An Overview of Non-Medical Use of Prescription Drugs and Criminal Justice Issues in Canada
In Canada, the non-medical use of prescription drugs, specifically prescription opioids (POs) and benzodiazepines (BDs), have gathered attention in recent years. Although nation-wide epidemiological data are currently sparse, provincial data and data from the US indicate an area of growing concern. The following report explores the trends of non-medical use of prescription opioids (NMUPOs) and benzodiazepines (NMUBDs), the health and societal implications of non-medical use and some of the criminal justice policy issues in Canada.
NMUPO & NMUBD Use & User Characteristics
The reported medical use of POs in Canada has approximately doubled in less than a decade, and currently ranks third after the US and Germany among the world’s largest PO consumer countries on a per capita basis. Concurrent with this increase in the general availability are additional opportunities for non-medical use. Unfortunately, information on the NMUPOs and NMUBDs in Canada is relatively constrained due to a lack of longitudinal data available and to methodological concerns (i.e. operational definitions, framing of questions and response rates).
Data that is available highlight NMUPO use among younger age groups within the general population, with no gender difference among adults, but an over-representation of young adults (19-24), with reported use higher among high-school females. Additionally, US studies have indicated lower socio-economic status, with associated variables such as poverty, unemployment or low income as risk factors for NMUPO in the general population. Among street drug user populations, there is evidence that NMUPO may be becoming more prevalent than heroin use. Unlike general populations of NMUPO users, street drug user populations using POs non-medically have been reported as older compared to other street drug users. Provincial data in Ontario indicate that PO citation as problem substances among treatment admissions has increased substantially, with over 80% reporting past year NMUPO. Specific analyses of socio-demographic characteristics of PO clients in treatment facilities are currently not available.
Unlike POs, Canada’s spending per capita on benzodiazepines (BDs) has remained quite stable over the past decade. Unfortunately, there are few studies on NMUBDs among Canada’s general population, and thus the extent of non-medical use is unclear at this time. Surveys among university and high-school students report past year use of tranquilizers around 2%; however, non-medical use was not specified in all studies. Prevalence changes over time for NMUBDs among street-drug user populations are unclear due to few over-time comparisons, with prevalence rates ranging from 6% in Vancouver’s’ Downtown Eastside to 31.3% in Victoria. NMUBD among treatment populations has shown stability over time, with citations of BD use as problem substance increasing with age, and being higher among women.
Tracking how prescription drugs such as POs and BDs are attained for non-medical purposes is challenging as they are legitimately generated products, available and distributed legally through the medical system. US data on diversion indicate heterogeneity of sources or routes, from the manufacturing site to the consumer, further complicating where to target points of intervention.
There is currently little data available on Canada’s general population regarding how POs for non-medical use are obtained; however, doctors, friends, family, the street, “double doctoring” and healthcare workers are reported as potential sources. Within street drug user populations, regular dealers, friends/partner, trade, or directly from the medical system have been identified as sources, with irregular dealers, doctors, and theft reported less frequently. A doctor’s prescription, the street, or a combination of the two, have been identified among NMUPO users in treatment facilities.
BDs are consumed at lower prevalence levels that POs and consumption rates have remained relatively stable over time. Unfortunately, there is little data available on sources for the NMUBDs in Canada. A multi-site study revealed that among NMUBD street drug users the most common sources were friends, followed by doctors, with irregular/regular dealers, a partner, and theft reported less frequently. Studies in the US among the general population report that youth and students primarily cite peers, friends and family members as BD sources. Additionally, there is some evidence suggesting healthcare worker involvement in diverting BDs.
It has been estimated that between 10%-33% of NMUPO users may develop dependence or other drug use disorders in Canada. While there are reports on specific PO related deaths in Canada (e.g., fentanyl or oxycodone), a lack of national data on overdose deaths related to NMUPOs makes an exact quantification difficult; however, in the US, such deaths have increased since the 1990s, replacing heroin and cocaine as the leading drugs involved in fatal drug overdoses. Based on Canada’s epidemiological profile and US rates, a large number of NMUPO-related mortality can be expected. Additionally, NMUPO is associated with a variety of diseases including elevated use disorders of other substances, higher levels of mental disorders, and somatic diseases (specifically pain). Although there are few Canadian studies on the associations between injuries and NMUPO, based on international literature both intentional and unintentional injuries can be linked to NMUPOs. And finally, a steady increase among clients reporting past year PO use and PO as presenting problem substances has been seen in Ontario among treatment facilities.
