Full report - BC Centre for Disease Control

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BC DOAP REPORT 2014

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~Contributors to the Report ~Prepared by ZACHARY TANNER | MOTOI MATSUKURA | VESNA IVKOV | ASHRAF AMLANI | JANE BUXTON

~Data was provided by the BC Drug Overdose and Alert Partnership organizations/agencies - BC Centre for Disease Control –

- First Nations Health Authority

Harm Reduction Program

- Health Canada Drug Analysis Service

- BC Ambulance Service

- Provincial Health Services Authority

- BC Centre for Excellence HIV/AIDS -

- Royal Canadian Mounted Police

Urban Health Research Institute

- Vancouver Police Department

- BC Coroners Service

- Vancouver Area Network of Drug Users

- BC Drug and Poison Information Centre - BC Provincial Toxicology Centre

~Other data sources

- BC Regional Health Authorities

- BC Centre for Disease Control –

- Fraser Health Authority

Clinical Prevention Services

- Interior Health

- BC Public Health and Microbiology Reference Laboratory

- Northern Health

- Canada Border Services Agency

- Vancouver Coastal Health

- College of Pharmacists of BC

(including Public Health Surveillance Unit)

- HealthLink BC

- Vancouver Island Health Authority - Centre for Addictions Research of BC,

University of Victoria

~Acknowledgments

~Suggested reference

We would like to thank the invaluable assistance of DOAP members and individuals at the organizations who provided data and interpretation including: Sara Forsting, Margot Kuo, Randy Slemko, William Speechley, Wrency Tang, Lianping (Mint) Ti, Kate Vallance and Victoria Wan. We also thank the enthusiastic students who assisted in writing and editing parts of this report including: Rabia Bana, Jennifer Campbell, Bryan Chow, and Alissa Greer.

Tanner Z, Matsukura M, Ivkov V, Amlani A, Buxton JA. British Columbia Drug Overdose and Alert Partnership report. BC Drug Use Epidemiology (September 2014) BCCDC.

We are grateful to the Canadian Community Epidemiology Network on Drug Use (CCENDU) staff at the Canadian Centre on Substance Abuse for their continued encouragement and support, and assistance obtaining data. CCENDU provides a unique opportunity for networking and discussing drug issues at a national level and provides the format on which DOAP is based. CONTRIBUTORS

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QUICK NAVIGATION HELPERS 1) click on any chapter in the Table of Content to move directly to the page 2) click on 'Back to Table of Content" in the header area of a page to return 3) links in the text are either taking you to other areas of the report, the glossary or external websites

01

CONTRIBUTORS TO THE REPORT

04 ACRONYMS 06

OBJECTIVE OF THE REPORT

06

EXECUTIVE SUMMARY

08 BACKGROUND 08 Harm Reduction Committees &

Health Authorities in BC

CHAPTER 3 30 MORBIDITY 30 0 Hospitalizations Attributable (related)

33

0 Emergency Department Attendees

33 39 40

0 Non-fatal Overdoses

41 42

0 HealthLink BC, 8-1-1 Service

CHAPTER 1 10 DEMOGRAPHICS OF BC POPULATION 0 Population 10 11 0 Life Expectancy 11 0 Housing

CHAPTER 2 13 SUBSTANCE USE TRENDS 0 General Population & Substance Use 13 20 0 High Risk Populations & Substance Use 21 0 Substance Availability & Cost 22 0 Oxycontin 22 0 Medical Marijuana 23 0 Fentanyl 25 0 Youth 25 YOUTH IN SCHOOL 27 HIGH RISK YOUTH

to Substance Use

Reporting Substance Use

0 BC Ambulance Ingestion Poisoning Calls 0 Drug and Poison Information Centre -

Poison Exposure Calls

0 Ambulance Naloxone Administrations

CHAPTER 4 45 HIV AND HEPATITIS C 0 HIV 45 45 HIV BACKGROUND 45 HIV TREND 47 DEMOGRAPHICS OF HIV CASES IN BC 48 HIV & ABORIGINAL POPULATIONS 48 HIV & EXPOSURE CATEGORY 50 HIV TREATMENT 52 AIDS 53 0 Hepatitis C Virus (HCV) 53 HCV BACKGROUND 53 HCV TREND 56 RECENT HCV INFECTIONS 58 HCV & INJECTION DRUG USE TABLE OF CONTENT

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CHAPTER 5

CHAPTER 7

60 MORTALITY 0 Illicit Drug Overdose Deaths 63 63 0 Mortality Attributable (related)

89 LAW ENFORCEMENT 0 Data Collection 89 89 0 Crime in BC 92 0 Crime in Vancouver 93 VANCOUVER CDSA OFFENCES 94 VANCOUVER DRUG EXHIBITS SEIZED 95 0 Comparison CDSA Offences

to Substance Use

65

0 Illicit drug overdose deaths

67 68

0 Classification of Illicit Drug Deaths

(BC Coroners Service)

0 Illicit Drug Deaths by Type of Drug

CHAPTER 6 71 HARM REDUCTION 0 HR Supply Distribution Programs 72 72 SAFER SEX SUPPLIES 73 SAFER INJECTION EQUIPMENT

(SYRINGE)

76 OTHER SAFER INJECTION EQUIPMENT 77 SAFER INHALATION EQUIPMENT 78 BORROWING & LENDING OF SAFER

INJECTION & INHALATION EQUIPMENT

82 SUPERVISED INJECTION SITE (INSITE) 82 TAKE HOME NALOXONE (THN) PROGRAM 85 0 Methadone Maintenance Therapy 87 METHADOSE 88 0 SALOME and NAOMI Studies

TABLE OF CONTENT

BC and Vancouver

95 0 Alternatives to Incarceration 96 DRUG TREATMENT COURT OF VANCOUVER 97 DOWNTOWN COMMUNITY COURT 98 0 Drug Thefts from Pharmacies 98 0 Drug Trafficking 98 OPIUM AND HEROIN 99 COCAINE 99 CANNABIS 99 SYNTHETIC DRUGS 101 CANADA BORDER SERVICES AGENCY 102 PRECURSOR CHEMICALS

104 GLOSSARY 105 DATA SOURCES 107 REFERENCES

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~Acronyms ACCESS

AIDS Care Cohort to Evaluate access to Survival Services (cohort study led by UHRI)

AIDS

Acquired Immunodeficiency Syndrome

AHS

Adolescent Health Survey (McCreary Centre Society, BC)

AOD

Alcohol and Other Drug monitoring program- led by CARBC

ART

Antiretroviral Treatment

ASSIST

Alcohol, Smoking and Substance Involvement Screening Test

AUDIT

Alcohol Use Disorders Identification Test

ARYS

At-Risk Youth Study (cohort study of youth aged 14-26 years led by UHRI)

BC

British Columbia

BCCDC

BC Centre for Disease Control (an agency of the Provincial Health Services Authority)

BCCS

BC Coroners Service

BC CfE

BC Centre for Excellence in HIV/AIDS

CADUMS

Canadian Alcohol and Drug Use Monitoring Survey

CARBC

Centre for Addictions Research of BC, University of Victoria

CDSA

Controlled Drug and Substances Act

CPBC

College of Pharmacists of British Columbia

CPSBC

College of Physicians and Surgeons of BC

DAA

Direct-Acting-Antiviral

DOAP

BC Drug Overdose and Alert Partnership

DTES

Downtown East Side of Vancouver

DTP

Drug Treatment Program

ED

Emergency Department

ER

Emergency Room

EIA

Enzyme Immunoassay

EKASS

East Kootenay Addiction Service Society

FH

Fraser Health Authority (one of 5 regional health authorities in BC)

FNHA

First Nations Health Authority

HA

Health Authority

HCV

Hepatitis C virus

HDM

Hydromorphone

HIV

Human Immunodeficiency Virus

ACRONYMS

Y

HR

PWUD

HRSS

RCMP

HSDA

RNA

IDU

SALOME

INCB

SAP

IH

SIF

Harm Reduction

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People Who Use Drugs

BC Harm Reduction Strategies and Services

Royal Canadian Mounted Police

Health Service Delivery Area

Ribonucleic Acid

Injection Drug Use

Study to Assess Longer-term Opioid Medication Effectiveness

International Narcotics Control Board

Special Access Programme

Interior Health Authority (one of 5 regional health authorities in BC)

Supervised Injection Facility

SMR

LHA

Standardized Mortality Ratio

Local Health Area

SVR

MMT

Sustained Virological Response

Methadone Maintenance Therapy

THN

MSM

Take Home Naloxone

Men who have Sex with Men

UHRI

NAOMI

North American Opiate Medications Initiative

Urban Health Research Institute (a program of BC CfE in HIV/AIDS)

NAT

VCH

Nucleic Acid Testing

Vancouver Coastal Health (one of 5 regional health authorities in BC)

NH

VIDUS

Northern Health Authority (one of 5 regional health authorities in BC)

Vancouver Injection Drug Users Study (cohort study led by UHRI)

PHSU

VIHA

Public Health Surveillance Unit (VCH)

Vancouver Island Health Authority (now Island Health)

PLHIV

VPD

People Living with HIV

Vancouver Police Department

POM

Prescription Only Medication

PWID

People Who Inject Drugs

ACRONYMS

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~Objective of the Report Information about drug use in British Columbia (BC) and its adverse consequences is available through a variety of sources. These sources include surveys, cohort studies, and administrative data. Surveys may be administered to the general population or specific subgroups such as youth or high risk populations. Information may be collected for defined geographic areas or the province as a whole, and for calendar or fiscal years. This

report collects and collates the most recent data available regarding substance use and associated morbidity, mortality and enforcement patterns. This report also includes up to date information on harm reduction strategies used to mitigate these adverse outcomes. We discuss interpretations, comparisons, and limitations of the data to provide the reader with a greater understanding of the bigger picture related to drug use in BC.1

~Executive Summary CHAPTER 1

Demographics— summarizes the demographic characteristics of BC population including geographic distribution, life expectancy and mortality.

, Crack cocaine use is highest in the Northern Health

- In 2013 the population of BC was estimated to be 4,581,978.

, Heroin use is highest in the Fraser Health region (54%).

- Of the five health authorities, Fraser Health has the smallest

, Marijuana use is highest in Interior Health (60%).

geographic area but a population of 1,689,875 (about 37% of BC’s population). Northern Health is the largest geographic area but is the region with the smallest population (284,000). - Life expectancy at birth in BC continues to increase in all

health authorities but disparities between them continue. In 2011, life expectancy at birth was 82.01 years overall in BC; Vancouver Coastal Health was highest at 83.67 years and Northern Health almost 5 years lower at 78.86 years .

CHAPTER 2

Substance use trends— explores substance use trends among the general and high risk populations in BC. A subsection reports drug use patterns among youth – both in the general and high risk populations. Key findings include:

region (67%).

- Among BC youth in school, self-reported use of all psychoactive

substances declined from 2008 to 2013. - Among a convenience sample of street-involved youth in

Victoria and Vancouver , Crystal methamphetamine and cocaine are the most

widely used illicit drugs after marijuana. , Reported crystal methamphetamine use in Victoria

increased from 6% in 2011 to over 50% in 2013 .

CHAPTER 3

reached its highest reported level to date in 2013 (17.8%).

Morbidity— analyzes substance related morbidity patterns. Hospitalizations related to tobacco, alcohol, and illicit drugs are analyzed by health authority. Overdoses experienced and witnessed are reported from various surveys. Emergency room visits related to overdoses in Vancouver and overdoses at Vancouver’s supervised injection site are reported. Calls to: BC ambulance determined as ingestion poisoning, Drug and Poison Information Centre, and HealthLink BC in 2013, and ambulance administered naloxone events throughout the province over time are shown. Key findings include:

, The availability (ability to obtain drugs within 10 minutes)

- Tobacco use results in more hospitalizations than alcohol or

- Among people who use illicit drugs in Vancouver

(Urban Health Research Initiative) , Crack cocaine use has declined since reaching a high of

70% in 2008, but remains the highest reported drug used (34% in 2013). , Crystal methamphetamine use (injection and non-injection)

of illicit drugs increased from 2005 to 2007 but has remained fairly constant since. - Among clients accessing harm reduction supplies through-

out BC in 2013

illicit drugs in BC; 28,206, 21,542 and 4,326 related hospitalization respectively in 2011. Tobacco-related admissions are declining but those related to alcohol are increasing. EXECUTIVE SUMMARY

Y - In Vancouver, alcohol is the main substance responsible for

overdose-related emergency room visits; visits appear higher in income assistance and/or disability assistance cheque issuance week. - Experiencing an overdose varied considerably by risk

population and site:

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- After a steady decline since 1997, the number of cases

of HCV identified in BC rose in 2013 to 2,105 (from 1,886 in 2012). - HCV testing has increased annually; in 2013 there were more

than 200,000 HCV tests performed - From 2008 through 2012, all regional health authorities

, About 30% of high risk recreational-use adults in

Vancouver and Victoria. , About 18% of street involved youth in Vancouver but

28% in Victoria.

experienced an overall decrease of 24 month HCV seroconversion in people who had repeat tests. In 2013 rates were similar in all health authorities. - New effective treatments for HCV with fewer side-effects

, Adult harm reduction clients varied from 10-18%

between health regions. - BC Ambulance Service receives between 150 and 200 calls

per week which are coded as Ingestion Poisoning calls. - BC Poison and Information Centre receives an average of 70

calls each day about poison exposures. - HealthLink BC received between 400 and 500 calls from the

public related to alcohol and other drugs per month in 2013. - In 2013, the BC Ambulance Service reported 2,011 naloxone

administration events throughout BC. Over the last 5 years Fraser Health had the highest number of naloxone events (3,211) followed by Vancouver Coastal Health at 2,868 events.

