Section II Some Preliminary Observations

THE PROBLEMS INVOLVED IN NON-MEDICAL DRUG USE
The Commission's terms of reference require it to make recommendations to the Government of Canada as to what it can do, alone or with other levels of government, to reduce the dimensions of the problems involved in the non-medical use of psychotropic drugs and substances. They do not suggest what the government considers to be problems, although the preamble to the Order in Council which authorizes the appointment of the Commission expresses concern about the increase in certain kinds of drug use in recent years, particularly among young people. In the Interim Report we suggested that the following were problems involved in non-medical drug use: the harm (whether personal or social) produced by certain non-medical drug use; the extent and patterns of such use, and in particular its increase among certain groups in the population; the aspects of our personal relations and social conditions today which encourage such use; the proliferation and adulteration of drugs; the lack of sufficient scientifically valid and accepted information concerning the phenomenon of non-medical drug use; the lack of a coordinated and otherwise effective approach to the timely collection and dissemination of such information as does exist, including appropriate drug education programs; our present approach to treatment and other supportive services required to assist people suffering from the adverse effects of non-medical drug use; and the content and application of the criminal law in the field of non-medical drug use.
These certainly remain problems, although the relative priority and emphasis to be given to them have in some cases altered since the Interim Report. The degree to which they are still problems has changed. The overall perspective in which they were identified as problems is not the same. For example, there has been an increase in research and in the attempt to gather and disseminate valid information since the Interim Report; there has been a development of drug education programs; there has been a constructive change in the general attitude of the medical profession towards drug users; there has been generous government support for innovative services of all kinds; and there has been a more enlightened approach to the use of the criminal law. Nevertheless, serious problems remain in the fields of research, information and education, treatment, other supportive services, and the law. Moreover, since the Interim Report our perspective has changed as to the nature and extent of the more serious forms of non-medical drug use. The principal concern is now with chronic multi-drug use. Prominent in this picture is the increasing experimentation with stronger drugs, and in particular with the opiate narcotics.

THE IMPORTANCE OF MULTI-DRUG USE
The relative importance of the problems referred to above varies according to the different kinds of drug use. With cannabis, for example, the problem of the content and application of the criminal law has been more important than the problem of treatment. With the opiate narcotics, treatment—and in particular opiate maintenance—is a major issue, as well as the extent to which the law is to be used for purposes of control. Thus, there are general observations which are applicable to the various kinds of drug use, but it is necessary to make distinctions on particular points. It might be desirable to be able to formulate a general response, but we are dealing, in multi-drug use, with a complex phenomenon that presents itself under many aspects. For purposes of systematic, detailed analysis it may be helpful to consider the various forms of drug use separately. In practice, however, the drug use of many individuals is complicated by the fact that they use several drugs. It is essential to bear this perspective of multi-drug use constantly in mind, or we shall think unrealistically in terms of separate, quite distinct forms of drug use which do not bear on one another.

SOCIAL POLICY AND INDIVIDUAL POLICY
In the Interim Report we developed the concept of 'social response'. We suggested the nature of this concept in the following passage:
We see non-medical drug use generally as presenting a complex social challenge for which we must find a wise and effective range of social responses. We believe that we must explore the full range of possible responses, including research, information and education; legislation and administrative regulation; treatment and supportive services; personal and corporate responsibility and self-restraint; and, generally individual and social efforts to correct the deficiencies in our personal relations and social conditions which encourage the non-medical use of drugs. We attach importance to the general emphasis in this range of social responses. We believe that this emphasis must shift, as we develop and strengthen the non-coercive aspects of our social response, from a reliance on suppression to a reliance on the wise exercise of freedom of choice. [Paragraph 389.]
It is necessary, however, to distinguish the response which we make as a society—working in an organized, collective way—and the response which we make as individuals at various points of contact with the phenomenon of non-medical drug use. The individual response is an essential part of the social response, but it is also something which may be considered from an entirely different perspective. For example, we may, as individuals, have an attitude towards non-medical use which we may consider inappropriate or simply not feasible for attempted implementation as social policy. In this report we are concerned with the search for a wise social policy—that is, a policy which the society may consciously pursue as a whole. Such a policy must of course be carried out not only by government and other institutions but also by individuals influencing the phenomenon of non-medical drug use at the various points at which they have contact with it. Within this framework of social policy there is room for a wide range of individual policy. On the whole, however, individual policy or behaviour must reinforce social policy, if the latter is to be effective.

