The use of these alkaloids is restricted in Canada. To address this restriction on their religious practice, the Santo Daime church officials applied for an exemption to the Controlled Drugs and Substances Act. In 2006 they were granted an exemption in principle, under section 56 of the Act, thereby allowing the importation and use of harmala alkaloids by the church’s members. In a related example the hallucinogen peyote (described in Chapter 14), which is listed as a Schedule III drug in the Controlled Drug and Substances Act, is exempt from restriction when used in religious ceremonies by members of the Native American Church of Canada. Psychoactive drugs have also played significant roles in the economies of societies in the past. Chapter 10 describes the importance of tobacco in the early days of European exploration and trade around the globe, as well as its importance in the establishment of English colonies in North America; Chapter 6 discusses the significance of the coca plant (from which cocaine is derived) in the foundation of the Mayan empire in South America; and Chapter 13 points out the importance of the opium trade in opening China’s doors to trade with the West in the 1800s. One area in which enormous change has occurred over the past 100-plus years is in the development and marketing of legal pharmaceuticals. The introduction of vaccines to eliminate smallpox, polio, and other communicable diseases, followed by the development of antibiotics that are capable of curing some types of otherwise deadly illnesses, laid the foundation for our current acceptance of

medicines as the cornerstone of our health care system. Some of the scientific and medical discoveries, problems, and laws associated with these changes are outlined in Chapter 3. The many kinds of legal pharmaceuticals designed to influence mental and behavioural functioning are discussed in Chapter 8. Another significant development in the past 100 years has been government efforts to limit access to certain kinds of drugs that are deemed too dangerous or too likely to produce dependence to allow them to be used in an unregulated fashion. The enormous growth, both in illegal trade and in the number of controlled substances, has led many to refer to this development as a “war on drugs.” Canada’s National Anti-Drug Strategy outlines the government’s heightened focus on illicit drug law enforcement. Critics of the strategy cite that it overlooks a critical element of Canada’s substance abuse problem in that the majority of our health and social consequences stem from the use of drugs that are legally produced. These laws are also outlined in Chapter 3, but we will trace their effect on different drug classes throughout the chapters. With both of these developments, the proportion of our economy devoted to psychoactive drugs, both legal and illegal, and to their regulation, has also expanded considerably. Drug use is an important topic for us to understand if only for that fact. In addition, drug use and its regulation are reflective of changes in our society and in how we as individuals interact with that society. Finally, drug problems and our attempts to solve them have in turn had major influences on us as individuals and on our perceptions of appropriate roles for government, education, and health care.

TAKING SIDES Can We Predict or Control Trends in Drug Use? Looking at the overall trends in drug use, it is clear that significant changes have occurred in the number of people using marijuana, cocaine, alcohol, and tobacco. However, while it’s easy to describe the changes once they have happened, it’s much tougher to predict what will come next. Maybe even harder than predicting trends in drug use is knowing what social policies are effective in controlling these trends. The two main kinds of activities that we usually look to as methods to prevent or reduce drug use are legal controls and education (including advertising campaigns). How effective do you think laws have been in helping

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prevent or reduce drug use? Be sure to consider in your analysis laws regulating sales of alcohol and tobacco to minors. What about the public advertising campaigns you are familiar with? How about schoolbased prevention programs? As you read this book, these questions will come up again, along with more information about specific laws, drugs, and prevention programs. For now, choose which side you would rather take in a debate on the following proposition: Broad changes in drug use reflect shifts in society and are not greatly influenced by drug-control laws, antidrug advertising, or drugprevention programs in schools.

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Section 1  Drug Use in Modern Society

Figure 1.1  Canadian Drugs and Substances Strategy This diagram highlights the four pillars of the Canadian Drugs and Substances Strategy.