CHAPTER 4

HIV and hepatitis C virus— describes HIV and hepatitis C virus (HCV) disease background and patterns in BC, including case demographics, exposure categories, and testing/treatment strategies. Key findings include: HIV: - Newly diagnosed HIV cases in BC generally declined from 408 cases in 2003 to 237 in 2012; an increase was reported in all health authorities in 2013 (272 total cases); this increase in HIV identification was associated with increased testing. - About 12% of cases were female (33 female and 239 male

in 2013) - Over half of cases diagnosed in 2013 were identified as men

who have sex with men. - There were 29 new HIV cases among people who inject drugs

in 2013 (same as 2012) down from 136 cases in 2003. HCV: - The BC HCV diagnosis rate continues to be higher than the Canadian average; 41.5 and 19.3 cases per 100,000 population respectively in 2012. EXECUTIVE SUMMARY

are being developed, are expensive and currently not yet widely available in BC.

CHAPTER 5

Mortality— analyzes deaths in BC related to substance use. - Vancouver Downtown East Side has an overall mortality rate

almost five times higher than the province. - In 2011, the tobacco-related death rate was three times the

alcohol-related death rate, which was three times the illicit drug rate (87, 23 and 7 cases per 100,000 population respectively). - Illicit drug-related mortality rates in 2011 were highest in

Fraser Health - In 2013, illicit drug overdose deaths in BC increased to over

300 deaths , About a quarter of these deaths were female , Males aged 20-29 years had the highest rate followed by

males 40-49 years. , The vast majority (90%) of these deaths were determined

to be accidental. - Since 2007, overdose deaths due to mixed drugs and multiple

narcotics have been the leading cause of illicit drug deaths. - BC is experiencing an increase of fentanyl-detected deaths

(15 in 2012 to 51 in 2013). - In 2010 there were 72 deaths identified in people

prescribed opioids.

CHAPTER 6

Harm Reduction— describes provincial safer sex, safer injection and safer inhalation supply distribution. Vancouver’s supervised injection facility (Insite), BC’s Take Home Naloxone program, methadone maintenance therapy (including the change to Methadose) and the NAOMI and SALOME studies are discussed. Key findings include:

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- 76% of British Columbians support harm reduction - In 2013, the harm reduction program distributed more than 4

million condoms throughout BC. - Needle/syringe distribution throughout BC increased from

4.18 million in 2006 to over 8 million in 2013. - Population rate of needle/syringe distribution varies by

health authority. Vancouver Coastal Health had the highest rate and Fraser Health the lowest (at 450 and 14.00 L 12.50 L - 14.00 L 11.00 L - 12.49 L 9.50 L - 10.99 L 8.00 L - 9.49 L < 8.00 L

11 12 13 14 21 22 23 31 32

1

Victoria

15 years and older

East Kootenay (11.69 L) Kootenay Boundary (11.13 L) Okanagan (11.45 L) Thompson Cariboo Shuswap (10.78L) Fraser East (7.20 L) Fraser North (5.83 L) Fraser South (6.48 L) Richmond (4.51 L) Vancouver (7.72 L)

CHAPTER 2

33 A North Shore/Coast Garibaldi North (13.31 L) 33 B North Shore/Coast Garibaldi South (10.49 L) 41 South Vancouver Island (9.96 L) 42 Central Vancouver Island (10.14 L) 43 North Vancouver Island (11.47 L) 51 Northwest (11.37 L) 52 Northern Interior (9.36 L) 53 Northeast (10.64 L)

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Self-reported tobacco use among males and females in BC is consistently lower than the rest of Canada. However, cannabis use in both sexes was higher in BC and an increase was reported

Figure 2.4

among BC males in 2012 (Figure 2.4a). Males in BC and the rest of Canada were significantly (p < 0.05) more likely than females to report cannabis use (Figure 2.4b).

CADUMS substance use trends in BC and Canada by gender, 2008-2012; a) Prevalence of tobacco smoking in the past year; b) Prevalence of cannabis use in the past 12 months20

b) Prevalence of cannabis use in the past 12 months among Canadians 15+ by gender, 2008-2012

25 Smokers (%)

20

19.2 16.1 14.7 11.9

15 10 5 0 Year 2008

BC Females

Cannabis users (%)

a) Prevalence of smoking in past year among Canadians aged 15+ by gender, 2008-2012

20

19.0

15

12.9

10

8.9 6.7

5 0

2009

Rest of Canada Females

2010

BC Males

2011

2012

Rest of Canada Males

Year 2008

BC Females

2009


SUBSTANCE USE TRENDS

2010

BC Males

2011

2012

Rest of Canada Males

Y CADUMS reported the prevalence of lifetime cannabis use in BC in 2011 as 44.3%.6 As shown in Figure 2.5, the Kootenay Boundary HSDA has the highest prevalence of lifetime cannabis

Figure 2.5

BC DOAP REPORT 2014

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Y

use (62%); closely followed by Northern Interior (61%), Northeast (60%) and South Vancouver Island (57%). Richmond has the lowest prevalence of lifetime cannabis use (35%).20

Percentage of lifetime cannabis use by HSDA in BC, 2008-200920 N

Fort Nelson 51

53

52 Prince George

33

33

22

14 Kamploops

43

32 31

42

43

23

21

13

Kewlona 12

11

42 41

Percent Lifetime Cannabis Use Among Adults1 53.7 – 62.0 51.2 – 53.6 44.7 – 51.1 34.4 – 44.6 Classified using quartiles

11 12 13 14 21 22 23 31

1

age15 years or older

East Kootenay (43.0%) Kootenay Boundary (62.00%) Okanagan (51.6%) Thompson Cariboo Shuswap (49.2%) Fraser East (41.4%) Fraser North (44.6%) Fraser South (45.6%) Richmond (34.4%)

CHAPTER 2

Victoria

32 33 41 42 43 51 52 53

Vancouver (46.5%) North Shore/Coast Garibaldi (52.4%) South Vancouver Island (57.3%) Central Vancouver Island (51.1%) North Vancouver Island (52.8%) Northwest (53.6%) Northern Interior (61.1%) Northeast (60.3%)

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Figure 2.6 illustrates the prevalence of illicit substance use (other than cannabis) in the past 12 months among adults aged 15 and older reported by CADUMS. Prevalence was estimated using the number of the people who reported using any illicit drugs including cocaine, speed, methamphetamine, ecstasy, hallucinogens, inhalants, heroin, pain relievers, stimulants, and

Figure 2.6


sedatives divided by the sample population. In BC and the rest of Canada, males were more likely than females to use illicit substances and the prevalence of illicit drug use between 2008 and 2012 is significantly higher (p < 0.05) in BC compared to the rest of Canada.20

CADUMS substance use trends in BC and Canada by gender, 2008-2012; Prevalence of other illicit substance use (excluding cannabis) in the past 12 months20

Prevalence of other illicit substance use (excluding cannabis) in the past year among Canadians 15+ by gender, 2008-2012 7 Illicit drug users (%)

6 5

- 4.7

4

3.6

3 2

1.6

1.4

1 0

Year

2008 BC Females

2009

2010

2011 BC Males


2012 Rest of Canada Males

BC numbers for females 2011-12 and males 2011 were suppressed due to unstable estimates

0 High Risk Populations and Substance Use CARBC’s High Risk Populations survey is a convenience sample of 50 street-involved adults and 50 adults using drugs recreationally, in Vancouver and Victoria every six months. These high risk populations report higher alcohol, cannabis, and other illicit substances use compared to the general population. However, substance use patterns vary between these two highrisk populations. Figure 2.7 shows that in 2012, 1% of recreational drug using adults compared to 78% of street-involved adults reported crack cocaine use in the previous month, while 88% versus 6% in the same groups used ecstasy. There are also

statistically significant differences in crystal methamphetamine, heroin, LSD, and mushroom use.20 The survey also found 36% of the recreational-use adult cohorts in Vancouver and Victoria reported simultaneous alcohol and marijuana use over the previous weekend, and 11% reported simultaneous use of alcohol and cocaine. Using more than one substance at a time (poly-substance use) was lower among street-involved adults, the most frequently mixed substances being alcohol and marijuana (10%) followed by crystal meth and heroin (7.5%).20 SUBSTANCE USE TRENDS

Y Figure 2.7

96

91

80

68

60

78

72

89

88 74

75

69 55

52 40 40

40

25 20

13

6

5

10 1

0 Street involved adults

Alcohol Crack Ecstasy

6

3

Recreational Adults

Marijuana Amphetamine LSD

Drugs used at least weekly reported by the VIDUS and ACCESS cohorts are shown in Figure 2.8 and 2.9. Figure 2.8 indicates considerable changes in weekly drug use (by any route) over time. Cocaine use declined since 1996, while crack cocaine use

Figure 2.8

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Past month substance use in high risk populations in Victoria and Vancouver, 2012 (Wave 2)20

100

Percentage

BC DOAP REPORT 2014

Tobacco Crystal Meth Magic Mushrooms

Cocaine Heroin

increased from 5.1% in 1996 to 70.6% in 2008 but declined to 34% in 2013. Crystal methamphetamine use reached its highest recorded level in 2013 (17.8 %).

Weekly drug use* patterns among people who use illicit drugs in Vancouver, Canada, 1996-2013 80 70

Percentage

60 50 40 30 20 10 0

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Cocaine

Crack

Crystal Meth

Heroin

Marijuana

(BC Centre for Excellence in HIV/AIDS, personal communication, June 10, 2014)* Note: each category in the graph captures both injection and non-injection use of the specified drug CHAPTER 2

Prescription opioids

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Figure 2.9 shows weekly drug use by route of administration; illicit prescription opioid use (i.e. use of prescription opioids without a valid prescription) includes OxyContin (oxycodone), Percocet (oxycodone/tylenol), Tylenol 3 (codeine/tylenol), morphine, Dilaudid (hydromorphone), Demerol (meperidine or pethadine), methadone, fentanyl, hydrocodone, and Talwin (pentazocine).

reduction distribution sites throughout BC were surveyed in 2012 and 2013 (HR client survey).22,23 In 2013, drug use was weighted by HSDA population; the three most commonly used substances were marijuana (51%), alcohol (48%), and crack (35%). Substance use patterns vary between regions as seen in Figure 2.10. Crack use was highest in NH (67%) and lowest in VCH (33%). Powdered cocaine use was also highest in the NH region. By contrast, reported use of heroin and crystal meth was lower in NH compared to other regions of BC and highest in FH (54% and 48% respectively).23

Most high-risk drug use research in BC is conducted in Vancouver and Victoria. To gain a better understanding of drug use outside these two cities, over 700 clients using harm

Figure 2.9

Weekly substance use prevalence among people who use illicit drugs in Vancouver, Canada, 2013 40 34.0

35

Percentage

30

26.1

25.2

25 19.3

20

14.9

15

0

n

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c nje

e

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Cr

c nje

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c nje

h

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c nje

k

ac

Cr

n No

c nje

io ipt

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sc

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p nO

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(BC Centre for Excellence in HIV/AIDS, personal communication, June 10, 2014)


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Y Figure 2.10

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21

Percent of HR clients reporting substance use in the past week by HA, weighted by HSDA population, 201323

70 60

Percentage

50 40 30 20 10 0 Marijuana

Alcohol FH

Crack VCH

Heroin VIHA

IH

Crystal Meth

Cocaine

NH

0 Substance Availability and Cost The availability of illicit drugs in Vancouver is reported by UHRI as the percentage of PWUD who can obtain the drug within 10 minutes. PWUD in Vancouver were more likely able to obtain crack cocaine (80%), cocaine (70%) and heroin (70%) than cannabis (65%) or crystal methamphetamine within 10 minutes in 2011. URHI cohort participants identified the cost of drugs has been stable over the past 10 years: - Heroin $20 per 0.1 gram since 2001, - Powder cocaine and crack cocaine $10 per 0.1 gram - Crystal methamphetamine $10 per 0.1 gram.

The availability and consistent price of drugs in the Vancouver area does not support the claim that law enforcement efforts have reduced the available drug supply and increased the cost of illicit substances.18 CHAPTER 2

The Centre for Addiction Research of BC (CARBC)’s High Risk Population survey in Vancouver and Victoria shows similar trends in drug prices and availability. Since 2008, cocaine, crack, heroin, and crystal meth have been reported by street-involved adults in both cities as being either “easy” or “very easy” to obtain. Furthermore, the reported street prices of these substances are very similar to those reported in UHRI’s research and have fluctuated little over the years.20 More information on drug trafficking can be found in the enforcement chapter of this report. The 2014 UNODC World Drug Report identifies Canada as the country with the highest consumption of prescription opioids, with 812.2 mg per capita of morphine equivalence (see Table 2.1); the next highest is United States at 749.79 mg per capita.24 Canada’s high rate of pain medication prescribing and availability has serious implications for drug-related harms and diversion.