Data on the health consequences on NMUBD is scarce in Canada; however, like POs, BDs have reinforcing properties with the potential for abuse and dependence. US survey data indicate that among respondents who reported past-year non-medical use of sedatives/tranquilizers, that 9.8% met criteria for abuse/dependence, with higher prevalence among adolescents (17.4%). Despite a lack of research exploring possible associations between NMUBDs and overdose deaths in Canada, international studies have identified drug poisoning by BDs in approximately 3.8% of all deaths caused by poisoning from a single drug. Although associations have been made between BD use and injuries (traffic injuries, suicide, and falls), the relationship is unclear. Unlike POs, treatment admissions related to BDs has remained stable.
The health/burden of disease and use related crime constitutes the primary factors determining direct ‘social cost’ impacts of substance use. Given the absence of Canadian data no social costing is currently available; however, in 2001 it was estimated that the societal costs related to PO abuse in the US were approximately $8.6 billion, costs which are likely higher today considering the increase in PO abuse.
PO-related admissions to substance treatment programs and emergency room admissions are key categories that indicate the health/burden of disease related to NMUPOs over-time. As emergency room admission data are not routinely or systematically collected in Canada, rates are currently unclear. In the US, it has been reported that emergency room visits involving POs rose by 120% in the period 1997-2002. Among treatment admissions in Ontario, PO related admissions approximately doubled in less than a decade (9.4% to 15.7%), which are likely an underestimation as the reporting system does not cover admissions to or initiations of opioid maintenance treatment.
Little is known about PO related mortality in Canada as information on psychoactive drug-related accidental deaths is not centrally collected. A recent analysis in Ontario suggests that PO-related mortality rates have doubled in the period 1991-2004. Additionally, several US studies indicate that PO-related accidental poisoning deaths have increased substantially in recent years, outnumbering those related to heroin or cocaine.
There are currently no empirical specific assessments of the crime and criminal impacts of non-medical use of prescription drugs in Canada, thus only the potential nature and extent of crime and criminal impact is offered. As supply and sourcing routes of prescription drugs are distinct from illegal drugs, including friends, family and double-doctoring, defining and the enforcement of drug-related acquisition crimes is highly complex. An analysis on a street drug user population cohort in Canada paralleled findings in the US where PO-only users may be more socially integrated and less crime-involved than predominantly heroin or cocaine/crack involved street drug users.
As Canada finds itself in the early stages of policy development, it is crucial that the best possible policy is developed for the complex issue of non-medical use of POs and BDs. As such, any policy should recognize that POs and BDs are important medications in areas of medical care, such as pain, sleep and mental health, and that any policy or intervention must take care not to interfere with effective health care in these areas. An exploration of several policy issues is presented, highlighting the use of active and expanded law enforcement, and tighter controls of medical care and drug providers. Additionally, some of the challenges and negative consequences of such initiatives are presented including the possible deleterious effects of criminalization on a youth population, enforcement impact on black market dynamics, monitoring challenges, and the phenomenon of opiophobia and its impact on access to effective medical care.
With a current inability to accurately assess the extent of NMUPOs and NMUBDs in Canada, there is a pressing need for more research before policies addressing this complex issue can be proposed. There has been a tendency for assessments, interventions, or calls for measures aimed at non-medical use of prescription drugs to predominantly see and analyze the root of the problem at the individual level. We strongly recommend that when developing policies that address the NMUPOs and NMUBDs in Canada that a broad perspective is kept, recognizing the possible systemic determinants or dynamics. Additionally, we recommend that the NMUPOs and NMUBDs are recognized first and foremost as health problems and are addressed by health based interventions or improvements to health care.