Prevention

Treatment

Preventing problematic drug and substance use

Supporting innovative approaches to treatment and rehabilitation

Harm Reduction

Supporting measures that reduce the negative consequences of drug and substance use

Enforcement

Addressing illicit drug production, supply, and distribution

Supported by a strong evidence base To better identify trends, target interventions, monitor impacts, and support evidence-based decisions

Source: © All rights reserved. Canadian Drugs and Substances Strategy: A Comprehensive, Collaborative, Compassionate and Evidence-Based Approach to Drug Policy. Health Canada. Adapted and reproduced with permission from the Minister of Health, 2018. Retrieved 2018, from https://c.ymcdn.com/sites /canadianpainsociety.site-ym.com/resource/resmgr/docs/Opioid_Resource_Page_/EN_-_CDSS.pdf.

In May 2003, the Government of Canada underscored its commitment to addressing the ongoing public health concern of substance abuse with its renewed Canada’s Drug Strategy (CDS), now known as Canada’s Drugs and Substances Strategy.3  The goal of the CDS was to significantly reduce the harm associated with alcohol and other drugs by using a broad four-component approach that includes prevention, treatment, harm reduction, and enforcement (see Figure 1.1). The CDS initiative balances a population-based approach, with the goal of decreasing consumption and related risks, with harm reduction measures that focus on reducing the risks and severity of adverse consequences arising from drug and alcohol use while not necessarily reducing consumption. Harm reduction strategies, unlike population-based approaches, normalize drug-taking behaviour and focus on the avoidance of problems. Numerous harm reduction strategies have been employed in Canada. Examples include needle exchange programs and supervised injection sites to reduce the transmission of blood-borne disease in intravenous drug users and the regulation of cheap drink promotions (e.g., happy hours) to reduce the incidence of alcohol-related poisonings, violence, and drunk driving, and more recently, initiatives to make access to naloxone easier. Discussions of evidence-based harm reduction strategies are provided throughout subsequent chapters.

Drugs and Drug Use Today In trying to get an overall picture of drug use in today’s society, we quickly discover that it’s not easy to get accurate information. It’s not possible to measure with great accuracy the use of, let’s say, cocaine in Canada. We don’t really know how much is imported and sold, because most of it is illegal. We don’t really know how many cocaine users there are in the country, because we have no good way of counting them. For some things, such as prescription drugs, tobacco, and alcohol, we have a wealth of legal sales information and can make much better estimates of rates of use. Even there, however, our information might not be complete (e.g., home-brewed beer and wine, which accounts for a portion of consumed alcohol and is shown in Figure 1.2, might not be counted, illegal tobacco sales are difficult to estimate, and prescription drugs might be bought and then resold or left unused in the medicine cabinet).

Extent of Drug Use Let us look at some of the kinds of information we do have. A large number of survey questionnaire studies have been conducted in junior high schools, high schools, and post-secondary institutions (universities and colleges), partly because this is one of the easiest ways to get a lot

Chapter 1  Drug Use: An Overview



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Figure 1.2  Homemade Beer and Wine Production in Canadian Provinces, 2004 According to the 2004 Canadian Addiction Survey, a minority of Canadians (6.7%) produce their own wine or beer at home. The figure shows the average number of bottles of homemade beer and wine produced in the provinces in 2004. Despite anecdotal evidence of an increase in home beer and wine production, comprehensive statistics on current trends are not available. Are there societal risks associated with home production of beer and wine, and what are the potential challenges associated with the lack of current data?  100 Beer

90

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86 79

80 Average Number of Bottles

72 70

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50 40 33 30

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Province Source: “Reproduced and adapted with permission from the Canadian Centre on Substance Abuse”. Adlaf, E. M., P. Begin, and E. Sawka, eds. Canadian Addiction Survey (CAS): A National Survey of Canadians’ Use of Alcohol and Other Drugs: Prevalence of Use and Related Harms: Detailed Report. Ottawa: Canadian Centre on Substance Abuse, 2005.

The Canadian Press/Aaron Lynett

Prime Minister Justin Trudeau, right, is shown at the Niagara College with winery and viticulture technician program students.

of information with a minimum of fuss. Researchers have always been most interested in drug use by adolescents and young adults, because this is the age when drug use usually begins, and current evidence suggests that early onset of drug use is predictive of long-term impairments.4 This type of data has some limitations. For example, we must assume that most self-reports are done honestly. In reality, however, we have no way of checking to see if Johnny really did inject methamphetamine last week, as he claimed on the questionnaire. Nevertheless, if every effort is made to encourage honesty (including assurances of anonymity), we expect that this factor is minimized. To the extent that tendencies to overreport or underreport drug use are relatively constant from one year to the next, we can use such results to reflect trends in drug use over time and to compare relative reported use of various drugs.