22 Table 2.1

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Morphine equivalence consumption per capita Canada, 2011 Drug

mg/capita

ME mg/capita 2.4366

203.0396

Hydromorphone

25.0938

125.4691

Methadone

20.0946

200.3782

Morphine

87.4741

87.4741

145.8966

194.0425

7.1278

1.7820

Total Morphine Equivalence

812.1855

Fentanyl

Oxycodone Pethidine

http://www.painpolicy.wisc.edu/country/profile/canada

0 Oxycontin OxyContin, a patented prescription version of oxycodone used to treat moderate to intense pain, was discontinued in Canada in March 2012. 25 OxyContin was a slow-release narcotic when taken orally as intended; however, users could release high levels of the drug instantaneously by crushing and snorting the tablet. OxyNEO was introduced by the same manufacturer, Purdue Pharma, as a replacement drug that was designed to be harder to crush and dissolve, limiting abuse through snorting and injecting. 25,26 Since its introduction, several provincial health plans altered their drug coverage to restrict coverage of OxyNEO. In BC, only exceptional case-by-base coverage requests for OxyNEO are considered and it is only covered through the palliative care plan. 27,28 There are concerns that the recent lack of OxyContin is leading some opioid dependant users to seek out more accessible and potentially more dangerous opioids. A US-based study found that after the formulation changed, misuse of OxyContin among patients undergoing opioid dependence treatment decreased from 35.6% to 12.8%. 29 However, fentanyl and hydromorphone use increased among these patients, and heroin use doubled. 29 Although the replacement of OxyContin with OxyNEO was intended to address concerns over misuse of the drug, Health Canada’s subsequent decision in November

2012 to approve generic production of extended release oxycodone allowed off-brand versions to enter the Canadian pharmaceutical market. 30 These generic versions are not currently covered under BC’s provincial formulary. 28

0 Medical Marijuana There have been recent developments regarding medical marijuana licensing. Health Canada’s 2014 proposed Marijuana for Medical Purposes Regulations (MMPR) required patients to end home production of medical marijuana on April 1, 2014. 31 However, following a constitutional challenge to the MMPR, a Federal Court granted an injunction on March 21, 2014. 32 This allows those with personal and designated production licenses (for persons responsible for the patient) to continue home production of medical marijuana until the case goes to trial in spring 2015. 32 The injunction does not affect Health Canada’s new medical marijuana licensing system for dispensing prescribed marijuana, and there are concerns that new patients will have difficulty affording the higher marijuana prices projected to result from the federal legislation. 32 On a related note, licensed sales of recreational marijuana began in Washington State on July 8, 2014. 33 This may have implications on illicit cannabis trade with BC, given the U.S. state’s close proximity. SUBSTANCE USE TRENDS

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23

0 Fentanyl BC has experienced a recent increase in fentanyl availability and fentanyl-detected deaths. Fentanyl is a synthetic narcotic that is used to relieve intense pain. In BC, fentanyl can be prescribed for pain management as a transdermal patch, which provides sustained release of the drug. 34 However, this formulation is susceptible to abuse through the extraction of patch contents and subsequent intravenous injection. 35 Fentanyl is 50-100 times more potent than morphine, which greatly increases the risk of accidental overdose. 36 Early signs of fentanyl overdose include severe sleepiness, slow heartbeat, difficulty breathing, cold/clammy skin, and trouble with walking or talking. 36

On May 30th, 2013 in response to an increase in fentayldetected deaths in BC, a joint alert was issued by the Provincial Health Officer, BC Coroners Service (BCCS), healthcare and enforcement partners, warning the public of the increase in deaths and availability of fentanyl within the street drug market. After the alert fentanyldetected deaths declined in June and July 2013, but have since increased. In 2012 there were 15 fentanyl-detected deaths; a total of 51 fentanyl-detected deaths were identified in BC in 2013; most 2013 fentanyl-detected deaths occurred in Metro Vancouver region (15), Island (14), and Fraser (12) (Figure 2.12).

The RCMP and municipal police forces in BC have identified illegally manufactured fentanyl as a white powder resembling heroin and in tablet form as counterfeit oxycodone (fake oxy) tablets. 37,38 Illegally-produced fentanyl can be significantly more toxic than the pharmaceutical-grade. 39 Tablets containing fentanyl are green and are stamped with “CDN” and the number 80 on the opposite sides (Figure 2.11). These pills are nicknamed “green jellies” and “street oxy” in Western Canada. 37 White tablets with “CDN” and “10” stamped on them have also appeared in British Columbia (Figure 2.11). Seized quantities of these two versions tested positive for fentanyl 89% of the time and contain variable, sometimes very high, dose of fentanyl. 37 Individuals using these drugs may be under the assumption that they contain oxycodone only and are therefore at high risk of accidental overdose.

Preliminary data from the BCCS indicates 49 fentanyldetected deaths occurred in the first eight months of 2014 (January 1st to August 31st) of these 10 occurred in the City of Vancouver and 18 in the Fraser region, about a third (16) were female. Please note that 2013 and 2014 data are preliminary and subject to change and these deaths only include fentanyl found in illicit drug-related circumstances, and exclude overdose deaths in persons prescribed fentanyl. 40 In June 2014, the BCCS issued another public warning urging all PWUD to exercise extreme caution when consuming substances that may contain fentanyl. More information regarding fentanyl can be found in the Mortality section. 37

Figure 2.11 Samples of seized counterfeit oxycodone tablets39

CHAPTER 2

24 Figure 2.12

Y

BC DOAP REPORT 2014


Y

Fentanyl-detected deaths by BCCS region, 2012-201440 16

Number of Deaths

14 12 10 8 6 4 2 0

2012

2013

Jan 1-Aug 31 2014

Fraser Metro

6

12

18

3

15

12

Island

2

14

7

Interior

3

3

7

Northern

1

7

5

Total

15

51

49

Figure 2.13

Fentanyl-detected deaths by sex, 2012-201440

Number of Deaths

50 40 30 20 10 0

2012

2013

Jan 1-Aug 31 2014

Male

12

42

33

Female

3

9

16


Y

BC DOAP REPORT 2014

25

Y

0 Youth YOUTH IN SCHOOL The McCreary Centre Society recruits grade 7-12 students in public schools throughout BC to participate in the Adolescent Health Survey (AHS) every five years. Since these participants are in school, they are unlikely to have major substance use problems. The 2013 survey had 259,138 participants and found that self-reported substance use among BC adolescents has declined since 2003 (Figures 2.14 and 2.15). Alcohol was the

Figure 2.14

most commonly used substance in 2013, with 45% of BC youth reporting that they had tried it.41 Self-reported use of steroids, heroin, inhalants, amphetamines, or cocaine has remained stable or declined since 2003. Adolescent use of prescription pills peaked in 2008.

Percentage of BC youth who have ever used alcohol, cannabis, tobacco; 2003-201341 60

Percentage

55 50

Alcohol

45

Cannabis

40

Tobacco

35 30 25 20

Figure 2.15

2003

2008

2013

Percentage of BC youth who have ever used prescription pills, illicit substances; 2003-201341 16

Cocaine

14

Prescription Pills

Percentage

12

Amphetamines

10

Heroin

8

Hallucinogens

6

Mushrooms

4 2

Steriods

0

Inhalants 2003

2008 CHAPTER 2

2013

26

Y

BC DOAP REPORT 2014


Y

Although some students experiment with alcohol and cannabis before the age of 13, the majority (65%) who tried alcohol and cannabis did so between the ages of 13 and 15 (Figure 2.16).41 Table 2.2 summarizes the self-reported reasons among adolescents for their most recent substance use event. The most cited reason was “I wanted to have fun” followed by “my friends were doing it” and “I wanted to try it/experiment”.

Figure 2.16

Mental health factors were also reported as reasons for drug use: ‘because of stress’ or feeling “down or sad”. Youth who reported self-harm in the past year were more likely to use substances compared to those who had not self-harmed (43% vs. 14% respectively).41

Age when BC youth used alcohol or cannabis for the first time41 25

Percentage

20

Alcohol Cannabis

15 10 5 0

17 _

Age (years)

Table 2.2

Reasons for last time substance uses for BC youth41 I wanted to have fun My friends were doing it I wanted to try it/experiment Because of stress I felt down or sad I felt like there was nothing else to do To manage physical pain I was pressured into doing it I thought it would help me focus Because of an addiction I didn’t mean to do it To change the effects of some other drug(s) Other


Males 60% 29% 27% 16% 11% 9% 5% 3% 3% 2% 1% 1% 21%

Females 69% 37% 29% 25% 21% 10% 7% 4% 3% 2% 1% 1% 16%

Y About half of youth who used substances in the past year reported negative consequences. The most frequent responses were “doing something they could not remember”, “passing out”, and “getting injured” (Table 2.3). 41 Substance use trends from the 2013 East Kootenay Addiction Service Society (EKASS) survey are similar to the AHS data. Since 2005, the proportion of East Kootenay area in-school youth experimenting with substances has declined. In 2013, females reported using fewer substances than males. This is in contrast to prior years; for example, alcohol use was 72.0% for girls and 70.3% for boys in 2007, but was 58.5% and 62.0% in 2013; similarly, cannabis use for girls and boys was 36.2% and 35.4% in 2007, but 27.3% and 33.6% respectively in 2013. 42 The EKASS reports the proportion of students admitting to being in a car with an alcohol-impaired driver reached a high of 60.1% in 2009, but was 46.4% in 2013; a considerable decrease but still unacceptably high. Youth who reported driving after drinking alcohol also dropped from 20.1% in 2005 to 12.0% in 2013. Rate of self-reports of

Table 2.3

BC DOAP REPORT 2014

Y

being a passenger in a car with a cannabis-impaired driver was 29.5% in 2011. These declines may also reflect the overall decrease in substance use among youth. 42

HIGH RISK YOUTH The proportion of lifetime drug use among a convenience sample of Vancouver and Victoria area street-involved youth aged 15-24 in the CARBC high risk survey is considerably higher than the in-school youth surveys (Figure 2.17). Although 2013 data is available for Victoria, the most recent data available for Vancouver is 2012. In 2012, marijuana use was more common than alcohol or tobacco, and over 90% of youth reported ever using cocaine at both sites. Reported lifetime use of amphetamines and ecstasy is more prevalent in street-involved youth from Victoria (53% and 95%) than Vancouver (38% and 83%). 20

Consequences of substance use by BC youth in the past year41

Was told I did something I couldn’t remember Passed out Got injured Argued with family members Damaged property Got in trouble with police Schoolwork or grades changed Got into a physical fight Lost friends or broke up with a girlfriend or boyfriend Had sex when I didn’t want to Overdosed Had to get treatment for alcohol or drug abuse Used alcohol or drugs but none of this things happened

CHAPTER 2

27

Males 31% 26% 12% 10% 10% 9% 8% 8% 5% 4% 2% 1% 52%

Females 42% 29% 17% 15% 5% 5% 10% 5% 10% 7% 2% 1% 46%

28

Y

Figure 2.17

BC DOAP REPORT 2014


Y

Percentage of Vancouver and Victoria street-involved youth who have ever used substances, 201220

100 90

Alcohol Marijuana

80

Tobacco

Percentage

70

Cocaine Crack

60

Amphetamine

50

Crystal Meth Heroin

40

Ecstasy

30

LSD Magic Mushrooms

20 10 0

Vancouver

Victoria

Figure 2.18 shows past 30 day substance use in Vancouver in 2012. More recent data (2013) for Victoria (Figure 2.19) shows alcohol use in the past 30 days reached its lowest reported prevalence (59.5%), while crystal meth use (81.1%) shows a

Percentage

Figure 2.18

steep increase since the second 2011 wave (28%). Crack, LSD, and heroin use declined between the two 2013 waves, however this is a small convenience sample (n=50 per wave per city) so rates may be unstable.20

Substance use trends in the past 30 days among street-involved youth in Vancouver, 2008-201220 100 90 80 70 60 50 40 30 20 10 0

2008 2008 2009 Wave 1 Wave 2 Wave 1 Cocaine

Crack

2009 2010 2010 2011 2011 2012 2012 Wave 2 Wave 1 Wave 2 Wave 1 Wave 2 Wave 1 Wave 2 Crystal Meth

Heroin


Marijuana

Alcohol

Y Figure 2.19

BC DOAP REPORT 2014

Y

29

Substance use trends in the past 30 days among street-involved youth in Victoria, 2008-201320

Percentage

100 90 80 70 60 50 40 30 20 10 0 2008 2008 2009 2009 2010 2010 2011 2011 2012 2012 2013 2013 Wave 1 Wave 2 Wave 1 Wave 2 Wave 1 Wave 2 Wave 1 Wave 2 Wave 1 Wave 2 Wave 1 Wave 2 Cocaine

Crack

Crystal Meth

When asked about the perceived benefits of drug use in 2013 reasons most cited were: helping with social connections, alleviating symptoms of mental and physical illness, and making respondents feel happy, calm, and in some cases, more productive.20

Marijuana

Alcohol

participants. Reported marijuana use declined considerably between 2012 and 2013. However, crystal methamphetamine use has increased over the past 3 years, similar to that seen in the high-risk youth in Victoria (Figure 2.19). The proportion of ARYS participants reporting weekly crack use in 2013 (16.4%) is considerably lower than the older Vancouver-based VIDUS and ACCESS cohorts (Figure 2.8), for which crack was the most widely used substance that year.