AMSTAR, a measurement tool to assess the methodological quality of systematic reviews (Shea et al., 2007), and the overview by Egger and colleagues (2001) were used as a guide to conduct this systematic literature review.
A systematic literature search on epidemiological studies reporting:
- prevalence of non-medical use of either POs or BDs in North America (search terms in italic; North America was operationalized as either Canada or US or North America)
- non-medical use of POs or BDs combined with either general population or street drug user
- consequences of POs orBDs in North America (we specified overdose, pain, injury and mental health separately)
was performed in multiple electronic bibliographic databases including: Ovid MEDLINE, PubMed, EMBASE, Web of Science (including Science Citation Index, Social Sciences Citation Index, Arts and Humanities Citation Index), PsycINFO, CABS (BIDS), WHOLIST, SIGLE, ETOH, Google Scholar, and the Cochrane Database of Systematic Reviews. The available published and unpublished literature was searched up to July 2008 inclusive. In addition, a manual search of the bibliographic pages of selected articles and reviews as well as the content pages of major epidemiological and addiction speciality journals were conducted. The search was not limited to English language publications.
In addition, we looked for data on NMUPOs or NMUBDs in major Canadian surveys, and analyzed the respective questions in the Ontario surveys, where the second author is currently the acting PI (for technical information see Adlaf & Paglia-Boak, 2007; Ialomiteanu et al., 2009; Ialomiteanu & Adlaf, 2009).
2. Epidemiology Of The Non-Medical Use Of Prescription Drugs In Canada
2.1. Prevalence of Non-Medical Use of Prescription Opioids (NMUPO)
In Canada, there have been substantive suggestions and concerns that non-medical use of prescription opioids Footnote 4 (NMUPO; [Note: Prescription opioids (POs) in the context of this analysis mainly include and refer to the following medical opioid compositions or products: codeine, morphine, oxycodone, hydromorphone, hydrocodone, fentanyl; where other substances are included or referred to, this is specified]) seem to have risen, following trends similar to those in the United States in recent years (Fischer et al., 2008c; Popova et al., 2009; Compton & Volkow, 2006; Hurwitz, 2005; Fischer et al., 2008b). These views, in part, are informed by the fact that the extent of medical PO use – a preeminent determinant influencing non-medical use - in Canada occurs at highest level in global comparison and has approximately doubled in the past decade (Fischer & Rehm, 2008). Correspondingly, inflation-adjusted retail spending on opioid drugs per Canadian also more than doubled between 1998 and 2007 (from $7 to $14.80 in 2007 dollars), mainly due to therapeutic choice and volume effects (Morgan et al., 2008). Canada – after the US and Germany – is the world’s third largest PO consumer country on a per capita basis, with the average consumption in defined daily dose (DDD) units per million inhabitants per day totaling 18,914 (19,965 in Germany and 40,604 in the US) (International Narcotics Control Board, 2009a).
2.1.2. General Populations
The most recently completed Canadian general population survey on substance use, the Canadian Addiction Survey (CAS; (Adlaf et al., 2005a)) contained no data on the non-medical use of prescription drugs, and hence no epidemiological data on NMUPO in the Canadian adult population at large are currently available. The new Canadian Alcohol and Drug Use Monitoring Survey (CADUMS) – conducted in 2008 by telephone with a representative national Canadian population sample of 16,672 respondents – for which 28.4% had used psychoactive pharmaceutical drugs in the past year. Of these, 2.0% reported that they used such substances to ‘get high’ [Note: This operational definition is much more narrow than definitions of ‘non-medical drug use’ as for example used in the US, and hence are not comparable to the latter data as they likely lead to substantial under-estimations. There are further methodological concerns with CADUMS, as the survey’s response rate was ~35% only] Footnote 5. The lion’s share of recent psychoactive pharmaceutical drug users in CADUMS – 21.6% - had used POs in the past year. Of these, 1.5% - or 0.3% of the total population – had used these ‘to get high’ (Health Canada, 2009). As will be discussed below, these figures are substantially lower than NMUPO rates reported for the US general population (i.e., 5.0% in 2007; (Substance Abuse and Mental Health Administration (SAMHSA), 2008b)).