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Section 1  Drug Use in Modern Society

DRUGS IN DEPTH Methamphetamine Use in Your Community Assume that you have just been appointed to a community-based committee that is looking into drug problems. A high school student on the committee has just returned from a residential treatment program and reports that methamphetamine use has become “very common” in local high schools. Some members of the committee want to call in experts immediately to give school-wide assemblies describing the dangers of methamphetamine. You have asked for a little time

to check out the student’s story to find out what you can about the actual extent of use in the community and report back to the group in a month. Make a list of potential information sources and the type of information each might provide. How close do you think you could come to making an estimate of how many current methamphetamine users there are in your community? Do you think it would be above or below the national average? How would it compare with the prevalence of daily intravenous drug users in Vancouver as described in Figure 1.3?

Figure 1.3  Intravenous Drug Users in Vancouver, British Columbia, 1996–2011 The figure illustrates the percentage of individuals from a cohort of injection drug users (n = 1979) who self-reported injecting crystal methamphetamine in the past year. 18

Crystal meth: Smoked

16

Crystal meth: Injected

Percentage

14 12 10 8 6 4 2 0

1996

1997

1998

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2000 2001

2002 2003 2004 2005 2006 2007 2008 2009 2010 Year

2011

Source: Drug Situation in Vancouver Report prepared by the Urban Health Research Initiative of the British Columbia Centre for Excellence in HIV/AIDS, Second Edition, June 2013. Retrieved 2018, from http://www.bccsu.ca/wp-content/uploads/2016/08/dsiv2013.pdf.

Trends in Drug Use Broad-based self-report information may be gathered through house-to-house surveys. With proper sampling techniques, these studies can estimate the drug use in most of the population. This technique is time-consuming and expensive and has a high rate of refusal to participate. We must also suspect that individuals engaged in illegal drug use would be reluctant to reveal that fact to a stranger on their doorstep or telephone. Despite potential limitations, snapshots into the general Canadian public use of alcohol and drugs have been provided through the Canadian Addiction Survey (CAS), last performed in 2004, and more recently through

the Canadian Tobacco, Alcohol and Drugs Survey (CTADS), conducted annually since 2008.3 The intent of these surveys is to measure how Canadians aged 15 years and older use alcohol, cannabis, and other drugs, and the impact that use has on their physical, mental, and social well-being. This information, when compared with past studies, indicates trends in drug use and harms associated with use.5,6 These surveys, which are collaborative initiatives by Health Canada, the Canadian Executive Council on Addictions—which includes the Canadian Centre on Substance Abuse; the provinces of Nova Scotia, New Brunswick, and British Columbia; the Alberta Alcohol and Drug Abuse Commission; the Addictions Foundation of