The At-Risk Youth Survey (ARYS) led by UHRI studies risk factors for 14-26 year old street-involved youth in Vancouver. Figure 2.20 represents drugs used by any route at least weekly among ARYS

Figure 2.20

Heroin

Weekly drug use patterns* among street-involved youth who use illicit drugs in Vancouver, Canada, 2005-2013 80 70

Percentage

60 50 40 30 20 10 0 Cocaine

2005

2006 Crack

2007

2008

Crystal Meth

2009

2010

Heroin Injection

2011

2012

Marijuana

2013 Prescription Opioids

(BC Centre for Excellence in HIV/AIDS, personal communication, June 10, 2014) Note: each category in the graph captures both injection and non-injection use of the specified drug. CHAPTER 2

30

Y

BC DOAP REPORT 2014


Y

CHAPTER 3

MORBIDITY 0 Hospitalizations Attributable (related) to Substance Use Substance use may result in serious illnesses requiring hospitalization. The most responsible diagnosis code from the Ministry of Health Discharge Abstract Database was used to calculate hospitalizations attributable to tobacco, alcohol and illicit drug use. All rates were standardized by age and sex using the 2001 BC population over 15 years of age as the standard. Figure 3.1 shows hospitalizations related to tobacco use

Figure 3.1

exceeded those due to alcohol and illicit drugs. The rate of tobacco hospitalizations dropped significantly, from 601 hospitalizations per 100,000 population in 2002 to 526 in 2011. However, while the rate of alcohol-related hospitalizations significantly increased, those attributable to illicit drugs did not significantly change.20

Hospitalizations related to substance use in BC20

b) Hospitalizations rates related to substance use in BC, 2002-2011

a) Number of BC hospitalizations related to substance use, 2011 30,000

650

28,206

25,000

Rates per 100,000 population

Number of hospitalisations

21,542 20,000

15,000

10,000

550

526

450

437 378

350

250

150

95

82

4,326

5,000

601

50

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

0

Tobacco

Tobacco

Alcohol Illicit drugs

MORBIDITY

Alcohol

Illicit Drugs

Y In 2011, Northern Interior HSDA had the highest hospitalization rate for tobacco and Richmond the lowest (Figure 3.2a). Similar trends exist for alcohol as seen in figure 3.2b. The highest alcohol-attributable hospitalization rate is in Northwest, while Richmond had the lowest. For illicit drug-attributable hospitalizations (Figure 3.2c), the highest rate was found in Northwest, followed by Northern Interior, Kootenay Boundary,

Figure 3.2

31

Y

and Northeast. The lowest rates were observed in Richmond, Fraser North, and North Shore/Coast Garibaldi. These data suggest that the interior and northern regions of the province have higher rates of substance-related morbidity. Similar trends are seen in the mortality rates related to tobacco and alcohol use, but not for illicit drugs. This is further discussed in the mortality section.20

Hospitalization rates attributable to substance use by HSDA in BC in 201120

A Hospitalization Rates Attributable to Tobacco,

B Hospitalization Rates Attributable to Alcohol,

51

51

53

23

53

52

33 14

43

22

51

52

33

31

2011 BC Health Service Delivery Areas

53

52

43

C Hospitalization Rates Attributable to Illicit Drugs,

2011 BC Health Service Delivery Areas

2011BC Health Service Delivery Areas

32

BC DOAP REPORT 2014

43 11

33 21

33 14

13

43

12

42 41

Hospitalization Rate per 100,000 Residents

32

22

31

23

11

33 21

13

12

42 41

43 32

22

31


14

43

23

11

33 21

13

12

42 41


> 749.99

550 - 749.99

> 699.99

600 – 699.99

> 119.99

105 – 119.99

550 - 649.99

450 - 549.99

500 - 599.99

400 - 499.99

90 – 104.99

75 – 89.99

< 450 11 East Kootenay (569.18) 12 Kootenay Boundary (561.58) 13 Okanagan (587.77) 14 Thompson Cariboo Shuswap (673.68) 21 Fraser East (648.97) 22 Fraser North (545.67) 23 Fraser South (500.19) 31 Richmond (414.42)

< 400 32 Vancouver (427.64) 33 North Shore/Coast Garibaldi (457.96) 41 South Vancouver Island (404.40) 42 Central Vancouver Island (527.77) 43 North Vancouver Island (560.76) 51 Northwest (730.15) 52 Northern Interior (752.35) 53 Northeast (656.05)

11 East Kootenay (509.29) 12 Kootenay Boundary (656.89) 13 Okanagan (585.67) 14 Thompson Cariboo Shuswap (613.56) 21 Fraser East (366.51) 22 Fraser North (319.04) 23 Fraser South (334.45) 31 Richmond (315.43) CHAPTER 3

< 75 32 Vancouver (321.60) 33 North Shore/Coast Garibaldi (400.89) 41 South Vancouver Island (466.37) 42 Central Vancouver Island (535.73) 43 North Vancouver Island (564.61) 51 Northwest (959.65) 52 Northern Interior (676.65) 53 Northeast (534.88)

11 East Kootenay (102.90) 12 Kootenay Boundary (131.75) 13 Okanagan (120.63) 14 Thompson Cariboo Shuswap (114.23) 21 Fraser East (109.58) 22 Fraser North (57.87) 23 Fraser South (73.07) 31 Richmond (52.97)

32 Vancouver (73.80) 33 North Shore/Coast Garibaldi (68.04) 41 South Vancouver Island (88.98) 42 Central Vancouver Island (93.75) 43 North Vancouver Island (98.66) 51 Northwest (171.38) 52 Northern Interior (133.33) 53 Northeast (121.53)

32

Y

BC DOAP REPORT 2014


Y

In 2011, among substance-related hospitalizations, most are due to cardiovascular conditions and injury/overdose. Figure 3.3 shows tobacco use was associated with the highest hospitalization rate by cardiovascular events, pulmonary, and cancer. Alcohol contributes most to injury/overdose, mental health, and a third of cancer hospitalizations attributable to substance use. Hospitalizations related to illicit drug use were mostly due to mental health reasons, injury/overdose, and other (e.g. HCV, HIV).20

Figure 3.3

Adverse health conditions resulting from the use of tobacco and alcohol are higher in males and as they may take years to manifest, rates are higher in the 65+ age group. In contrast, illicit drug-related morbidity rates tend to be higher among males and among younger age groups; the 25-44 age group is the most affected among both genders.20

Hospitalization rates attributable to substance use by condition in BC in 201120

50.6

97.9

Mental health

45.6

Other

38.1

6

Cardiovascular

211.1

Cancer

112.1

Pulmonary

Injury/Overdose

42

60.6

152.5

1

197.4

37.9

Rates per 100,000 population Tobacco

Alcohol

MORBIDITY

Illicit drugs

Y

BC DOAP REPORT 2014

33

Y

0 Emergency Department Attendees Reporting Substance Use Another study within CARBC AOD Monitoring Project measures the use of alcohol and other drugs in patients who attend the emergency department (ED) at Vancouver General Hospital and Victoria’s Royal Jubilee Hospital. Between 2008 and 2011, 22.6% of Vancouver and 32% of Victoria ED attendees self-reported moderate or high risk alcohol consumption in the previous year (Figure 3.4a and 3.4b). In both Vancouver and Victoria, nearly

Figure 3.4

AUDIT and ASSIST score classifications in past year among Emergency Department attendees in Vancouver and Victoria, 2008-201120

a) AUDIT & ASSIST score classifications in past year among ED attendees, VANCOUVER, 2008-11, n=705 2.8 7.5 15.1

one-quarter of ED attendees reported moderate or high risk cannabis use, about 5% reported moderate or high risk cocaine and amphetamines use, and approximately 1% in both sites reported moderate risk use of opioids in the past year, with no reports of high risk use.20 It should also be noted that St Paul’s Hospital is the closest to, and most used ED by residents of DTES of Vancouver.

20.2

0 4.6 2.8

0 4.6 5.5

b) AUDIT & ASSIST score classifications in past year among ED attendees, VICTORIA, 2008-11, n=705 0 0.9 4.6

2.8 13.5 20.2 19.4

48.6 92.7

89.9

94.5

43.5

92.7

89.9

0 0.9 4.6

94.5

68

67.9

28.8

Alcohol

2.8 2.8

0.9 3.7 5.5

9.2

Percent

Percent

9.2

1.8

24 Cannabis

Cocaine Amphetamines Opiods HIGH RISK

Alcohol

MODERATE RISK

Cannabis LOW RISK

Cocaine Amphetamines Opiods ABSTAINERS

ASSIST – Alcohol Smoking and Substance Involvement Screening Test AUDIT – Alcohol Use Disorders Identification Test

0 Non-fatal Overdoses Overdoses experienced and witnessed in the last six months in the combined VIDUS and ACCESS cohorts are shown in Figure 3.5 and in the ARYS cohort in Figure 3.6. In 2013, the proportion of youth who self-reported overdose was double that of the CHAPTER 3

VIDUS/ACCESS cohorts (17.8% and 8.9% respectively); however the proportion who witnessed an overdose was similar 23% and 24% respectively. Data collection for the latter variable began in 2005.

34

Y

Figure 3.5

BC DOAP REPORT 2014


Y

Overdose and witnessed overdose events in the last six months among people who use illicit drugs in Vancouver (VIDUS/ACCESS cohorts) Overdose event: Overdosed by accident where you had a negative reaction from using too much drugs

Percentage

50 40 30 20 10 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year Witnessed overdose in last 6 months

Overdosed in last 6 months (BC Centre for Excellence in HIV/AIDS, personal communication, June 10, 2014)

Figure 3.6

Overdose and witnessed overdose events in the last six months among street-involved youth who use illicit drugs in Vancouver (ARYS cohort) Overdose event: Overdosed by accident where you had a negative reaction from using too much drugs

Percentage

60.0 50.0 40.0 30.0 20.0 10.0 0.0 2005

2006

2007

2008

2009 Year

Overdosed in last 6 months (BC Centre for Excellence in HIV/AIDS, personal communication, June 10, 2014)

MORBIDITY

2010

2011

2012

2013

Witnessed overdose in last 6 months

Y Self-reported overdoses experienced and witnessed were also collected in the 2013 HR client survey (Figure 3.7). The proportion of respondents who reported overdosing in the last six months was highest in VIHA (18%) and FHA (17%). More than a third of all participants reported witnessing an overdose in the previous six months; FH was highest at 50%.21

35

Y

Vancouver and Victoria (Figure 3.8 and Figure 3.9, respectively). For both cities, overdoses among recreational-use adults are considerably higher than the other two at-risk populations surveyed. Among street-involved youth in both cities, there was a considerable decline in reported overdoses from 2011 through 2012. Available data for Victoria shows that this decline continues into 2014. The most recent data for both cities identify street-involved adults had the lowest prevalence of self-reported overdose.18

CARBC’s High Risk Populations Survey provides self-reported overdose events in past 12 months among recreational-use adults, street-involved adults, and street-involved youth in

Figure 3.7

BC DOAP REPORT 2014

Percent of HR clients reporting overdose and witnessed overdose events in the last six months by HA, weighted by HSDA population, 201321 Overdose event: Overdosed by accident i.e. where you had a negative reaction from using too much drugs 60

50

Percentage

50

36

40 30 20

31

26 17

20

18

13

11

10

10 0 FH

VCH

VIHA

Overdosed in last 6 months

Figure 3.8

IH

NH

Witnessed overdose in last 6 months

Overdose events in the last twelve months among high-risk populations in Vancouver.20

Overdose event: Overdosed on any drug i.e. where you had a negative reaction from using too much drugs including alcohol

35

Percentage

30 25 20 15 10 5 0

2008

2009

2010

Recreational Adults

Street-Involved Adults

(CARBC, personal communication, July 9, 2014) CHAPTER 3

2011

2012 Street-Involved Youth

36

Y

Figure 3.9

BC DOAP REPORT 2014


Y

Overdose events in the last twelve months among at-risk populations in Victoria20 Overdose event: Overdosed on any drug i.e. where you had a negative reaction from using too much drugs including alcohol

60

Percentage

50 40 30 20 10 0

2008

2009

2010

Recreational Adults

2011

2012

2013

Street-Involved Adults

2014

Street-Involved Youth

(CARBC, personal communication, July 9, 2014)

Table 3.1 summarizes the overdoses witnessed and experienced from the different data sources and the corresponding time period.

Table 3.1

Summary of Experienced and Witnessed Overdoses in BC, 2012 and 201320,23 Experienced Overdose Witnessed Overdose (Last 6 or 12 months) (Last 6 or 12 months)

Region (Study Population)

Year

Adult Vancouver (VIDUS & ACCESS)*

2013

8.9% (6 months)

22.8%

Vancouver (High risk street-involved adults)**

2012

15.2% (12 months)

-

Vancouver (High risk recreational adults)**

2012

29.8% (12 months)

-

Victoria (High risk street-involved adults)**

2013

31.2% (12 months)

-

Victoria (High risk recreational adults)**

2013

34.2% (12 months)

-

FH (HR Client Survey)

2013

17% (6 months)

50% (6 months)

VCH (HR Client Survey)

2013

13% (6 months)

26% (6 months)

VIHA (HR Client Survey)

2013

18% (6 months)

36% (6 months)

IH (HR Client Survey)

2013

10% (6 months)

31% (6 months)

NH (HR Client Survey)

2013

11% (6 months)

20% (6 months)

Vancouver (ARYS)*

2013

17.8% (6 months)

23.7% (6 months)

Vancouver (High risk street-involved youth)**

2012

17.3% (12 months)

-

Victoria (High risk street-involved youth)**

2013

28% (12 months)

-

Youth

* BC Centre for Excellence in HIV/AIDS, personal communication, June 23, 2014 ** Overdosed on any drug i.e. where you had a negative reaction from using too much drugs including alcohol MORBIDITY

Y

BC DOAP REPORT 2014

37

Y

More than a quarter of adults using drugs recreationally in both Vancouver and Victoria; and street-involved youth and adults in Victoria report experiencing a negative reaction from using too much drugs including alcohol. These populations should be targeted with appropriate education to reduce the risk of serious harms of overdose.

The Public Health Surveillance Unit (PHSU) at VCH monitors injuries and overdoses using data from VCH emergency departments (EDs).43 Figure 3.10 shows the number of ED visits related to overdose by substance type in the VCH region, based on the epidemiological week in 2013. This data summarizes overdose visits to the ED of 9 of 13 VCH acute care facilities . VCH experienced overall more overdose episodes in 2013 compared

Figure 3.10

to the historical average, with alcohol as the main cause for patient ED visits. Combination of heroin and other known drugs also represent about a quarter of overdose visits to ED. There is also a noticeable pattern of overdose events within the week that social assistance and disability cheques are issued; the highest monthly overdose rates occur either during this week or the following week.

Number of ED visits related to overdose by substance type and epidemiological week in VCH region in 2013, compared to historical average

250

NUMBER OF ER VISITS

200

150

100

50

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 41 43 44 45 46 47 48 49 50 51 52

JAN

FEB

MAR

Heroin

APR

MAY JUN JUL AUG EPIDEMIOLOGICAL WEEK

Other known drugs

Historical average & upper 95% Cl (Vancouver Coastal Health, personal communication, January 20, 2014) CHAPTER 3

Medication

SEP

Unknown

OCT

NOV

DEC

Alcohol

Week with cheque issued Note: ER (emergency room) is synonymous with ED emergency department

38

Y

BC DOAP REPORT 2014


Y

The Safe Injection room at InSite also experienced more overdose events in 2013 compared to the historical average (Figure 3.11). Similar to the VCH ED data, overdoses at InSite appear to be higher in weeks that social assistance and disability cheques

Figure 3.11

are issued. These numbers reflect overdoses identified by the surveillance system, and may not represent the actual number of overdoses seen in VCH EDs and at InSite.