Using available Canadian data and projections based on ratios from epidemiological indicators from the US, a different approach had estimated that in Canada in 2003 there were between 321,000 and 914,000 NMUPO users in the general population aged between 15 and 49 (Popova et al., 2009). Several local indicators from across the country describe the prevalence of NMUPO. For example, in Edmonton in 2002, 7.8% of adults over 18 reported past year non-medical use of prescription drugs, with POs being the most common (4.9%) (Wild et al., 2008).
The Canadian Campus Survey (CCS) collected
data on substance use and other health issues from a random sample of 6,282
full-time university undergraduate students from 40 universities in 2004. 13.7%
reported lifetime use of
‘other opiate-type prescription drugs’, 5% reported
past year use and 1% reported use in the past 30 days. However, although these
questions were framed and placed together with questions on illicit drug use,
the CCS did not specify whether use was medical or non-medical (Adlaf et al., 2005a). The previous
iteration of the CCS (1998; (Gliksman et al., 2000) did not include any
items on NMUPO, and so no overtime comparisons can be made.
The Ontario Student Drug Use and Health Survey (OSDUHS) is a representative survey of middle and secondary school students in the province of Ontario. In the most recent (2007) iteration of the survey, 21% of respondents reported NMUPO in the past year (Adlaf & Paglia-Boak, 2007). Over-time trend data could only be provided on the use of OxyContin, which had been first surveyed in 2005; past year non-medical use of OxyContin increased from 1% (2005) to 1.8% (2007) (Adlaf & Pagila-Boak, 2005; Adlaf & Paglia-Boak, 2007). Analogous to the OSDUHS, other provincial studies have shown patterns of NMUPO prevalence among high school students. The Student Drug Use Survey in the Atlantic Provinces (SDUSAP) included a new item on NMUPO in 2007 (yet again without previous data for over-time trends). Between 17% and 20% of students respondents in the provinces of NS, NB, NL and PE reported such use (Poulin & Elliot, 2007). In Alberta, the 2005 Alberta Youth Experience Survey reported that 0.8% of young people in grades 7-12 reported past year use of OxyContin (Lane & AADAC Research Services, 2006). In the fall of 2007 in Manitoba, a total of 3.5% of males and 3.9% of females in grades 7 to senior 4 reported past year use of opioids. However, although students were asked generally whether they used prescription drugs to get high, it appears that they were only asked specifically about the drug Ritalin (Friesen et al., 2008). Finally, the OxyContin taskforce in Newfoundland and Labrador and the Cape Breton Victoria Regional School Board both reported problematic use of OxyContin among young people that required further investigation (OxyContin Task Force, 2004; Covell, 2004).
2.1.3. Street Drug User Populations
A recent study estimated that there were 72,000 NMUPO users, heroin users, or both among the Canadian street drug using population based on overdose death data and a key informants survey, with more individuals using POs non-medically than heroin in 2003 (Popova et al., 2009). Several studies in Canada examine drug use patterns among so-called street drug users, e.g. injection drug users (IDUs) or other high-risk drug users who obtain drugs mainly from street drug markets. The multi-site OPICAN study, a cohort study of opioid and other drug users conducted in 7 Canadian cities (N=484), found in 2005 that POs were used by 80.6% of the total sample, either with or without heroin (ranging from 29.5% to 100% by site; (Fischer et al., 2008a)). Comparisons with baseline assessments suggested that PO use had substantially increased in the cohort since 2001, and largely substituted for decreasing heroin use (Fischer et al., 2006a). In 2005, NMUPO was more prevalent than use of heroin (for the last 30 days) in five of the seven city samples. Prevalence of heroin use significantly decreased among untreated participants since baseline (2001 onward) in all study sites, suggesting a recent shift from heroin to PO use in the study sample (Fischer et al., 2006b).