GOVERNMENTAL AND NON-GOVERNMENTAL ACTION
While the Commission's terms of reference require it to recommend to the Federal Government what it can do alone or with other governments to reduce the problems involved in non-medical drug use, it is impossible to consider the appropriate role for government without reference to what other institutions and individuals are capable of doing. The government's role must be seen in the context of the society's response as a whole. Government acts directly by legislative prohibition or regulation, but it also acts by supporting the efforts of others. Action by government in the form of legislation can have a beneficial or an adverse effect upon non-governmental efforts in various areas. For example, a certain use of the criminal law may affect efforts in the fields of education and treatment. Government, through legislation and the kinds of social response it supports, conveys its own characterization and perspective of the phenomenon. It conveys an impression as to how seriously it regards a social problem. The extent to which this impression actually influences attitudes is another question. The attitude concerning the potential of harm of cannabis has been at extreme variance with the impression given by its classification in the law with the opiate narcotics. Conversely, the absence of an offence of simple possession for the amphetamines has not impeded the development of a widespread understanding concerning the dangers of 'speed'.
Although our terms of reference only require us to recommend the action to be taken by the Federal Government, we feel that this necessarily involves a commentary upon what should be done by other institutions and individuals. This non-governmental response is a necessary assumption or basis of any governmental action. What it is prudent for government to do or not to do will depend on what it may reasonably expect from other kinds of intervention and influence in the society.
The terms of reference speak of action in cooperation with other governments. Clearly, then, we are not to be confined, in considering a wise social policy, to the limits of Federal Government jurisdiction under the constitution. We also have to consider what provincial and municipal governments may do and how the Federal Government may assist them.

THE OBJECTIVES OF SOCIAL POLICY
The legal distinction between medical and non-medical drug use turns essentially on medical judgment as evidenced by prescription. There is no such basis for distinguishing between non-medical drug use which may be relatively harmless, in particular circumstances, and that which is not. With drugs which have an accepted medical value, the law relies in the final analysis on the judgment of physicians to assure a proper medical use of them. As we have seen, we cannot take prescription as the infallible criterion of the distinction between medical and non-medical use; the issue is whether the drugs are in fact prescribed for generally accepted medical reasons. In other words, the judgment and general prescribing practices of physicians must be subject to critical review. But in the final analysis the law relies on medical judgment to confine the use of such drugs to medical purposes. The physicians are the final gatekeepers. Some drugs with medicinal value do escape this control by medical prescription. Such are the over-the-counter drugs which are available for self-medication and use at the discretion of the individual. Where such drugs present a particular potential for harm they may be brought under the control of the requirement of a prescription.

Where drugs do not have an officially recognized medical value there is no regulatory means such as medical judgment to distinguish acceptable from non-acceptable use. There is no judgment or discretion to which the law can delegate the responsibility for making this distinction. In such circumstances, the law is faced with the choice of making the drug legally available or prohibiting its distribution altogether. There is no intermediate system of control to distinguish between harmful and relatively harmless use, between moderate use and excessive use, between use and 'misuse' or `abuse'. It is difficult through legal regulation to pursue a policy of moderation, as distinct from one of abstinence. If the decision is to make a drug legally available for non-medical purposes the law must rely on individual judgment and other influences to assure a level of use that avoids harm.
Such a policy presupposes that a particular drug is capable of controlled, moderate and relatively harmless use. Here we encounter other difficulties in an attempt to formulate wise social policy with respect to non-medical drug use. Is any drug which has a potential for significant harm capable of a controlled non-medical use? It is, of course, a matter of degree and the price we are prepared to pay for certain satisfactions. It is a question of what we are prepared to regard as 'significant harm'. Theoretically it may be possible to restrict one's smoking of cigarettes to the point which avoids any appreciable danger of harm, but comparatively few people are able to maintain this level of consumption. In the end a very
high proportion of smokers are inevitably exposed to the dangers of tobacco.