Number of Vancouver InSite visits resulting in an overdose by epidemiological week in 2013, compared to previous 3-week average and historical average

OVERDOSES AT INSITE

30

20

10

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 41 43 44 45 46 47 48 49 50 51 52

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

2013 EPIDEMIOLOGICAL WEEK Overdoses involving other/unknown drug

Historical average (overall overdoses)

Overdoses involving heroin without Narcan intervention

Previous 3-week average (overall overdoses)

Overdoses involving heroin with Narcan intervention

Week with cheque issued

*Supervised injection site. †Historical data includes data since week 10 of 2004. Data source: Insite, Vancouver Coastal Health, HIV/AIDS & Harm Reduction Programs. Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit.

(Vancouver Coastal Health, personal communication, January 20, 2014)

Standard harm reduction education to help prevent overdose events and associated harms includes the following messages: - Be aware: you never know what is in the drug or how potent it is - Don’t use alone. - Make a plan/know how to respond in case of an overdose - Taste [use a small amount of] the drug first - Do not mix drugs with alcohol or other drugs - Get overdose prevention training and carry naloxone - Use InSite if possible - Call 911 right away if someone overdoses - Know your health status and your tolerance - Be aware: using drugs while on prescribed medications can increase overdose risk - Talk to an experienced person or a trusted healthcare provider about reducing risk - Choose a safer route of taking drugs MORBIDITY

Y

BC DOAP REPORT 2014

Y

39

0 BC Ambulance Ingestion Poisoning Calls The BC Ambulance Services (BCAS) records the date, time and location of each emergency call and uses the advance medical priority dispatch system (AMPDS) to assign a dispatch code, which includes information regarding the chief complaint and response category (BC Ambulance Service, personal communication, January 3, 2014). The ingestion poisoning code is used when the call is thought to be caused by any toxic substance, such as prescribed and over the counter medication, street drug, or chemical. Figure 3.12 illustrates ingestion poisoning counts for BC in 2013. Call data is not confirmed by the responding ambulance crew; the historical average is based on 2004-2012.

Figure 3.12

Weekly ingestion poisoning counts for BC in 2013 were lower than the historic average, with the exception of week 39 where ingestion poisonings surpassed the historical average. Both FH and VIHA had counts consistently below their historic averages. For VCH, weeks 39 and 47 were higher than the region’s historical averages. In comparison, the 2013 counts for IH and NH repeatedly exceeded historical averages, on 12 and 13 weeks respectively (data not shown), and also approached or surpassed historical maximums on several occasions. Ingestion poisoning counts are received by BC CDC weekly from BCAS, reported by health authority, health service delivery area and local health area and shared on the password protected DOAP website.

BC Ambulance Service ingestion poisoning counts, 2013

450 400 350 300 250 200 150 100 50 0

1

3

5

7

9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

History-Maximum

History-Average

(BC Ambulance Service, personal communication, January 3, 2014) CHAPTER 3

Current

40

Y

BC DOAP REPORT 2014


Y

0 Drug and Poison Information Centre - Poison Exposure Calls The BC Drug and Poison Information Centre (DPIC) provides poison information services to the BC public and health professionals and is available 24-hours a day for over-thephone advice. DPIC receives an average of about 70 calls a day about poison exposures.44 The substances included in each of the six drug categories are shown in Table 3.2.

Table 3.2

Figure 3.13 illustrates poison exposure calls to BC Drug and Poison Information Centre by substance and 2013 epidemiologic week per 100,000 population and indicates the income assistance and/ or disability assistance cheque issuance week. Poison exposure information is received each week at BCCDC broken down by health authority and is another component of the DOAP data which helps to build a timely picture of harms related to substances.

Substance classification in DPIC call data

Drug Category Alcohol Benzodiazepines Hallucinogens Opioids Sedative Hypnotics Stimulants

Substances Included Meant for ingestion, Not meant for ingestion, Illicitly manufactured No specifications Cannabis, Ketamine, LSD, Mushrooms, Other Hallucinogens Heroin, Methadone, Fentanyl, Codeine, Hydromorphone, Oxycodone, Other Opioids GHS, Barbiturates, Sleeping Medications, Other Sedatives Cocaine, Amphetamines, Methampheamines, MDMA, Other Stimulants

(British Columbia Drug and Poison Information Centre, personal communication, July 28, 2014)

Number of poison calls per 100,000 population

Figure 3.13

Number of poison exposure calls per 100,000 population by substance and epidemiological week in British Columbia, 2013

2.7 2.3 2.0 1.6 1.2 0.8 0.4 0.0 1

3

5

7

9 11 13 15 17 19 21 23 25 27 29 31 33 33 37 39 41 43 45 47 49 51 53

Weeks of year (2013) Hallucinogens Benzodiazepines Opioids Alcohol Sedative Hypnotics Stimulants Week with cheque issued

Data Source: BC Drug and Poison Information Centre Prepared for: BC Drug Overdose Alert Partnership

*Week 53 represents week 1 of 2014 (British Columbia Drug and Poison Information Centre, personal communication, July 28, 2014) MORBIDITY

Y

BC DOAP REPORT 2014

41

Y

0 HealthLink BC, 8-1-1 Service HealthLink BC 811 service is a free-of-charge health information and advice phone line that can connect public callers to registered nurses.45 Over the phone, nurses assist with non-emergency health concerns, discuss symptoms, and recommend whether the caller should seek medical attention.45 In 2013, there were a total of 5,414 calls related to alcohol and other drugs (Table 3.3). FH had the largest call volume, but VIHA had the highest rate of nursing service calls when adjusted for population size. In over a third of all calls the region was unknown, so it is difficult to make conclusions regarding the geographic distribution of the calls.

Table 3.3

The largest call volumes for alcohol and drugs occurred between 6:00pm and 2:00am; and call volumes on Saturday and Sunday (18.8% and 19.4% of all calls respectively) were higher than the weekday average (12.4%). Figure 3.14 shows the number of calls in 2013 by month. October and January had the highest call volumes (above 500) while June had the lowest (less than 400). Caller age is recorded but this is not necessarily the person who needed information/assistance. The data do not classify the substance type related to each call.

Number and rate of alcohol and drug-related nursing service calls by HA, 2013 Health Authority FH VCH VIHA IH NH Unknown Total

Call Count 1,190 761 753 623 226 1,861 5,414

Calls per 10,000 Population 17 10 27 4 2

(HealthLink BC, personal communication, July 17, 2014)

Number of alcohol and drug-related nursing service calls by month, 2013 600 Number of nursing service calls

Figure 3.14

500 400 300 200 100 0

Call Count

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

495

401

441

478

443

399

424

468

404

507

441

513

(HealthLink BC, personal communication, July 17, 2014)

CHAPTER 3

42

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Y

0 Ambulance Naloxone Administrations increased drug use in outdoor and public settings and therefore more likely to be observed and for an ambulance to be called.

Naloxone is a pure opioid antagonist that when administered reverses life-threatening respiratory depression due to opioids to restore breathing in 2-5 minutes. In BC, emergency medical assistants at licence level 3 or higher are trained and authorized to administer naloxone. All BC Ambulance paramedics are appropriately trained and can administer naloxone. However, most firefighters are level 1 (first responder) or level 2 (Emergency medical responder) and thus are unable to administer naloxone.

Table 3.4 displays naloxone events by region, from 2009 through 2013. The overall number of naloxone events reported in 2009 is lower than those given in the subsequent four years. This may be partially attributed to the paramedic strike that lasted from April through November 2009. Ambulance administered naloxone events in BC peaked in 2011 (the year that overdose deaths due to increased heroin potency were also noted see chapter 5) with 2,242 events, and decreased subsequently reaching 2,011 in 2013. The reduction of administered naloxone follows the same trend of decreasing ingestion poisoning counts depicted in Figure 3.12.

Figure 3.15 shows the number of events where naloxone was delivered by BC ambulance service crews from 2009 through 2013. If a patient received more than one dose of naloxone it was counted as a single event. These data suggest naloxone events increase in the summer months. Province-wide, the months with the highest 5-year average of naloxone events were in May (188), June (194.4), July (194.6) and August (187.2). The increase in summer months may be due to more frequent opioid use or

Figure 3.15

Figure 3.16 shows the rate of ambulance administered naloxone by HA. Note that IH had the highest rate at 57.4 events per 100,000 population in 2011 while VCH had the highest rate in 2013 at 56.3 events per 100,000 people.

Number of naloxone events by month, 2009-2013

Number of Naloxone events

250 200 150 100 50 0

Jan 2009

Feb

Mar 2010

Apr

May

Jun

2011

(BC Ambulance Service, personal communication May 21, 2014) MORBIDITY

Jul 2012

Aug

Sep 2013

Oct

Nov

Dec

5-YR Average

Y Table 3.4

BC DOAP REPORT 2014

43

Y

Count of naloxone events by year, 2009-2013

Region FH Fraser East Fraser North Fraser South VCH Richmond Vancouver North Shore Coast Garibaldi VIHA South Vancouver Island Central Vancouver Island North Vancouver Island IH East Kootenay Kootenay Boundary Okanagan Thompson Cariboo Shuswap NH Northwest Northern Interior Northeast (Unknown) BC

2009 577 80 193 304 471 37 369 65 367 171 149 47 323 17 24 196 86 131 23 66 42 8 1869

Count of Naloxone Events by Year 2010 2011 2012 669 757 613 126 126 124 216 230 190 327 401 299 559 603 594 27 32 40 454 504 489 78 67 65 351 333 339 186 145 146 116 128 141 49 60 52 348 412 351 15 25 24 20 28 26 218 261 212 95 98 89 116 137 131 15 33 25 69 76 75 32 28 31 16 1 1 2043 2242 2028

2013 595 104 193 298 641 33 550 58 338 153 138 47 327 16 23 204 84 110 24 66 20 2011

5-year total 5- year Average 3211 642 560 112 1022 204 1629 326 2868 574 169 34 2366 473 333 67 1728 346 801 160 672 134 255 51 1761 352 97 19 121 24 1091 218 452 90 625 125 120 24 352 70 153 31 26 5 10193 2039

(BC Ambulance Service, personal communication, May 21, 2014)

Rate per 100,000 population

Figure 3.16

Rate of naloxone events per 100,000 population in BC by HA, 2009-2013 70 60 50 40 30 20 10 0 2009

2010 FH

VCH

2011 VIHA

CHAPTER 3 May 21, 2014) (BC Ambulance Service, personal communication,

2012 IH

NH

2013 BC

44

Y

BC DOAP REPORT 2014

Y

Figure 3.17 shows the population rate of ambulance administered naloxone by HSDA in 2013. Vancouver has the highest (83.7 per 100,000), which may reflect the prevalent drug use in the Downtown East Side and willingness to call 911. PWUD may be concerned about calling an ambulance if the police routinely

Figure 3.17


arrive; in Vancouver, the Vancouver Police Department (VPD) has a policy to only attend situations where assistance is requested by ambulance dispatch services.46 More information on naloxone can be found in the harm reduction chapter of this report.

Rate of naloxone events per 100,000 population in BC by HSDA, 2013

N

Rate per 100,000 population by HSDA 33.1

16.4 – 31.1

28.8

31.2 – 42.0 42.1 – 60.0 60.1 – 83.8

46.5

30.3 83.7 16.4

20.7 38.9

38.6 39.5

52.7

39.5 41.2

36.2

25 km

HSDA 11 East Kootenay 12 Kootenay Boundary 13 Okanagan 14 Thompson Cariboo Shuswap 21 Fraser East 22 Fraser North

21.0

20.7

52.7 Rate 21.0 30.0 58.8 38.6 36.2 30.3

Cases 16 23 204 84 104 193

HSDA 23 Fraser South 31 Richmond 32 Vancouver 33 North Shore/Coast Garibaldi 41 South Vancouver Island 42 Central Vancouver Island

Rate 38.9 16.4 83.7 20.7 41.2 52.7

58.8

30.0 200 km

Cases 298 33 550 58 153 138

HSDA 43 North Vancouver Island 51 Northwest 52 Northern Interior 53 Northeast

Rate 39.5 33.1 46.5 28.8

Cases 47 24 66 20

(BC Ambulance Service, personal communication, May 21, 2014)

Severe neutropenia (agranulocytosis) associated with levamisole in cocaine In 2008, cases of severe neutropenia (low white blood cells) were identified in BC and Alberta associated with the use of cocaine which contained levamisole (a de-worming medication no longer available in Canada).47 Cases of neutropenia in BC presented with bacterial or fungal infections and fever, which led to hospitalizations. A reporting system was implemented

in BC which identified 51 cases of neutropenia associated with levamisole in cocaine between 2008 and 2011. Studies of levamisole-associated neutropenia suggest a genetic predisposition to adverse- drug events. Levamisole in cocaine was also associated with necrosis of the earlobes and face.47 MORBIDITY

Y

BC DOAP REPORT 2014

Y

45

CHAPTER 4

HIV AND HEPATITIS C 0 HIV HIV BACKGROUND Human Immunodeficiency Virus (HIV) was identified over 30 years ago. Left untreated, HIV will lead to acquired immunodeficiency syndrome (AIDS). Untreated individuals become increasingly susceptible to opportunistic infections such as pneumonia, cytomegalovirus, tuberculosis, and various cancers. HIV is transmitted through contact of infected blood, semen, vaginal fluid, or breast milk through mucous membrane, abraded skin, or needle penetration. HIV is most frequently transmitted through anal and vaginal sex, and needle sharing. The virus can also be passed from mother to child, either during pregnancy/ delivery or through infected breast milk.1 Once considered a terminal illness, HIV is now regarded as a chronic illness. A 20-year-old HIV-positive individual taking appropriate doses of antiretroviral treatment (ART) can survive through his/her early 70s. Even though there is no cure for HIV, ART can prevent the replication of the virus and suppress the viral load to undetectable levels. This improves the health of the infected individual, as well as minimizing the risk of spreading the infection.48

HIV TREND There are approximately 1.3 million people living with HIV (PLHIV) in North America; 71,300 of these cases are in Canada. 51,52 BC is estimated to have 11,700 HIV-positive individuals, which comprises 16.4% of those infected in Canada.6 Newly identified HIV cases in BC have declined considerably since 2004 (Figure 4.1). In 2010/11, the BC rate was lower than the Canadian rate for the first time. In 2012 BC reported its lowest annual diagnosis count (237); but this subsequently increased in 2013. This increase may reflect the expanded testing.

