Chapter 17

Treatment practices

With the exception of the treatment given to offenders imprisoned in federal institutions and Aboriginals, the care available to individuals who are substance-dependent is essentially the responsibility of the provinces and territories. This chapter will therefore be brief since we received only a few submissions and heard few witnesses on this question.

In order to place the discussion in context, we should begin by noting certain data concerning dependency induced by cannabis and its derivatives. We shall then examine the various forms of treatment that are available. Finally, we shall take a brief look at the state of knowledge concerning the effectiveness of these treatments. 

 

Cannabis dependency 

Let us first clarify the terminology. We saw in Chapter 7 that, while the word addiction is used most often to refer to those who have a problem of dependency on psychoactive substances, the WHO recommended as long ago as 1963 that this expression not be used because of its vagueness. We prefer to use the term dependency for at least two reasons. First, it is more encompassing and may include different types of addictive behaviour: substance-related (food, alcohol, illicit drugs) and activity-related (gambling, sex, extreme sports, etc.). In the cases of substances, it is also more specific, referring to both the physical and psychological components of dependency. We share the distinction made by the WHO between physical and psychological dependency:

 

[Translation] … psychic dependency is a ‘state in which a drug produces a feeling of satisfaction and a psychic urge that requires period or ongoing administration of the drug in order to cause pleasure or to avoid discomfort’.

Physical dependency is an ‘adaptive state marked by the appearance of intense physical problems when the administration of the drug is delayed or its action is counteracted by a specific antagonist. These problems, that is the symptoms of withdrawal or abstinence, consist of symptoms and signs of a physical or mental nature that are characteristic of each drug. [1][1]

 

And third, it is a more neutral term. While dependency is described as a state induced by the prolonged and abusive consumption of a substance, addiction has a connotation of mental illness, indeed a moral connotation. Some authorities such as NIDA, for example, do not hesitate to classify addiction as a true illness that has certain genetic components. Seen in this way, drug use triggers biophysiological mechanisms that lead to addiction. Hence the focus on abstinence. Treatment programs in Canada tend to regard dependency as a bio-psychosocial phenomenon; “[h]owever, support for the various modifications of the disease model continues in some service sectors”.[2][2] It is interesting to note that more rehabilitation programs for alcoholism (51%) than programs for ‘addiction’ (47%) accept a harm-reduction strategy and thus objectives other than abstinence.[3][3]

These precisions made, the Committee noted the ambivalence in the terminology, depending on the language. The English name of the Centre canadien de lutte contre l’alcoolisme et la toxicomanie [Canadian centre for the battle against alcoholism and addiction] is the Canadian Centre on Substance Abuse (centre canadien sur l’abus des substances). The French title of the brochure published by the Department of the Solicitor General describing the Department’s activities is La lutte contre la toxicomanie [the battle against addiction] while the English title is Countering Substance Abuse (combattre l’abus de substances). The name of a government organization in Quebec is the Comité permanent de lutte à la toxicomanie [standing committee on the battle against addiction]. In addition to projecting a strong moral thrust, the French word “toxicomanie” evokes a vocabulary of struggle and combat, whereas the term substance abuse is more neutral and we might even go so far as to say more measured. However, the difference between the two languages cannot be explained by the lack of an appropriate noun in French: dépendance is the equivalent of drug addiction, and some in French even use the term addiction. A little rigour and clarity would be beneficial in light of the emotion surrounding the debate about drugs.

Having distinguished between use, at-risk use and excessive use, we feel that we should logically avoid the term drug addiction to refer to dependency induced by excessive use. Moreover, federal government departments and agencies should modify their terminology and ensure that both language versions are in accordance.

How common is cannabis dependency? In Chapter 7 we determined that physical dependency on cannabis was definitely rare and insignificant. Some symptoms of addiction and tolerance can be identified in habitual users but most of them have no problem in quitting and do not generally require a period of withdrawal.

