Use evidence in substance policy

Quick quiz: Which psychoactive substance is responsible for the most deaths in Ontario? How about the most emergency department visits? If you guessed opioids, you aren’t even close. Opioids claimed the lives of roughly 2,400 Ontarians in 2020, less than 15 per cent of the more than 16,000 lives lost to tobacco.

And opioids were responsible for about 28,000 emergency visits in Ontario in 2020, little more than one tenth of the 258,000 visits that resulted from alcohol.

Nonetheless, our misperception of the relative risks of alcohol and tobacco compared to opioids has led to our adopting two completely different legal regimes — one involving regulation, the other, criminalization — for managing them. Or not managing them. As the death and hospitalization statistics demonstrate, neither regime has proven particularly successful, largely because they’ve been influenced more by political factors than by the medical evidence.

Consequently, Health Canada’s expert task force on substance use recommended in 2021 that Ottawa use “rigorous evidence” to implement “a single public health framework” for all psychoactive substances. Ottawa has yet to do so, but Ontario chief medical officer of health Kieran Moore recently gave us an example of what that framework might look like.

In his 2023 annual report, Moore emphasizes the need to address all substance-related harms, and to that end, he devotes as much space to tobacco and alcohol as he does to opioids. He therefore advises bringing all nicotine-containing products under a broad regulatory framework, one that employs a variety of measures, including tax policy and age of purchase, to reduce smoking and vaping, particularly among youth.

Moore also recommends strengthening alcohol policies through pricing and taxation, and he advises exploring whether to raise the minimum drinking age from 19 to 21. In addition, he suggests launching a multimedia campaign to educate people about alcohol-related harms, particularly its carcinogenic effects, and to improve access to treatment programs.

Similarly, Moore recommends increasing access to treatment for opioid-use disorder, as well enhancing harm reduction services, including safer supply programs. And since opioid criminalization decreases the likelihood of people seeking help when they need it, Moore recommends decriminalizing the possession of unregulated drugs.

Finally, aside from these substance-specific recommendations, Moore emphasizes the need to address the factors that influence all forms of substance use, including poverty, housing insecurity, mental illness and childhood adversity.

This is what an evidence-based, single framework for substance use looks like. But sadly, the provincial government seems less than enthusiastic about it.

Shortly after the framework was released, Premier Doug Ford, Health Minister Sylvia Jones and ministry spokesperson Hannah Jensen launched an all-out assault on the recommendations. Jensen said the government appreciates Moore’s “specific viewpoint,” but “his recommendations to restrict legal substances while decriminalizing hard drugs are inconsistent.” Now if by “hard drugs,” Jensen means substances that cause the most harm, then the hardest drugs are already legal. And the real inconsistency lies in criminalizing some hard drugs and not others.

Nevertheless, Jones maintained “there is a better way than legalizing drugs, and opioids in particular,” though she didn’t explain what that better way is. She did stress the importance of treatment — as did Moore — but didn’t address how to overcome the fact that criminalization deters users from seeking help.

The inconsistency doesn’t end there. In contrast to its draconian approach to opioids, the province seems reluctant to even consider regulatory reform to reduce alcohol-related harms.

While Jensen acknowledged alcohol and tobacco “are already highly regulated by the province,” both she and Ford maintained they believe in treating people “like adults.” That sounds like code for eschewing evidence-based regulations, and the premier confirmed as much when he bridled at the very thought of raising the drinking age.

By characterizing the matter as a mere clash of opinions, Ford frees himself to use political considerations in crafting drug policy. But if we’re to free Ontarians from the harms of substance use, we need a policy informed by the evidence. And now we have one, if only our leaders could look past politics to see it.