New HIV diagnosis in BC and Canada 2003-201354 Rate per 100,000 population

Figure 4.1

Even though HIV is treatable today, it is estimated that 27% of HIV infected individuals in Canada do not know their infection status (not tested or not received their result).49 The BC Centre for Excellence’s Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) project has expanded HIV testing, treatment, and support services.50 STOP HIV/AIDS was implemented initially in NH and VCH in 2010, but was expanded in 2013 to include all health regions in BC.50 This program has led to an increase in HIV testing and increased identification of HIV cases.

BC Diagnoses BC Rate Canadian Rate

12 10 8 6 4 2 0

2003 408 9.9 7.8

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013* 442 400 361 391 345 337 300 288 237 272 10.6 9.5 8.5 9.1 7.9 7.6 6.6 6.3 5.1 5.8 7.9 7.7 7.8 7.5 7.9 7.2 6.9 6.4

*2012 and 2013 Canadian rates are not available. 2013 BC diagnoses and BC rates are preliminary and subject to change (BCCDC Clinical Prevention Services Division, personal communication, May 13, 2014) CHAPTER 4

46

Y

BC DOAP REPORT 2014


Y

Figure 4.2 presents HIV diagnoses by HA by year. VCH had the highest rate of HIV diagnosis during the previous ten years but, similar to the provincial picture, has declined over the last

Figure 4.2

decade with a slight increase in 2013. NH has the second highest rate of diagnosis, at 5.8 per 100,000 population in 2013.

New HIV diagnoses in BC by HA, 2003-201354


25

20

15

10

5

0

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013*

FH

6.6

7.5

6.0

4.8

5.4

4.5

5.5

4.5

3.3

2.7

4.1

VCH

20.8

20.3

20.2

17.7

19.3

17.0

14.7

14.6

15.4

12.0

12.1

VIHA

6.9

10.1

6.3

7.1

7.3

5.3

5.2

4.4

2.8

3.4

3.8

IH

4.2

3.0

2.9

2.5

2.4

3.6

2.5

1.5

1.5

1.6

1.7

NH

7.4

9.0

9.9

10.3

9.9

8.5

9.4

5.5

8.2

4.1

5.8

BC

9.9

10.6

9.5

8.5

9.1

7.9

7.6

6.6

6.3

5.1

5.8

*2013 BC diagnoses and BC rates are preliminary and subject to change (BCCDC Clinical Prevention Services Division, personal communication, May 13, 2014)

HIV AND HEPATITIS C

Y

BC DOAP REPORT 2014

47

Y

DEMOGRAPHICS OF HIV CASES IN BC Detailed HIV data for 2013 is not yet available except for sex; therefore, we report 2012 data for geographic, age, and ethnicity where it is the latest available. As shown in Figure 4.3, Vancouver HSDA had the highest HIV incidence rate in 2012, at 19.1,

Figure 4.3

followed by Northern Interior and Northwest HSDA, at 5.5 and 5.3 respectively. However most HSDAs outside the BC lower mainland had less than15 cases reported in 2012 so HIV incidence rates may be unstable.

New HIV diagnosis in BC by HSDA, 201254 N


0.0 – 1.4

0.0

2.0 – 3.7 5.3 – 5.5 19.1 5.5

Southwestern BC Inset 2.4

2.4

3.2

0.9 19.1 2.0

3.3 2.6 3.3

3.0

2.1

3.0 3.7

2.5

2.4

25 km


1.4

3.7

200 km

Rate 2.5 3.7 1.4 0.9 2.1 3.2

Cases 2 3 5 2 6 20


CHAPTER 4

Rate 2.6 2.0 19.1 2.4 3.7 3.0

Cases 19 4 131 7 14 8


Rate 3.3 5.3 5.5 0

Cases 4 4 8 0

48

Y

BC DOAP REPORT 2014

Y

Sex distribution of BC cases is shown in Figure 4.4. Overall, there has been a steady decrease in HIV rate in both sexes, but males continue to exhibit much higher (5-10 times) infection

Figure 4.4


rates compared to females. This is largely explained by higher rates among men who have sex with men (MSM).

HIV diagnoses in BC by sex, 2003-201354*


25 20 15 10 5 0

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013*

15.7 16.4 15.5 13.7 14.2 13.2 Rate - Male Rate - Female 4.2 5 3.6 3.4 3.9 2.7 Diagnoses - Male 320 337 322 289 303 286 Diagnoses - Female 87 105 77 72 85 59 Diagnoses - Other** 1 0 1 0 3 0

12 3.2 266 71 0

10.6 10.8 2.7 1.9 238 245 62 43 0 0

9.1 1.2 208 29 0

10.3 1.4 239 33 0

*2013 BC diagnoses and BC rates are preliminary and subject to change **Other – transgender and gender unknown

(BCCDC Clinical Prevention Services Division, personal communication, May 13, 2014)

HIV AND ABORIGINAL POPULATIONS

HIV AND EXPOSURE CATEGORY

According to Statistics Canada census data Aboriginal peoples comprise 5% of the BC population, but in 2003 they represented 16.2% of newly diagnosed HIV cases; this proportion reduced to 12.6% in 2012. From 2003 to 2012, between 29 and 60 HIV cases per year were reported among First Nations people and ten or fewer cases annually in people who identified Métis or Inuit heritage. In 2012, there were 29 HIV diagnoses among First Nations people; 18 males, 11 females; 18 (62.1%) were in VCH and 5 (17.2%) in NH. Rates of HIV diagnosis in both First Nations women and men (15.9 and 26.8 per 100,000) exceed those of women and men of all other ethnicities (1.2 and 9.1 per 100,000) in BC. The highest rate of new HIV diagnosis among First Nations people by age group is 30-39 years for men (61.0 per 100,000) and 25-29 years for women (53.6 per 100,000).55

Figure 4.5 shows new HIV cases by exposure category in BC. It is notable that while injection drug use (IDU) was the most predominant mode of infection in the 1990’s, MSM now comprise the largest group of new HIV cases followed by heterosexual contact.1 Since 2007 there has been a rapid decline in infection rates in people who identify as injection drug users. Despite the increase in HIV diagnosis from 2012 to 2013, detection among PWID remained stable within that timeframe (29 cases for each year).

HIV AND HEPATITIS C

Y

Number of Diagnoses

Figure 4.5

BC DOAP REPORT 2014

49

Y

New HIV diagnoses in BC by exposure category, 2003-201354 200 180 160 140 120 100 80 60 40 20 0

MSM IDU HET Other NIR/UNK

2003 158 136 105 5 4

2004 188 137 104 9 4

2005 181 125 82 8 4

2006 160 115 73 11 2

2007 173 118 90 7 3

2008 181 65 81 7 11

2009 153 64 92 12 16

2010 153 52 83 6 6

2011 170 34 75 7 2

MSM > men who have sex with men IDU > injection drug use HET > heterosexual contact NIR > no identified risk UNK > exposure unknown Other > blood/blood products, occupied perinatal, and other exposures *2013 BC diagnoses and BC rates are preliminary and subject to change (BCCDC Clinical Prevention Services Division, personal communication, May 13, 2014)

The reduction in HIV infection rates associated with injection drug use is far greater than that associated with other risk factors. This can be explained by several factors including: 1) the expansion of provincial harm reduction programs such as safer injection supply distribution, methadone maintenance programs and the supervised injection site in Vancouver; 2) the shift from injection drugs to non-injection drugs, which has a lower risk of HIV transmission when sharing paraphernalia; and 3) the expanded uptake of and adherence to ART which is associated with a reduction in the community viral load. These public health prevention programs have contributed to the reduction in HIV associated with injection drug use and should be sustained and expanded.55

CHAPTER 4

2012 149 29 52 2 5

2013* 150 29 60 12 21

50

Y

BC DOAP REPORT 2014


Y

Research from UHRI shows after 15 years of follow-up unstably housed PWID were nearly twice as likely to become infected

Cumulative incidence of HIV infection among PWID in Vancouver, 1996-2011, stratified by housing status57

Cumulative incidence of HIV infection

Figure 4.6

with HIV compared to PWID with stable housing (22% and 11.6% respectively) (Figure 4.6).18

20% Unstable housing 15% 10% Stable housing 5% p = 0.0021 0% 0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Time for enrolment (years)

HIV TREATMENT Although there is no cure or vaccine available for HIV today, ART can improve and maintain the health of PLHIV and prevent the spread of infection. Improving HIV testing through healthcare services is a crucial step to ensuring ART success. In 2010 BC adopted the pilot STOP HIV/AIDS program in Vancouver's DTES and NH; in 2013 the program was implemented as an official provincial five-year program. The STOP HIV/AIDS program aims to expand HIV testing, treatment, and support services

Figure 4.7

to clinically eligible individuals in BC, and places an emphasis on engaging hard-to-reach.50 Since the implementation of this program, BC’s HIV testing rate has rapidly increased, especially in VCH, as illustrated in Figure 4.7. In Vancouver, which has the highest concentration of HIV cases in BC, the expanded uptake is associated with a lower community viral load among all HIV positive patients (Figure 4.8).57

Rate of HIV testing in BC and HAs, 2009-201358

HIV Testing episodes per 100,000 population

9000 8000 7000 6000 5000 4000 3000 2000 1000 0

2009

FH

2010

VCH

2011

VIHA

2012

IH

HIV AND HEPATITIS C

NH

2013

BC

Y Figure 4.8

BC DOAP REPORT 2014

51

Y

Mean community HIV viral load (copies/ml) for all HIV positive patients in Vancouver, before and after the implementation of STOP HIV/AIDS program through 201243 Vancouver local health areas, since STOP HIV/AIDS July 1, 2010 to current.

Vancouver local health areas, 2008 – 2009

North Vancouver

North Vancouver City Centre

City Centre

DTES

DTES

Westside

Midtown

North East

Westside

North East

Midtown South

South

Richmond

Richmond Mean viral load (copies/mL) 35 to < 200 copies/mL

200 to < 1,000 copies/mL

1,000 to < 6,500 copies/mL N

Public Health Surveillance Unit • [email protected] Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit, February, 2013 Spatial source: BC STATS, BC Ministry of Labour and Citizens’ Services Population data source: BC STATS, BC Ministry of Labour and Citizens’ Services (Population Estimates). Data Source: Provincial Public Health Microbiology and Reference Laboratory (Misys Laboratory Database) & Providence Health Care Virology Laboratory.

4 kilometers

Copyright @ 2012 Vancouver Coastal Health, Public Health Surveillance Unit. Not for Commercial Use.

Successful treatment outcomes for PLHIV depend on measures to keep viral levels suppressed. These stages of HIV-care can be summarized as follows: 1) HIV diagnosis, 2) Linkage to HIV care, 3) Retention in HIV care, 4) Taking ART and 5) Achieving a suppressed viral load. An interruption between any of these stages can lead to an increase in viral load and risk of HIV transmission. VCH and FH maintained relatively higher levels CHAPTER 4

of HIV suppression in 2013, with over 60% of HIV diagnosed individuals successfully suppressing HIV to undetectable levels; but this suppression rate was below 40% in NH. Individuals with a history of IDU demonstrate lower success rates in maintaining HIV suppression (56.9%) compared to non-IDU individuals (69.3%). Success rates are much lower for individuals who do not identify their IDU status (28.3%)57

52

Y

BC DOAP REPORT 2014


Y

AIDS The AIDS diagnosis rate in BC has steadily declined since 2007, reflecting the trend of HIV incidence and improved HIV treatment see Figure 4.9. Although the total provincial AIDS rate has declined over the last decade, this reduction is not apparent within First Nations subpopulations. This indicates that more resources and strategies for culturally appropriate HIV education and awareness for health promotion and prevention need to be implemented. In addition a focus on reducing stigma and increasing culturally appropriate services and screening to reduce the transmission of HIV would be appropriate. Making early testing, treatment, and care more accessible to this community could help prevent HIV opportunistic infections and progression to AIDS. Barriers for Aboriginal people to access and benefit from health services include stigma, geographic isolation, poverty, racism, issues of confidentiality and other social and systemic barriers.54

Figure 4.9

Community ownership and control of HIV and hepatitis C initiatives are essential. Including health care team members, such as Community Health Representatives and Nurses from First Nations communities, in the circles of care in the Regional Health Authorities will foster meaningful engagement and bridge the gaps in the leaky HIV prevention and care cascade for First Nations people living in BC. In 1997, about one person died of AIDS every day on the AIDS ward at St. Paul’s Hospital in Vancouver and there were insufficient beds to care for these patients.59 In May 2014, St. Paul’s Hospital closed its AIDS ward citing that there were not enough AIDS patients to require its continued use.59,60

AIDS diagnosis rate in BC, 1983-201254*

12

8 6

4 2

0

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012


10

*2013 rates are not available. Due to delays associated with the reporting of AIDS cases, published data is a year behind (BCCDC Clinical Prevention Services Division, personal communication, April 4, 2014)