This is a difficulty which we encounter in attempting to formulate social policy. We know comparatively little about safe and unsafe levels of consumption of drugs for non-medical purposes. Such knowledge can only be produced by long-term research into effects at various dose levels. For example, although cannabis, like alcohol, is susceptible of controlled use, we are not yet in a position, as we pointed out in the Cannabis Report, to give assurances as to what are moderate and relatively harmless levels of use. Thus, even with drugs which are capable of controlled use, we may not be able to provide the information required for wise personal decisions.

Some drugs are not susceptible of controlled use. There may be risk of harm at any level of use, even initial, experimental use. Such is the case with the strong hallucinogens such as LSD. There are particular dangers in ever using heroin or 'speed'. It is irrelevant to speak of a policy of moderation with respect to such drugs. Excessive use certainly increases the risk of harm, but harm may occur on any occasion of use. The effects of a number of these drugs at a normal level of use are quite unpredictable. In such circumstances the law must decide whether the risk of harm from these drugs is such as to call for total prohibition. There are, of course, other factors to be taken into consideration in determining what is a feasible legislative policy, including the price one pays for certain use of the law, but the actual risk of harm is the first factor to be considered. The fact that a drug has a significant potential for harm and does not lend itself to a controlled use does not automatically lead to a policy of prohibition. We may decide for a number of reasons, as we do with other risks, to rely on peoples' judgment, wisdom, self-interest or learning capacity to avoid harm.

Another difficulty which we encounter in attempting to formulate the objectives of social policy is the possible relationship between any drug use and excessive or harmful use. There can be no harmful use unless in the first instance there is some use. Moreover, the lines between occasional use, moderate use, and excessive use, or between harmless and harmful use, are not clearly marked. They are levels of drug use which slide into one another. Finally, the climate of drug use as a whole and the prevailing attitudes towards it are factors which can influence use at various levels. There is a view which holds that the potential for harm—the total incidence of harmful effects—increases as drug use increases generally, and that if we wish to reduce the total incidence of harm we may do so by reducing per capita drug consumption generally. This point of view is based on evidence that the distribution of the per capita consumption of alcohol in the population of users follows a certain pattern or curve (referred to as "log normal"). (See Appendix C Extent and Patterns of Drug Use.) It is hypothesized that regardless of an increase or decrease in drug use in any sector of the population, the overall shape of the distribution is constant and the relative proportion of occasional, moderate and heavy users in the population would remain the same. According to this view, a general increase in drug use would increase the number of heavy or excessive users; if we wish to reduce the number of such users we must reduce the consumption of essentially all users. Further research will be necessary to evaluate the general validity of these hypotheses.

Another point of view is that it is wrong in principle to make any use of drugs for the purpose of altering our state of mind—that such a practice interferes with the full development of our potential as human beings. This is a concern with the effect of any kind of drug use on the personal development of the individual. The reasoning is that each time the individual turns to a drug instead of his own internal resources to cope with stress, anxiety, disappointment, and the like, he diminishes his capacity to deal with these situations or conditions by natural means and increases his ultimate reliance upon drugs for such purposes. This view tends to exaggerate the extent of our independence of external aids of various kinds. It does, however, reflect a concern with the tendency of occasional reliance to develop into permanent reliance.