The ‘I-Track’ study examines drug use and related risk behavior among IDUs in multiple cities across Canada, recording both participants’ injected and non-injected drugs in the last 6 months in 2004 (‘Pilot Phase’ (Health Canada, 2004)) and 2006 (Phase 1 (Health Canada, 2006)). Among injected drugs, morphine (54.3% in 2004; 53.7% in 2006) and Dilaudid (50.2%; 32.9%) were recorded at high but relatively stable or decreasing levels; in comparison, injected heroin use decreased from 42.8% (2004) to 27.6% (2006). Among non-injected drugs, Tylenol with codeine (52.3%) in 2004; 51.5% in 2006, Dilaudid (27.0%; 23.6%), and Demerol (15.8%; 11.5%) were recorded at overall stable levels; in comparison, non-injection heroin use decreased from 25.6% (2004) to 15.6% (2006). Overall in the 7 sites in 2006, greater proportions of study participants injected Dilaudid than heroin in the previous 6 months (27.6% vs 32.9%) and the former drug’s use prevalence was higher in 4 of the 7 cities. Overall in the 7 sites, more injected non-prescribed morphine than heroin in the previous 6 months (27.6% vs. 32.9%) (Health Canada, 2006).
Additional local sites across Canada have highlighted the prevalence of NMUPO in street drug users. A comparison of available Phase 1 (2003) and Phase 2 (2005) I-Track study data for the site of Victoria suggests a similar picture to the overall data, with prevalence rates for injection drug use for morphine (49.8%; 52.8%) and Dilaudid (40.3%; 39.6%); and prevalence rates for non-injection use for Tylenol/codeine (47.6%; 31.3%) and Dilaudid (24.4%; 24.1%) (Epidemiology and Disease Control and Population Health Surveillance Unit, 2006). Among clients of the Vancouver Supervised Injection Site (‘Insite’; N=4764), as a percentage of all visits between March 2004 and April 2005, morphine (13.2%), Dilaudid (6%) and OxyContin (0.5%) use were reported by minorities; these use rates however were substantially lower than those recorded for heroin (40%) and cocaine (28.2%) (Tyndall et al., 2006). The CHASE project team in the Downtown Eastside in Vancouver reporting non-injection drug patterns found that 6% reported use of Dilaudid (compared to 55% crack-cocaine, 6% benzodiazepines) (CHASE Project Team, 2005). Finally, several studies have reported that Edmonton has a very small heroin using community and POs have filled the void. Overall, in a survey of IDUs in inner-city Edmonton, 33.3% reported that their current drug of choice is morphine (compared to 3.3% cocaine, and 10% cocaine and opiates) (Wild et al., 2003; Strang & Rashiq, 2005). More recent data from ARC (2007) showed that past month use of specific POs by Edmonton inner-city drug misusers ranged from 60% for OxyContin and 50% for Dilaudid, to 8.9% for morphine and 3.3% for Demerol (Wild et al., 2008)
2.1.4. Treatment Populations
Some trend data are available on problematic PO use from individuals entering addiction treatment services. Specifically for the province of Ontario, the Drug and Alcohol Treatment Information System (DATIS) records use prevalence (in last 12 months) as well as problem substance citations for POs for nearly all individuals entering publicly funded addiction treatment services (N=80, 881 in 2003/4; N=103,345 in 2007/8, excluding family members). Both indicators, i.e. PO use prevalence (from 13.6% in 2003/04 to 20.1% in 2007/08) and PO citations as problem substance (7.6% to 13.6% in same period) among admissions have increased substantially, e.g., almost doubled, in recent years (Drug and Alcohol Treatment Information System (DATIS), 2008). Among patients admitted to the Methadone Maintenance Treatment program at the Centre for Addiction and Mental Health – Canada’s largest addiction treatment hospital – in Toronto, 82% reported past year NMUPO (either in conjunction with or without heroin (Brands et al., 2004)). Among admissions for CAMH’s opioid detoxification program between 2000 and 2004, the percentage of cases citing OxyContin use increased from 3.8% in 2000 to 55.4% in 2004 (Sproule et al., 2009).