HIV AND HEPATITIS C

Y

BC DOAP REPORT 2014

Y

53

0 Hepatitis C Virus (HCV) HCV BACKGROUND Hepatitis C is caused by the hepatitis C virus (HCV), primarily affecting the liver. About 2% of the world’s population (150 million people) are infected with chronic HCV.61 However, HCV prevalence among PWID globally is estimated to be 51% (7.2 million people).62 About 250,000 Canadians are thought to be infected with HCV, including 21% who are unaware of their infection until symptoms appear.63,64 To date approximately 75,000 people in BC have been diagnosed with HCV since 1992; 1.5% of the BC population 60,000 are estimated to be currently living with HCV.65 HCV is primarily transmitted through exposure to infectious blood.60 Before HCV testing was introduced in 1992, HCV was transmitted through blood transfusions and organ transplants1. Sharing HCV-exposed needles/syringes and other injecting equipment (e.g. water, cooker, filter) during intravenous drug preparation and use is the most common risk factor for HCV infection. HCV is more easily transmitted than HIV through needle sharing, which explains its high prevalence among PWID.66 Sharing drug snorting and smoking paraphernalia such as straws and crack pipes may also transmit HCV but less efficiently than injection.1 The risk of HCV transmission through vaginal and anal sex increases with multiple partners, STI co-infection, HIV infection, and traumatic sex.1 Tattooing, piercing, pedicure, manicure, medical procedures with unsterilized tools, and sharing of personal hygiene items are also linked to HCV infection.63 HCV may be transmitted vertically, from an infected mother to her child during birth in 2-5% of cases but is much higher if mother is co-infected with HIV; transmission through breast-feeding has not been established.1 The incubation period for HCV is 2 weeks to 6 months (usually 6-9 weeks), but most (80%) infected individuals do not experience symptoms of acute HCV infection - including fever, fatigue, decreased appetite, nausea, abdominal pain and jaundice.62 About 25% of infections resolve (clear the virus) within several months of infection.67 Thus the majority of HCV cases develop chronic hepatitis C, which can lead to cirrhosis (up to 20% of chronic HCV cases over 20 years) or liver cancer (up to 6% of chronic HCV cases).62 1-5% of chronic HCV patients die from cirrhosis or liver cancer following 20-30 years of disease progression.62,68 HCV infection is diagnosed by identifying antibodies against HCV (anti-HCV) using an enzyme immunoassay (EIA).69 However, this does not differentiate individuals who have cleared the virus (spontaneously or through HCV treatment) from those CHAPTER 4

who are chronically infected. Chronic HCV infection is identified by nucleic acid test (NAT), which detects the presence of HCV RNA (the genetic component of the virus). In BC, the Public Health Microbiology Reference Laboratory performs the majority (95%) of anti-HCV testing, as well as all HCV RNA and genotype testing.69 Although there is no HCV vaccine available, HCV treatment can eradicate the virus. Treatment success depends on which of the six HCV genotypes an individual is infected with. According to the BC Laboratory Information System, 63% of HCV tested in BC are genotype 1, 36% genotype 2 and 3, and 1% genotype 4, 5 and 6.1 Pegylated Interferon-α and ribavirin combination therapy is currently the main treatment available in BC today: The sustained virological response (SVR), (i.e. no detectable virus six months after treatment completed) for genotype 2 and 3 is 80% but about 40-50% for the other genotypes with this current treatment. In 2011, “triple therapy” i.e. adding a DirectActing-Antiviral (DAA) protease inhibitor to the interferon-ribavirin therapy was shown to improve SVR for genotype 1 patients up to 75% using reduced duration of the therapy.70,71 HCV treatment is rapidly evolving and it is predicted that within five years, oral treatments with 90% cure rates and minimal side-effects will be available.73 Boceprevir and telaprevir, the first DAA agents for HCV, have been approved in Canada.72 Interferon-free regimens using sofosbuvir and ribavirin have also been found effective. These new treatments are reported to have fewer side-effects but are expensive, potentially costing more than $65,000 per complete course.73

HCV TREND Newly identified HCV cases are reportable to public health by the laboratory. Although newly reported HCV cases in BC have steadily declined since the 1997 peak, BC still has the highest HCV rate in Canada (see Figure 4.10). Reported cases of HCV include both recent infections and remote infections (past infections that were identified recently).74 The increase in HCV cases identified in 2013 coincides with an increase in HCV testing (Figure 4.11). As of 2013, over 2 million HCV tests have been performed in BC. Figure 4.11 shows the number of annual anti-HCV tests performed in BC in relation to the annual number of detected HCV cases. Various local (STOP HIV/AIDS) and international (2012 US CDC guidelines advising HCV testing for persons born between 1945 and 1965 ) testing initiatives have contributed to an increase in awareness and testing, and subsequent increase of cases detected.

54

Y

Figure 4.10

BC DOAP REPORT 2014


Y

HCV rates by year in Canada and BC, 2004-201353 Rate per 100,000 population

100 80 60 40 20 0

2004 2005 2006 2007 2008 2009 2010

BC Hepatitis C Reports 3042 BC Hepatitis C Rate 73.2 Canadian Hepatitis C Rate 45.2

2832 67.5 40.3

2903 68.4 36.9

2879 67.1 36.6

2509 57.7 35.8

2476 56.1 33.3

2011 2012 2013*

2217 49.6 31.1

1970 43.8 28.9

1886 41.5 19.3

2105 45.9 0.0

*2013 Canadian rates are not available. 2013 BC diagnoses and BC rates are preliminary and subject to change (BCCDC Communicable Disease Prevention and Control Services, personal communication, May 22, 2014)

Figure 4.11

Total anti-HCV test volumes and HCV cases, 1992-2013, BC*

225000

200

200000 160

150000 120

125000 100000

80

75000 50000

40

25000 0

Number of Tests

HCV Rate per 100,000 population

*2013 BC rates are preliminary and subject to change (BCCDC Clinical Prevention Services Division, personal communication, June 19, 2014) HIV AND HEPATITIS C

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

1994

1993

1992

0

HCV Rate

Number of Tests

175000

Y When HCV rates were mapped by HSDA for 2013 (Figure 4.12); Fraser East had the highest HCV rate, followed by Northern Interior, Vancouver, and North Vancouver Island. Richmond, Northeast, and North Shore have the lowest rates. Based on age group (Figure 4.13), HCV rates peak in males in the 40-59 age group, but females have higher rates of HCV than males

Figure 4.12

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Y

at younger ages. Women generally use health services more frequently than men and are thus more likely to be tested, and HCV detected. Males dominate the HCV cases after age 30. The highest male rate is in the 40-59 age group when it is over twice the female rate, which reflects the age and sex of PWID in BC.

HCV rate in BC by HSDA, 201353 N

49.6

24.5


45.0 29.3

77.0 58.9

64.9 Southwestern BC Inset 29.3 58.9 20.4

36.5

29.3 45.0

57.9

40.1

38.2

29.3

53.8

57.9

77.0

47.9

54.7

53.8 39.1

25 km


Rate 38.2 54.7 47.9 45.0 77.0 36.5

Cases 29 42 166 98 221 232


Rate 40.1 20.4 58.9 29.3 39.1 53.8

*2013 BC diagnoses and BC rates are preliminary and subject to change (BCCDC Communicable Disease Prevention and Control Services, personal communication, May 22, 2014)

CHAPTER 4

Cases 307 41 387 82 145 141


Rate 57.9 49.6 64.9 24.5

Cases 69 36 92 17

Note: Map classification by Jenks natural breaks method

56 Figure 4.13

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HCV rate in BC by age group and sex, 201353*


125

100

75

50

25

0

1.45) 4 (1.00-1.45) 3 (0.77-1.00) 3 (0.55-0.77) 1 ( 94% 14,833 of 15,754 in 2012/13) of patients on OST in BC are prescribed methadone.116 Figure 6.14 shows patients on methadone maintenance therapy by health authority.

Methadone Maintenance Therapy patients by health authority, BC 2007/08 to 2012/13

Cumulative Patient Count

16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0

FH VCH VIHA IH NH BC

07/08 3,521 3,530 1,860 1,128 294 9,466

08/09 3,983 3,784 2,034 1,317 320 10,372 CHAPTER 6

09/10 4,494 3,901 2,202 1,512 333 11,385

10/11 5,247 4,106 2,443 1,755 345 12,703

11/12 5,812 4,318 2,538 1,984 406 13,895

12/13 6,331 4,510 2,614 2,143 408 14,833

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In 2012/13 53% of patients received a stabilizing dose of methadone >60mg; and between 34% and 45% of people started on methadone in 2011/12 were retained in treatment at 12 months.116 In 2012/2013 FH had the highest number of new and continuing patients but the number of patients in MMT in NH has remained low and relatively unchanged during over the past 10-years.116 Long travel times to Northern MMT clinics remains a barrier to access. In 2011, about 9% of NH MMT clients lived over 100 km from the nearest methadone prescriber.118

Figure 6.15


The distribution of OST clients in BC varies by LHA. (Figure 6.15) A recent review of FNHA’s National Native Alcohol & Drug Abuse Program found that harm reduction approaches are supported in the majority of residential treatment centres in BC. Additionally about half of the centres accept clients who are receiving methadone. However, accessibility to MMT service providers and pharmacies offering methadone can be limited,

Opioid substitution treatment patients by local health area 2012/1379 Persons per 1000 population 18+ 0 0.30 - 1.76 1.77 - 3.04 3.05 - 4.90 4.91 - 8.01 8.02 - 39.29

Prince George

Kitimat Kamloops

Downtown Eastside

Victoria South Island

Downtown Vancouver HARM REDUCTION

Lower Mainland

Y particularly in rural and remote areas, which poses challenges for methadone initiation and continued adherence and may require clients to travel considerable distances.119 The FNHA welcomes future opportunities for dialogue related to harm reduction and other aspects of these programs and services to better meet the treatment needs of First Nations clients, in collaboration with regions, communities and other partners and services providers.

METHADOSE In February 2014, BC changed the formulation of methadone from a compounded 1mg/ml solution dispensed as an orange flavored drink, to a standard 10mg/ml, cherry flavored liquid called Methadose®. Benefits of Methadose include 1) longer shelf life and no need to refrigerate 2) quality control and consistent dosing, 3) painful when injected so discourages injection. The new BC guidelines also reduced home delivery of methadone by pharmacists to only exceptional circumstances (i.e. due to a patient’s restricted mobility, and with physician authorization). 120 Alberta changed to Methadose in September 2012 and some US states have used Methadose since the 1970’s. Other jurisdictions may permit pharmacists to dilute unflavoured Methadose at their discretion. In BC, only the cherry flavoured formulation is available and if dispensed for carry out is done so in individual doses. Concerns related to the change in BC were expressed by

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people on methadone, communities, and local health agencies. Concerns included the potential for unintended overdose due to: 1) difficulty in titrating dose changes; 2) diversion (i.e. persons consuming illicitly without a prescription being unaware of 10fold higher concentration); and 3) accidental ingestion by a child because Methadose looks like Children’s Tylenol®, and a small amount (1 ml) can be fatal in children.121 Raising public and professional awareness of the new Methadose formulation was important to ensure a smooth and safe transition. All pharmacy managers, staff, relief pharmacists, and pharmacy technicians employed in community pharmacies that provide MMT-related services were required to complete training designed to help them transition patients over to Methadose. Educational pamphlets and posters were developed collaboratively by CPSBC, CPBC, and the BC Ministry of Health. Posters developed by HRSS (Figure 6.16) were translated into Chinese and Punjabi to help inform patients of the change. Some MMT patients report the effect of Methadose does not last as long as the previous methadone formulation, needing higher doses or have returned to illicit opioid use. To assess these concerns more objectively a question was added to the 2014 HR client survey. For further updates and information regarding the change to Methadose in BC, please refer to the Toward the Heart website.

Figure 6.16 Public awareness poster for the methadone formulation change in BC121

CHAPTER 6

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0 SALOME and NAOMI Studies MMT may be ineffective for a small proportion of long-term heroin users. The North American Opiate Medications Initiative (NAOMI) study, which took place between 2005 and 2008, was the first clinical trial to investigate whether providing injectable pharmaceutical grade heroin was more effective than oral MMT in recruiting, retaining, and benefiting chronic treatment resistant opioid users. NAOMI found that participants treated with diacetylmorphine (the active ingredient of heroin) showed improved mental and physical health. After one year, 88% of the diacetylmorphine group remained in treatment, compared to 54% of the MMT group. Many participants in the diacetylmorphine group also successfully transitioned to oral treatment, detox programs, and abstinence. Furthermore, the NAOMI study found that many participants could not tell the difference between diacetylmorphine and hydromorphone (HDM), a licensed pain medication. The Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) study was established to determine if HDM is as effective as diacetylmorphine.122 In 2013, 75 participants in the SALOME study had completed 12 months in the clinical study. Some of individuals were transferred to

methadone, HDM, or drug-free programs. However, some patients did not respond to these treatments and still required diacetylmorphine assisted therapy after the trial. In response to their health needs, doctors with the SALOME project applied to Health Canada’s Special Access Programme (SAP) to legally prescribe diacetylmorphine outside of the study. SAP approved the 21 applications. But the federal Health Minister intervened by introducing new regulations identifying diacetylmorphine as a restricted substance under the Food and Drug Act. This subsequently barred access to the treatment, despite SAP approval. In response, Providence Health Care and five former SALOME patients launched a constitutional challenge on November 13, 2013 arguing that the Health Minister’s actions violated the Charter of Rights. On May 29, 2014 the BC Supreme Court granted a temporary injunction that re-establishes access to diacetylmorphine assisted treatment. This decision will permit prescription diacetylmorphine for SAP approved cases and future requests made by SALOME until the case goes to trial.123