Whether drug dependence is to be considered an evil in itself is also a matter of some debate. Some would argue that it is not the fact of dependence itself but the degree to which it actually interferes with effective functioning that is the evil. Others would argue that the evil lies in the impairment of autonomy or freedom of choice that is brought about by dependence. It is seen as a significant loss of personal dignity for the individual. This issue is brought into focus by the use of methadone maintenance to manage opiate dependence. The individual is enabled to function more effectively but he exchanges one form of opiate dependence for another. The serious secondary effects of heroin dependence are removed —the need to have contact with an illicit market and to commit crime to support the habit—but the individual is left with a dependence which is just as strong, if not stronger, than heroin dependence. Those who see drug dependence as an evil in itself, regardless of its effect on the individual's capacity to function, tend to see methadone maintenance as a mere transfer of the problem from one form to another. Those who tend to judge dependence in terms of its actual effects on behaviour are not so concerned about the fact that the individual remains dependent if he is able to function more or less in an otherwise normal fashion.

The individual who is dependent upon drugs is less free than one who is not. He is dependent not only upon the drug but upon others for his ability to function. If the system by which he obtains the drug fails, he is faced with a crisis which can overturn his entire equilibrium. This is, of course, true of the individual whose life is kept alive by a drug or a mechanical device—as, for example, in cases of diabetes or heart disease. Why should drug dependence which is managed by legally available maintenance doses be regarded any differently? Does the fact that drug dependence (unlike diabetes) is self-imposed make the difference? If such is the case, we are no longer characterizing drug dependence in terms of its effect upon the individual but are investing it with a moral judgment which we pass upon the individual. Drug dependence becomes an evil not simply because of its effect upon the individual but because it is a state into which he has voluntarily entered. This tends to ignore the extent of personal responsibility for various forms of ill health. Illnesses which result from neglect or abuse of one's health—poor diet, lack of exercise, insufficient rest, overwork, excessive worry or stress—all these can be said in some measure to be self-inflicted. Yet they do not carry the same connotation or stigma of personal responsibility as drug dependence. If we search for reasons for this difference in attitude we may be led to the conclusion that in the one case the behaviour which causes illness—for example, overwork—is regarded as socially acceptable, if not desirable, or at least normal, while in the other case the behaviour which is associated with drug dependence—escape from stress, self-indulgence and so on—is regarded as socially unacceptable, at least in that form. Work addiction produces useful results for the society (although it may inflict considerable harm on the individual and those with whom he has contact), but drug addiction does not. In the final analysis we are not nearly as concerned about the effects of self-destructive behaviour on the individual himself as we are about the effects on the society as a whole. It is this which accounts for the difference in our characterization of self-indulgent behaviour which renders the individual impotent or virtually useless socially and that which makes some contribution, however distorted, to social utility. Thus the social drinking which lubricates business relations is accepted as a necessary, if not desirable, part of business behaviour, although it often lays the foundation for problem drinking and alcoholism and no doubt frequently results in impaired judgment.

On the whole, then, we tend to characterize non-medical drug use according to its behavioural manifestations, actual or presumed. This is the approach which distinguishes moderate from excessive use according to its actual effects upon the individual and society. If the individual can function effectively and continue to discharge his responsibilities, despite reliance on drugs, we are not overly concerned. The logical conclusion of this point of view is that the law should not attempt to interfere with non-medical drug use that does not produce apparently harmful effects for the individual or society, and even then it should confine its concern to the behavioural manifestations of use that result in harm to others. This is in effect the present policy with respect to alcohol, which makes alcohol legally available to persons above a certain age but punishes harmful behaviour resulting from the use of alcohol, such as impaired driving.