Local cross sectional data also indicates problematic use among treatment populations. For example, in Regina in 2004/5, 1,192 clients being treated within drug treatment agencies reported using prescription narcotics, and 70% identified their use as problematic (Addictions Services Regina Qu’Appelle Health Region, 2006). In 2003, the OxyContin Task Force reported a 9.5% increase in admissions for OxyContin abuse in Newfoundland compared to the previous year (OxyContin Task Force, 2004). Finally, between May and December 2000, 209 new clients at the Native Addiction Services (NAS) in Calgary completed a self administered questionnaire. Overall, 48% reported inappropriate use of prescription drugs, 62% of whom reported using opioids or other analgesics (Wardman et al., 2002).
2.2. Prevalence of Non-Medical Use of Benzodiazepines (NMUBD)
In Canada in 2007, approximately $7.50 per capita was spent on retail purchases of benzodiazepines (BDs) and the related drugs zopiclone and zaleplon. Unlike POs, however, there was very little increased spending per Canadian between 1998 and 2007 after accounting for inflation (Morgan et al., 2008). Correspondingly, in the most recent INCB report on psychotropic substances, compared to other countries, Canada’s consumption of BDs varies according to drug category, yet has overall been quite stable over the past decade. For example, Canada’s average consumption in defined daily dose (DDD) per thousand inhabitants per day of BD-type sedative hypnotics totals 8.74 in the latest reporting period (compared to 12.77 in Australia, 16.47 in the United States and 32.44 in the UK). However, consumption of BD-type anxiolytics is higher than a decade ago at 24.66 (compared to 43.03 in the United States, 12.76 in the UK and 19.02 in Australia). Finally, consumption of BD-type anti-epileptics (specifically Clonazepam) is considerably lower at 2.95, yet is higher than the US (1.45), the UK (1.3) and Australia (0.76) (International Narcotics Control Board, 2009b).
2.2.2. General Populations
The most recently completed Canadian general population survey on substance use, the Canadian Addiction Survey (CAS; (Adlaf et al., 2005a)) contained no data on prescription drug use, and hence cannot give any indication of NMUBD in the Canadian adult population at large. The recent national CADUMS population survey reported that 10.7% of the Canadian adult population had used pharmaceutical sedatives, mostly BDs, in the past year. Of these, 1.4% - or 0.2% of the total sample population – had used these “to get high” ((Health Canada, 2009); see methodological caveats for CADUMS discussed above).
Further available data shows an unclear picture of the extent of NMUBD. For example, the 7 Addictive Behaviours Study by the Addiction and Mental Health Research Laboratory in Alberta in 2002 found that 0.9% of Alberta’s general population reported non-medical use of tranquilizers (e.g. Ativan, Valium and Xanax) in the past 12 months, compared to 4.9% for analgesics and 3% for sedatives (Wild et al., 2008).
The Canadian Campus Survey (CCS) collected data on substance use and other health issues from a random sample of 6,282 full-time university undergraduate students from 40 universities in 2004. 5.2% reported lifetime use of tranquilizers (prescription type drugs like Valium, Librium, Xanax, Ativan, Klonopin), 2% reported past year use and 1% reported use in the past 30 days. However, these questions were framed and placed together with questions on illicit drugs, and did not specify whether use was for medical or non-medical purposes (Adlaf et al., 2005b). The previous iteration of the CCS (1998; (Gliksman et al., 2000)) did not include any items on non-medical use of prescription tranquilizers, and so no overtime comparisons can be made. Higher rates have been found in smaller-scale studies of university students, for example at McGill University in a study of 149 students in 2003-4, 8.1% reported lifetime NMUBD (Barrett et al., 2006)
Several recent studies with high school student populations have shown similar rates of past year non-medical use of tranquillizers. The Ontario Student Drug Use and Health Survey (OSDUHS) is a representative survey of middle and secondary school students in the province of Ontario. In the most recent (2007) iteration of the survey, 1.8% of respondents reported use of tranquilizers (e.g. Valium, Ativan and Xanax) in the past year and 2.2% reported lifetime use. There have been no significant changes in past year use over the past decade, with percentages hovering around 2% (Adlaf & Paglia-Boak, 2007). Other provincial studies have shown comparable results, with between 2.3% and 3% of student respondents in the provinces of NS, NB, NL and PE reporting such non-medical use of tranquilizers in the Student Drug Use Survey in the Atlantic Provinces (SDUSAP). This shows a decrease since 1998, when past year non-medical use in the four provinces ranged from 3.4%-5.9% (Poulin & Elliot, 2007). Past year use of tranquilizers decreased from 2002 to 1% in the 2005 Alberta Youth Experience Survey (Lane & AADAC Research Services, 2006). Finally, reports on adolescent drug use showed past 30 day use of anti-anxiety drugs (e.g., Valium, Xanax, Ativan) at 0.8% - 2.3% in areas of Cape Breton (Covell, 2004).