Chapter 1  Drug Use: An Overview



Manitoba; the Centre for Addiction and Mental Health; the Prince Edward Island Provincial Health Services Authority; and the Kaiser Foundation—and the Centre for Addictions Research of BC, have four key objectives: 1. To determine the prevalence, incidence, and patterns of drug and alcohol use 2. To measure the personal (e.g., physical health, home life and marriage, work and studies, financial position, legal problems, housing, learning) and social harms (e.g., friendships and social life) associated with patterns of use of alcohol, tobacco, and illicit drugs, including opiates, cocaine and crack, amphetamines, hallucinogens (including MDMA), and inhalants, during a person’s lifetime and during the 12 months before the survey 3. To assess the context of use and identify risk and protective factors related to drug use and consequences of such use in specific subgroups and the general Canadian population 4. To establish baseline data against which to evaluate the effectiveness of CDS and harm reduction efforts focused on alcohol and other drug use in the Canadian population aged 15 years and older The CTADS, a national telephone survey based on a random sample, biannually collects information on alcohol and drug use and its consequences from approximately 15 000 respondents 15 years of age and older. The overall sample size of the survey is divided equally across all 10 Canadian provinces. The sample consists of approximately 5000 persons aged 15‒25 and 10 000 individuals aged 25 years and older. Data is not collected for residences of the Yukon, Northwest Territories, Nunavut, and full-time residents of institutions. Beginning in 2015, the CTADS used cell phones in its sampling frame. Surveys prior to 2015 were restricted to landline phones. One limitation of this study is that it excludes groups that often contain a disproportionally high number of drug and alcohol users: people in prisons, those on military bases, and transient populations such as homeless people. Comparisons of the key findings from the 1994 and 2004 CAS and 2015 CTADS are presented in Table 1.1. Data collected through tools like the CAS and the CTADS provide a wealth of information about trends in drug and alcohol use in Canada. We strongly recommend that you visit the websites for these surveys to gain a full appreciation of the uses and limitations of the information these surveys provide.7,8 At the beginning of this chapter we discussed that we may be more concerned with young adults and children using alcohol and drugs. Three surveys, the Canadian Campus Survey (CCS), the American College Health Association (ACHA) National College Health Assessment, and the Ontario Student Drug Use and Health Survey (OSDUHS), provide insight into the alcohol and drug use practices of Canadian youth.

13

Table 1.2 compares past-year use of alcohol and other drugs among Canadian undergraduates measured in the 1998 and 2004 CCS. Only two drugs, hallucinogens and LSD, showed small, albeit statistically significant, decreases. Alcohol use showed little change. Among all students, the past-year use of cannabis remained similar in 1998 and 2004, 28.8% versus 32.1%. Between 1998 and 2004, the CCS also showed that cannabis use declined among students in the Prairies, from 24.1% to 19.4%, and increased in the Atlantic region, from 26.5% to 36.9%.9 The CCS has not been implemented since 2004. However, in 2016 the Canadian Association of College and University Student Services published results of the ACHA National College Health Assessment survey, which reported selected drug use trends among 43 780 students from 41 postsecondary Canadian institutions.10 A difference in the categorization of specific drugs in the respective surveys prevents trend comparison between the 2004 and 2015 surveys. The 2016 ACHA National College Health Assessment data do, however (as shown in Table 1.3), provide a snapshot of current use patterns among postsecondary students. For example, past-30-day use of alcohol was 69.5%, while 15.6% of students self-reported as lifetime abstainers. By far the most commonly used illicit drug was cannabis, used by 16.9% of students during the past 30 days and 47.8% during their lifetime. Now let’s consider the epidemiological trends in drug use among students in grades 7 through 12. The OSDUHS, which began in 1977, is the longest ongoing school-based survey in Canada. The OSDUHS interviews thousands of students every second year from 150 elementary and secondary schools across Ontario. The purpose of the survey is to identify epidemiological trends in student drug use, harmful consequences of use, and risk and protective factors.11 What the OSDUHS data tells us is the percentage of students (grades 7 to 12) who have ever used the drug (% Lifetime Use) and the percentage who report having used it within the past year (% Past-Year Use). For example, in 2017 survey data told us that many of these students have tried alcohol at some time in their lives. Twenty-two percent have tried marijuana, and 13% have reported non-medical use of prescription opioid pain relievers. It is interesting to note that the lifetime and daily use of many of these drugs can be considered rare.12 The OSDUHS results also allow us to see changes over time in the rates of drug use.  Pertaining  to  rates of marijuana use among students in grades 7 through 12 in 1999, fewer than 28% of students reported having previously used marijuana. This proportion rose in 2003 to approximately 30% and then declined each year until 2017, when only 22% of students reported past-year use of marijuana. Because marijuana has been by far the most

14

Section 1  Drug Use in Modern Society

TABLE 1.1 Lifetime and 12-Month Prevalence of Alcohol and Other Drug Use, Canadians Ages 15+, 1994, 2004, and 2015 Report of Use Drug                              