In the face of all these considerations what are we to conclude is a sound general attitude towards non-medical drug use and a realistic objective of social policy? Non-medical drug use is too deeply rooted and too pervasive to be eliminated entirely. It cannot be swept away. There will always be a very high proportion of our population who will engage in non-medical drug use of various kinds. The proportion that can remain strictly abstinent—that is, avoid the use of psychotropic drugs of any kind, including those which are present in coffee and tea—will remain infinitesimal. If one considers the number of persons who are likely to continue to use tobacco and alcohol, then one develops a realistic appreciation of the inevitable proportions of nonmedical drug use. If one also thinks of the number who are likely to continue to use tranquilizers and barbiturates, one has an overwhelming impression of a climate of reliance on psychotropic substances. As we said in the Interim Report:

One could go on. The point is that there must be very few people who do not use some psychotropic drug for non-medical reasons. The general climate, therefore, is not one of moral condemnation of the use of drugs for mood-modifying purposes, but rather one of acceptance of such use. [Paragraph 390.]

In the face of such widespread and persistent non-medical use of drugs a social policy of abstinence is not a feasible one. It is unrealistic to expect the majority of people to give up non-medical drug use altogether. But it is feasible to attempt to persuade people to reduce their overall use in order to reduce harmful use and to set a better climate of example for young people. To the extent we engage in non-medical drug use at all, we must bear our share of responsibility for the more harmful forms of use. We contribute to a general climate which encourages use. Our objective of social policy should be to discourage the non-medical use of drugs as much as possible and to seek a general reduction in such use, but at the same time, to equip those who persist in use with sufficient knowledge to enable them to use drugs as wisely as possible.

THE MEANS OF SOCIAL RESPONSE
How such a social policy is best pursued is another question. The identification of problems does not automatically indicate solutions. We must distinguish between the potential for harm of a particular form of non-medical drug use and the measures of social policy which it is feasible to adopt in relation to it. The fact that we are confronted by harmful behaviour does not necessarily mean that we are justified in using the most drastic measures of social intervention at our command. We have to determine what it is reasonable and feasible to attempt to do, having regard to the benefits and costs of alternative policies.

There are basically two kinds of intervention with respect to nonmedical drug use: the preventive and the remedial. Both forms of action are necessary in an attempt to check its growth and impact.

The preventive approach presupposes that we know something about cause and the remedial that we know something about treatment. Unfortunately, our knowledge leaves much to be desired in both of these areas.

In the area of prevention, not only do we know little about the motivating or predisposing factors with respect to various forms of nonmedical drug use but we know little about the efficacy of the various methods of prevention. In particular, we know little about the effect of education on behaviour or about the deterrent effect of the criminal law.

With respect to remedial intervention, we have indicated in our Treatment Report how relatively unsuccessful have been most attempts to treat drug dependence. Our most successful response is still the attempt to manage dependence, rather than to cure it, by the substitution of one dependence for another. And even this method must still be regarded as in the experimental stage and subject to very serious critical re-evaluation.

Despite this relative lack of knowledge and the essentially discouraging outlook for treatment, we must persist in our efforts to develop a more effective social response to non-medical drug use and its effects. What we have to avoid are unreal expectations of success. This has a very important bearing on the measures which are considered to be justified on a weighing of benefits and costs. In the field of non-medical drug use we have to learn to live with a discouraging rate of apparent failure. At the same time we have to demonstrate persistence and endurance and enormous patience. Up to now the field has been characterized by exaggerated and competing claims of success because people have been conditioned to expect a rate of success comparable to that which may be attained in other fields. As a society we are gradually becoming aware of the extremely baffling and intractable nature of this phenomenon, and this discovery may be expected to result in more realistic expectations. This in turn will make it possible to share our respective experience and knowledge with greater candour and less defensiveness. The field of non-medical drug use is one in which we need very tough self-evaluation and the maximum of cooperation in sharing bad news as well as good. The problems are far too difficult to be successfully confronted by divided and conflicting responses, although there is room here, as elsewhere, for a healthy competition directed to testing rival theories in a spirit of underlying cooperation. In other words, a successful assault upon this phenomenon calls not merely for the massing of effort behind the most promising lines of solution but the maintenance of an essentially cooperative competition among a variety of methods. We have to avoid over-commitment to any particular response, recognizing that we are dealing with human beings whose needs and responsiveness vary enormously. There is no room in this field for monolithic responses. Variety and flexibility should be the watchwords. We have to leave room for a great variety of human intervention and relationships—in a word, for the personal touch. We have to leave sufficient room and flexibility within our institutional arrangements for the creative play of the human spirit. For it is that which contains the capacity for profound change.