As far as forms of psychological dependency are concerned, the studies are still incomplete but the international data tend to suggest that between 5% and 10% of regular users (at least during the last month) are at risk of becoming dependent on cannabis. If we recall that approximately we estimated that approximately 3% or 600,000 adult Canadians have consumed cannabis in the last month and that approximately 100,000 or 0.5% use it on a daily basis; this indicates that somewhere between 30,000 and 40,000 might be at-risk and 5,000 to 10,000 might make excessive use. For 16 and 17 years old, the numbers were between 50,000 and 70,000 at-risk and 8,000 to 17,000 potentially excessive users. The data also indicated that the peak period for intensive use is between 17 and 25 years. These broad parameters indicate where to look to prevent dependency and offer treatment services for those in need.

What form does cannabis dependency take? Most of the authors agree that psychological dependency on cannabis is also relatively minor. In fact, it cannot be compared in any way with tobacco or alcohol dependency and is even less common than dependency on certain psychotropic medications. Ceasing to consume the substance for two to four weeks, which can be accompanied by certain symptoms similar to those involved in nicotine withdrawal (insomnia, irritability, perspiration, etc.), is usually sufficient to cause the symptoms to disappear. When treatment is necessary, in the case of some people, it does not take as long as and is less difficult than the corresponding treatment for dependency on alcohol or “hard” drugs. It is also worthy of note that those seeking treatment for cannabis dependency are younger than those who receive treatment for dependency on other drugs. A number of factors may explain this situation: consumption of cannabis is more a phenomenon of youth than that of other substances, reaching its peak when young people are in their early twenties and declining significantly when they reach their thirties. Young people who need treatment also display problems of multiple addiction since cannabis is not the only drug they consume.

Overcoming dependency or consumption that the user regards as abusive is often a matter of personal choice and does not necessarily require therapeutic intervention.

 

There is the phenomenon called spontaneous remission. Many people, when they get into their thirties either stop using drugs altogether or tone down their habit. There is an obvious phenomenon of maturity in terms of drug use.

Among long-term users, we also see the retirement phenomenon, that is these individuals become fed up of their drug-using lifestyle. These individuals lose interest in the ongoing quest for drugs and for the pleasure that these drugs can provide them. In fact, it can be equated with a type of cost benefit analysis, whereby as the individual gets older, he/she decides that the habit is no longer worth it. The individual considers that the negative impact of his/her habit is no longer worth it. [4][4]

 

While most people who experience substance abuse problems do not receive help, there is good evidence that people exposed to some types of treatment subsequently reduce their use of psychoactive substances and show improvement in other life areas. In general, treatment outcomes are improved when appropriate treatments are also provided for significant life problems (communications problems, lack of assertiveness, unemployment). [5][5]

 

There is every reason to believe that, as far as cannabis is concerned, most problem users do not make use of the various forms of treatment and probably do not need any, firstly because the effects of cannabis are not as marked as those of other drugs and secondly, because cannabis users are more likely to be integrated into society than hard-drug users, which enables them to make use of their natural support groups. The third reason, in our view, why most cannabis users can avoid the trajectory of dependency is the fact that its use is not associated with “degenerate addiction” in the view of society or in the popular imagination, unlike the use of heroin, for example. Furthermore, a Canadian study has indicated that “few (3%) users of illicit drugs, identified in a population survey, reported seeking any kind of help for drug problems.” [6][6]

Nevertheless, as in the case of any psychoactive substance, some people opt for or need treatment.

 

It has in fact been observed in groups undergoing treatment - and this is a theory - that there are two groups of people trying to stop using. First, there are people who have mainly used opiates on a regular basis for six or more years. Second, there is the group of users who have been using for two years or less and no longer want to deal with the secondary effects of drugs. [7][7]

 

The decision to seek treatment is determined in particular by the increase in social and personal problems that use of a substance may cause and by the fact that it is often combined with problems of a psychiatric nature.[8][8] Women systematically make fewer requests for specialized drug and alcohol treatment services; this situation can be explained by the fact that fewer services are available and women are otherwise looked after by traditional psychiatric services.

However, people do not always choose or at least not totally.  Family pressures or pressure in the work place and, in some cases, orders made by judges are only some of the factors that lead people to seek treatment. Furthermore, little is known about the trajectories of people who abuse drugs and especially those who seek treatment for the problem. For example, we do not know to what extent the search for treatment is more the result of other earlier problems–family or psychiatric problems–than of the actual use of the substance itself.  In the case of drug users who also have problems with the law and a career of delinquency, deviant and delinquent behaviour often precedes the start of a trajectory of drug dependency, as we saw in Chapter 6. Demand for treatment in these cases will result at least as much from a desire – or indeed obligation – to put an end to a criminal career as from the detrimental effects of using the substance.