Lifetime

12-Month

1994

2004

2015

1994

2004

2015

Alcohol

n/a

92.8

90.9

72.3

79.3

76.9

Males

n/a

94.6

94.2

n/a

82

81.3

Females

n/a

91.1

87.7

n/a

76.8

72.7

Cannabis

28.2

44.5

44.5 

Males

33.5

50.1

52.1

Females

23.1

39.2

37.2

4.9

10.2 

9.7

3.8

10.6

8.3

0.7

1.9

1.2

Males

4.9

14.1

10.7

0.8

2.7

1.5

Females

2.7

7.3

5.9

0.5

1.1

0.9

Cocaine/Crack

7.4 10

14.1

12.3

18.2

14.9

Hallucinogens

5.2

11.4

12.2

0.9

0.7

1.2

Males

7.2

16

15.6

1.3

1.0

1.8

Females

3.3

7.1

8.9

0.6

0.3

0.6

Speed

2.1

6.4

2.7

0.2

0.8

0.2

Males

3.1

8.7

3.0

0.4

1.0

s

Females

1.2

4.1

2.5

s

0.6

s

Heroin

0.5

0.9

s

s

s

0.4

Males

0.8

1.3

s

s

s

0.6

Females

s

0.5

s

s

s

s

Ecstasy

n/a

4.1

6.2

n/a

1.1

0.7

Males

n/a

5.2

7.7

n/a

1.5

1.0

Females

n/a

3.0

4.6

n/a

0.7

0.5

Inhalants

0.8

1.3

n/a

n/a

n/a

n/a

Males

1.2

1.9

n/a

n/a

n/a

n/a

Females

0.3

0.7

n/a

n/a

n/a

n/a

Steroids

0.3

0.6

n/a

n/a

n/a

n/a

Males

0.4

1.0

n/a

n/a

n/a

n/a

s

s

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

2.2

Females Non-Medicinal Prescription Opioids Males

n/a

n/a

n/a

n/a

n/a

3.1

Females

n/a

n/a

n/a

n/a

n/a

0.0

Notes: s = estimate suppressed due to high sampling variability; n/a = data not available Sources: Adapted from Adlaf, E. M., P. Begin, and E. Sawka, eds. 2005. Canadian Addiction Survey (CAS): A National Survey of Canadians’ Use of Alcohol and Other Drugs: Prevalence of Use and Related Harms: Detailed Report. Ottawa: Canadian Centre on Substance Abuse; Health Canada. 2017. Canadian Tobacco, Alcohol and Drugs Survey. Detailed Tables for 2015. Ottawa: Author. 

commonly used illicit drug, we can use such data to make a broader statement: Illicit drug use among students in grades 7 through 12 slowly declined between 2003 and 2017. Interestingly, the trend for drinking alcohol follows the same pattern as that for cannabis. It is tempting to speculate that these drugs are used in combination, but we don’t have data to support such statements. Evidence like that described above is important because some groups

say that drug use is increasing among young people or that people are starting to use drugs at younger and younger ages, but the best data we have provide no support for such statements. How can we explain these very large changes in rates of marijuana use over time? Maybe marijuana was easier to obtain in 1999, less available in 2017, and so on. Each year the same students were asked their opinion about

Chapter 1  Drug Use: An Overview



TABLE 1.2

15

TABLE 1.3

Changes in Past-Year Alcohol and Other Drug Use, Canadian Undergraduates, 1998, 2004

Prevalence of Alcohol and Other Drug Use among Canadian Postsecondary Institution Students (N = 43 780), 2016

Drug

1998

2004

Report of Use

Lifetime

30 Days

Alcohol

86.5

85.7

Drug

Cannabis

28.8

32.1

Alcohol

84.4  

69.3

Any illicit drug use (excluding cannabis)

10.3

  8.7

Cannabis

41.6  

17.9

26.9 

11.0  

Hallucinogens

  8.2

  5.7

Cigarettes

Ecstasy (MDMA)

  2.4

  2.5

Hallucinogens (LSD, PCP)

6.3

0.9

1.4

0.4

Amphetamines

   1.8

  2.6

Opiates (heroin, smack)

LSD

   1.8