THE APPROPRIATENESS AND EFFECTIVENESS OF THE VARIOUS INSTRUMENTS OF SOCIAL POLICY
In considering the extent to which we may rely on the various means of social response we must have some general impression of their relative appropriateness and effectiveness. So often it is said that we should shift from one emphasis to another. Such suggestions generally rest on an assumption that the proposed alternative will be at least as effective as the policy to be abandoned. Yet this is not always the case. One policy is to be preferred to another if it is a more efficient policy—that is, a better policy on a balance of benefits and costs. Here we are considering not merely the effectiveness of a policy in terms of its ability to achieve a certain result, but also the price which must be paid for the result. It may pay us to forego some effectiveness, or at least to risk such a loss, in return for paying a less onerous price. Still, the result in the form of a reduction of certain kinds of use is so important and so much to be desired in the field of non-medical drug use that many may feel it is worth almost any price. At least, they may be relatively unimpressed by talk of the price. Thus, an analysis of policy options requires consideration not merely of the balance of benefits and costs—the net yield, so to speak—but also of the ability of alternative policies to produce a desired result.

It is also important to be quite clear as to how far it is necessary to choose between various policies or means of social response, and how far they may be pursued in combination. It is not essential that we think in terms of altenatives if there is not something mutually exclusive about the various options.

THE WISE EXERCISE OF FREEDOM OF CHOICE
In our Interim Report we said that the emphasis in social policy should "shift, as we develop and strengthen the non-coercive aspects of our social response, from a reliance on suppression to a reliance on the wise exercise of freedom of choice." The important qualifications here—not always given due weight in references to this passage—are, of course, the words "as we develop and strengthen the non-coercive aspects of our social response" and the word "wise". Such a shift in emphasis is only possible in the measure that we have developed effective alternatives to the punitive approach. The objective is not freedom of choice as such, but the wise exercise of freedom of choice—that is, choice that will avoid harm.

While most people would agree with such a shift of emphasis as an ideal, there is a serious question as to how far people are capable of wise exercise of freedom of choice in actual practice, and how far we may rely on non-coercive means of social response. People do not question the soundness of the ideal; they question its practicality.

The capacity for wise exercise of freedom of choice is certainly not to be taken for granted. Wisdom does not automatically flow from the provision of ample and accurate information, important as such information is. Information has not deterred millions of people from continuing to run the risks inherent in the smoking of tobacco and the excessive use of alcohol. In a word, there does not appear to be any magic in information alone. The wise exercise of freedom of choice in relation to drugs depends on at least three factors: the possession of accurate and adequate information about the effects of drugs; the capacity (generally based on some experience and maturity) to make rational judgments in using this information; and the personal motivation, security and discipline required to abide by the behavioural directives issuing from these judgments. While adequate information on drugs can be imparted with relative ease by a variety of educational techniques and media, the capacity to make appropriate rational judgments in actual life situations is much less easily controlled by educational techniques. The factors of personal motivation, inner security and behavioural discipline—for example, the wish and the power to delay immediate gratification on rational grounds—are difficult to reach by traditional, short-term educational methods, and are mainly developed by the profounder influences of character formation in the family, religious life, and peer-group relations. They find their main basis in the early relationship between parent and child. The ideal of a wise exercise of freedom of choice is not an easily attainable one, but it is one towards which we must continue to strive, beginning with the early influences on child development.

The wise exercise of freedom of choice must take place within a framework of influences that support and reinforce the capacity for such choice. Some of these influences may be coercive and some non-coercive. They may be either preventive or remedial in their effects, or both. Together they will constitute a climate or continuity of influence that will contribute to knowledge and judgment.