2.2.3. Street Drug User Populations
The ‘I-Track’ study examines drug use and related risk behaviors among IDUs in multiple cities across Canada, recording both participants’ injected and non-injected drugs in the last 6 months in 2004 (‘Pilot Phase’ of four sites (Health Canada, 2004)) and 2006 (Phase 1 – total of seven sites across Canada (Health Canada, 2006)). Among injected drugs, NMUBD remained stable in the total study population across sites between the two phases (12.1% in 2004; 8.4% in 2006). Among non-injected drugs, NMUBD increased substantially from 13.2% in 2004 to 49.1% in 2006. However, it must be noted that examples of BDs (e.g. Xanax, Valium, nerve pills) were added as a specific choice of response at phase 1, therefore direct over-time comparisons need to be made with this caveat in mind. The multi-site OPICAN study, a cohort study of opioid and other drug users across Canada, found that BDs were the most commonly used non-opioid prescription drug used across sites, with 36.2% of the sample reporting past 30 day use (legitimate and/or non-medical use) (Haydon et al., 2005).
Several local studies have shown high prevalence for NMUBD among street drug users. Key informants in an assessment in Edmonton confirmed BDsamong the prescription drugs most commonly used non-medically among street drug users. Furthermore, past 30 day use among inner city drug users was reported by 43.7% of respondents in the local OPICAN cohort and by 45.6 % in the Assessment of Risk Contexts (ARC) study (Wild et al., 2008). Looking specifically at non-injection drug use patterns, a comparison of available Phase 1 (2003) and Phase 2 (2005) I-Track study data for the site of Victoria show prevalence rates for NMUBDs at 33.9% in Phase 1 and 31.3% in Phase 2(Epidemiology and Disease Control and Population Health Surveillance Unit, 2006). However, the CHASE project team in the Downtown Eastside in Vancouver reporting non-injection drug patterns found that only 6% of study participants reported NMUBD(CHASE Project Team, 2005).
2.2.4. Treatment Populations
Some over-time data are available on NMUBD from individuals entering addiction treatment services, generally showing stability over time. Specifically in the province of Ontario, the DATIS records use prevalence (in last 12 months) as well as problem substance citations for BDs for nearly all individuals entering publicly funded addiction treatment services (N=80,881 in 2003/4; N=103,345 in 2007/8, excluding family members). Both indicators, i.e. BD use prevalence (11.2% in 2003/04 compared to 10% in 2007/08) and BD citations as problem substance (3.9% in 2003/4 and 3.4% in both 2006/7 and 2007/8) among treatment admissions remained relatively stable in this time period (Drug and Alcohol Treatment Information System (DATIS), 2008). Treatment requests specifically in Toronto recorded by the Drug and Alcohol Registry of Treatment (DART), showed that in 2002-3, 1% regarded BDs as a problem substance, while the corresponding total for the succeeding year was <2% (Research Group on Drug Use, 2004). Of admissions to methadone maintenance treatment at CAMH between 1994-1999, overall 26% reported problem BD use, with no significant changes observed over time (Brands et al., 2002). Amongst all treatment enrollees in 2003/4 at the Addictions Foundation of Manitoba (AFM), 28% of clients reported lifetime use of sedatives/hypnotics and tranquilizers at least once, with the most common being BDs. Use of sedative hypnotics and tranquilizers increased from 22.4% in 2000/1 to 31.3% in 2005/6, yet it is not clear how much of this increase can be attributed to NMUBD (CCENDU, 2004; Stevens & The Winnipeg Site Network Team, 2006).
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