Can people be forced to seek treatment? That was one of the questions raised by the introduction in France of a requirement to seek care in the 1970 Law respecting narcotics, which has now taken the form of a therapeutic injunction,[9][9] and of drug courts in Canada, as we saw in Chapter 15.

Certain sections of the Criminal Code deal with the issue of requiring offenders to seek treatment for problems related to alcohol and drugs. For example, where a court is making a probation order, it has the discretion to require, as a condition to the probation order that:

··        The offender, if he or she agrees, participate actively in a treatment program approved by the province, subject to the program director’s acceptance; and

··        The offender visit a treatment facility for assessment and curative treatment in relation to the consumption by the offender of alcohol or drugs that is recommended pursuant to the program (where a program has been established in a province).[10][10]  

 

In addition, when a court imposes a conditional sentence, one of the optional conditions of the probation order may be that the offender participate in a treatment program approved by the province.[11][11]

If a person has not been convicted of a criminal offence, it is unlikely that a court will order treatment for alcohol or drug problems, with some exceptions. For example, persons falling under the authority of provincial mental health legislation may be detained because of mental health problems. Such legislation regulates and limits when a person may be confined against their will.  

The reluctance of courts to detain a person for substance abuse problems is illustrated in the Supreme Court of Canada decision in Winnipeg Child and Family Services (Northwest Area) v. G. (D.F.).[12][12] In this case, a young Aboriginal was five months pregnant with her fourth child and was addicted to glue sniffing, a practice which may damage the nervous system of the developing foetus. The Winnipeg Child and Family Services requested assistance from the courts to involuntarily secure the mother in treatment. The case revolved around the issue of the rights of the unborn child, and the Supreme Court of Canada found that neither tort law nor the court’s parens patriae jurisdiction supported an order for the detention and treatment of a pregnant woman for the purpose of preventing harm to the unborn child.  

In France, the therapeutic injunction has been harshly criticized, especially because it involves enforced treatment. The question is still open despite the guarded assessments that have been made of the results of this practice.[13][13]

 

The therapeutic injunction system has been in place in France since 1970. A study by a colleague at the Institut national de santé et de recherche médicale, in France, showed that many people fell through the cracks because of the therapeutic injunction forcing them to follow a treatment program. These people were never treated, because there were not enough places or follow-up. If we want to set up drug courts in Canada, we shall have to plan effectively and organize consultation mechanisms with the treatment systems to ensure that the required treatment services are available. If we fail to do this, setting up drug courts will be nothing more than a sham, if the people requiring treatment fall through the cracks of the system. [14][14]

 

It is estimated that approximately 10% of the offenders imprisoned in federal institutions are there for offences under the Controlled Drugs and Substances Act. Moreover and more importantly, it is estimated that at least 50% of all inmates, whether in provincial prisons or federal detention centres, have dependency problems (drugs and alcohol).[15][15] Generally, few of these inmates receive any kind of treatment. In the United States, studies indicate that fewer than 10% of inmates receive treatment for dependency problems while they are in prison.[16][16]

In the case of provincial institutions, this situation can be explained by the short duration of the sentences and by the budget cuts made in correction institutions in the early 1990s. In the case of federal institutions, treatment programs are available but they are still very far from meeting the needs. Furthermore, it may be somewhat ironic to offer treatment programs in institutions where drugs circulate freely and where it is not uncommon for the inmates to have access to cannabis in particular.

Nevertheless, the treatment offered to inmates is an essential component of their reintegration into society given the magnitude of the problems caused by dependency on drugs, especially harder drugs, and alcohol.

One final comment: some of the people who appeared before us observed that in certain cases cannabis maintenance could be used in combination with other forms of withdrawal and treatment for dependency on opiates.[17][17] To the best of our knowledge, there are no studies on the subject–for good reason! However, we should note, as we did in Chapter 5, that cannabinoid and opioid systems engage in complex interactions, and we may be justified in assuming that the consumption of D9-THC could cause a dopaminergic response that could reduce opiate withdrawal.