HARM REDUCTION

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CHAPTER 7

LAW ENFORCEMENT A psychoactive substance is defined as “an intoxicating, stimulating, or narcotic chemical or drug”.124 The federal government categorizes them based on their potential for abuse or addiction; categories range from illegal street drugs to prescription medications.125 Drug regulation in Canada goes back to the early 20th century. The first such law was the Opium Act of 1908, which prohibited opium use.126 Today the Food and Drug Act and the Controlled Drugs and Substances Act are Canada’s federal drug control statutes, which were developed to comply with three United Nations conventions on substance control established in 1961, 1971 and 1988.126 Production, trafficking, importation and use of illicit drugs are associated with crime at all levels of society. Enforcement, recognized as one of the City of Vancouver’s four pillars of drug strategy, is an important component to keep public order and safety. 2 Law enforcement in BC is provided by the Royal Canadian Mounted Police (RCMP) (federal, provincial and municipal forces) and independent police departments, including one First Nations administered police service. The RCMP serves most areas in BC. There are eleven independent municipal police departments which serve twelve municipalities. Vancouver is served by the Vancouver Police Department (VPD), which covers the area from Boundary Road in the east to Point Grey in the west, excluding the University Endowment Lands. Other municipalities include, on Vancouver Island - Central Saanich, Saanich, Oak Bay, Esquimalt and Victoria; and in the rest of BC Abbotsford, Delta, New Westminster, Port Moody, West Vancouver and Nelson.127

0 Data Collection Data about Criminal Code and Controlled Drugs and Substances Act offences are collected using the Uniform Crime Reporting (UCR2) Survey. Changes made to the UCR Survey that became effective in 2009 enabled police officers to collect more detailed information about each event reported to the police. The three main categories of Criminal Code offences (violent, property and other crime) were revised to better reflect the nature of crime. For example the number of violent crimes now equals the number of identified victims in each violent incident and the number of property crimes and other crimes is equal to the number of distinct incidents.128 Since 1997, offences involving drugs have been prosecuted under the Controlled Drugs and Substances Act (CDSA). 129 Offences arising from this federal statute are categorized by CHAPTER 7

type of drug: heroin, cocaine, cannabis and other drugs including methamphetamines (crystal meth), methylenedioxyamphetamines (MDMA - ecstasy), and hallucinogens. Drug offences are also classified by type of crime: possession, trafficking, importation/ exportation and production. An amendment to CDSA introduced in 2011 added another violation code for precursor/equipment (crystal meth or ecstasy) making it illegal to possess, produce, sell or import anything that can be used in production of crystal meth or ecstasy.130 Beside changes in reporting methods, other factors such as demographic changes, police enforcement practices and policies influence the number and rate of Criminal Code and CDSA violations reported by the police.128

0 Crime in BC According to the latest available publication by Statistics Canada, in 2012 the province of BC had the second highest number of total Criminal Code offences and was ranked sixth by the policereported crime rate.131 Drug crime rate in BC was higher than the Canadian average; only Yukon and Northwest Territories had rates higher than BC. 132 Figure 7.1 shows overall and drug crime in BC in 2012. While drug crimes account for only 6.6% of overall crime in BC, illicit drugs are associated with a range of criminal offences, including murder, attempted murder, break and enter, robbery, car theft, possession of stolen property, sexual assault, uttering threats, prostitution, etc. These crimes may be committed in order to fund drug habits (gainful crimes), offenders may have been under the influence of a drug when committing the crime, or the criminal activity was part of a business transaction in relation to drugs. Although numerous studies support the strong association between drugs and criminal behaviour, the actual proportion of crimes attributable to illicit drugs is difficult to estimate. A study carried out by the Canadian Centre on Substance Abuse (CCSA) in 2002 estimated that the prevalence of substance use among federal inmates was 40%. Approximately half of violent crimes (e.g. homicide, attempted murder, and assault) and half of gainful crimes (e.g. theft, break and enter, and robbery) were associated with alcohol and/or illicit drugs.133

90

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Figure 7.1 Total criminal code offences* and CDSA offences in BC, 2012134

Other Crime

CDSA Offences

75,540

Property Crime

Cannabis 69.5%

CDSA Crime

217,767

25,432 Cocaine 17.1% Heroin 2.9% Other Drugs 10.5%

Violent Crime 63,885

*Total Criminal Code Offences excluding traffic offences

Figure 7.2 shows the number and rate of drug crime in BC from 2005 to 2012, categorized by type of crime. The rate is calculated per 1,000 population using BC Stats population estimates based on 2006 Canada Census data. The rate of drug offences decreased from 6.6 per 1,000 population in 2007 to 5.5 per 1,000

population in 2012. Possession continues to be the main drug offence, comprising almost 80% of all CDSA offences in 2012. In 2012 offences of trafficking represented 14%, importation/ exportation 0.5%, and production 6% of all CDSA offences.

30,000

6.6 6.1

25,000

6

6.2

5.9

5.9

5.4

5.5

20,000 15,000 10,000 5,000 0

2005 2006 2007 2008 2009 2010 2011 2012 LAW ENFORCEMENT


Number of CDSA Offences

Figure 7.2 Number and rate of drug offences in BC by type of crime, 2005-2012130

Possession Trafficking Import/Export Production Total rate

Y The police consider the offence is cleared when at least one offender in relation to a criminal incident is identified and there is sufficient evidence to solve the case. This may result in the police filing a Report to Crown Council recommending charges be laid and this status is reported in the UCR2 Survey, or despite sufficient evidence to support the charges, the police recommend another course of action, i.e. referral to a diversion program as an alternative to prosecution.128 In 2012, out of the total of 25,432 drug offences, 18,363 (72%) were cleared by charge or other means.

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The number of persons charged with CDSA offences reached its highest peak in 2007, with 9,919 persons charged, but decreased over the next five years, with 7,634 persons charged in 2012. In 2012, 65% of charges were for possession, 30% for trafficking, 4% for production and less than 1% for importation/ exportation offences (Figure 7.3). The proportion of CDSA offences categorized by type of drug is shown in Figure 7.4. The relative proportion of drug offences involving cocaine decreased from approximately 30% in 2006 to 17% in 2012, while offences involving cannabis increased from 60% to 70%.

Number of Persons Charged

Figure 7.3 Number of persons charged with CDSA offences in BC, 2005-2012130 12,000 10,000

Possession Trafficking Import/Export Production

8,000 6,000 4,000 2,000 0

2005 2006 2007 2008 2009 2010 2011 2012

Percentage of CDSA Offenders

Figure 7.4 Proportion of CDSA offences in BC by type of drug, 2005-2012130 100% 90% 80% 70%

Cannabis Cocaine Heroin Other Drugs

60% 50% 40% 30% 20% 10% 0%

2005 2006 2007 2008 2009 2010 2011 2012 Source: Ministry of Justice, Police Services Division. British Columbia Crime Trends, September 2013. CHAPTER 7

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CANNABIS and its derivatives are Schedule II controlled substances. Offences involving cannabis (including hashish or marijuana in powdered, leaf, liquid or resin form) represent almost 70% of all drug offences in 2012. There were 17,670 cannabis offences recorded, with a rate of 3.8 offences per 1,000 population. In 2012, possession represented 86% (15,197) of cannabis offences, cultivation 8.2% (1,449), trafficking 5.7% (1,006) and importation/exportation 0.1% (18). Almost 74% of cannabis offences were cleared. Of the 4,420 persons charged with cannabis offences in 2012, 78% (3,465) were charged with possession, 15% (646) with trafficking, 0.1% (4) with importation/ exportation and 7% (305) with production offences. COCAINE and its preparations are Schedule I controlled substances. The number of cocaine offences continues to decrease from its highest point in 2006, with 7,518 offences, to the lowest recorded number of 4,350 offences in 2012. Offences of possession represented 59% (2,572), trafficking accounted for 40% (1,746) and importation/exportation accounted for less than 1% (32) of all cocaine offences. Close to 72% (3,129) of cocaine offences were cleared. Of the 1,997 persons charged with cocaine offences in 2012, 61% (1,216) were charged with trafficking, almost 39% (775) with possession and 0.3% (6) with importation offences.

Figure 7.5


HEROIN and other derivatives of opium are Schedule I controlled substances. Between 2005 and 2012 the number of offences involving heroin peaked in 2006 with 698 offences, then continued to be stable around 500 for four years, only to increase sharply again in 2012 with 730 offences. Offences of possession accounted for 68% (500), trafficking for 31% (224), and importation/exportation accounted for less than 1% (6) of all heroin offences. Almost 80% of heroin offences were cleared in 2012. There were 376 persons charged with heroin offences: trafficking accounted for 53% (200), possession for 46% (174) and importation/exportation accounted for less than 1% (2) of all charges involving heroin.

0 Crime in Vancouver The City of Vancouver is home to more than 650,000 people and is the integral part of the Vancouver Census Metropolitan Area (CMA), which has close to 2.5 million inhabitants.7 Vancouver is the economic, transportation and export/import centre of the region, with the largest seaport in Canada and the second largest airport in the country.135 According to Statistics Canada, of the five census metropolitan areas with the highest drug crime rate in Canada in 2012, four, including Vancouver, are in BC.131

Rate of CDSA offences by census metropolitan area, 2012131

6 5 4 3 2 1

Ab

low

na bot sfo rd Re gin a Vic tor ia Va nco uve r Sh erb roo ke Ga tine au Tro is-R iviè res Ha lifa x St. Joh n’s Bra ntf ord Edm ont on Sa ska too n Qu ébe c Tor ont o Mo ntr éal Ott aw a Kin gst on Ca lga ry Wi nni peg

0 Ke


7

Drug offences (rate)

Canada average drug offences (rate) LAW ENFORCEMENT

Y Metro Vancouver’s advanced transportation network makes it easy for offenders to commit a crime in one area and quickly move to another. The introduction of Police Records Information Management Environment (PRIME) BC in November 2009, made it possible for police officers to track offenders across different jurisdictions within the City of Vancouver. However, it is challenging to present data for the whole Vancouver CMA because several municipalities within Vancouver CMA are served by independent police departments, which have different practices in publishing their data. Therefore, only Vancouver Police Department (VPD) data is presented in this section.

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have resulted in decreasing numbers of Criminal Code offences in all three categories, although this downward trend has been the most significant in the property crime category (Figure 7.6).

VANCOUVER CDSA OFFENCES A downward trend is also seen when looking at the CDSA offences separately (Figure 7.7). The highest number of CDSA violations was recorded in 2006 (5,183 violations) with the rate of 8.5 per 1,000 population. Since 2006, the number and rate of CDSA offences continued to decrease, reaching the lowest point in the last 15 years in 2013 (drug crime rate was 3.48 per 1,000 population in 1999).1 From the highest point in 2006, offences involving cannabis decreased by 36%, offences involving cocaine decreased by 64%, offences involving heroin decreased almost 60% and offences involving other drugs decreased by close to 75%.

As outlined in the latest Strategic Plan, the major goal of VPD is to make Vancouver the safest major city in Canada.136 The continuous efforts and partnership projects with local communities

Figure 7.6 Trends in number of criminal code and CDSA offences in Vancouver, 2005-2013137

Number of Offences

60000

Violent crime Property Crime Other Crime Drug Offences

50000 40000 30000 20000 10000 0

2005

2006

2007

2008

2009

2010

2011

2012

2013

*Total Criminal Code offences excluding traffic offences

Number and rate of CDSA offences in Vancouver by type of drug, 2005-2013137 6,000 5,000 4,000

7.9

8.5

9 7.5

6.6

8 5.8

7 5.5

6 4.4

3,000

4.4 3.5

4 3

2,000

2

1,000 0

5

1

2005 2006 2007 2008 2009 2010 2011 2012 2013 CHAPTER 7

0


Number of CDSA Offences

Figure 7.7

Cannabis Cocaine Heroin Other Drugs Rate per 1,000 population

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VANCOUVER DRUG EXHIBITS SEIZED More than one drug ‘exhibit’ may be seized at one occasion and not all drugs seized lead to prosecution. The probable drug seized is reported by the VPD member and is not routinely confirmed by testing (only drugs seized where a person is prosecuted and pleads not guilty are tested). Data prior to the introduction of PRIME is not comparable to subsequent data. Table 7.1 shows total number of ‘exhibits’ seized 2006-2009;

Table 7.1

cocaine and crack exhibits are combined. The number of exhibits seized recorded by the VPD from 2010 to 2013 is seen in table 7.2. Table 7.3 shows the weight of each drug seized by year. This should be viewed with caution; the reported weights combine different drug formulations e.g. powder, leaves, resin, tablets and liquids; the weight is estimated and sometimes missing; finally the potency of the drug is unknown.

Vancouver Police Department number of exhibits seized of specific drugs 2006-09*

Drug Cocaine (including crack) Ecstasy Hashish Heroin Ketamine Marijuana Methamphetamines Psilocybin Total exhibits seized

2006 3886 278 58 878 6 2144 570 35 8154

2007 3480 277 52 918 18 2432 536 27 7990

2008 3533 741 61 828 35 2052 340 44 8145

2009* 2753 288 24 561 25 1397 269 29 5139

+All 2009 data is up to November 17th 200912

Table 7.2

Vancouver Police Department number of exhibits seized of specific drugs 2010-13*

Drug Cocaine (including crack) Ecstasy Hashish Heroin Ketamine Marijuana Methamphetamines Psilocybin

Table 7.3

2010 2,079 187 48 369 22 1853 258 31

2011 1,293 151 41 482 24 1443 370 36

2012 1,372 57 38 746 7 1451 355 21

2013 1,795 37 66 906 8 2150 757 19

Vancouver Police Department weight in grams of seizures of specific drugs 2010-13*

Drug Cocaine (including crack) Ecstasy Hashish Heroin Ketamine Marijuana Methamphetamines Psilocybin

2010 19,716 3604 (567) 460 766 9081 999405 1356 1911

2011 19,811 5217 (275) 1834 1221 3136 330260 4065 1181

2012 19,285 269 (65) 1728 3217 103 842850 4367 3538

++Some ecstasy exhibits were recorded as dosage not grams; both are reported. (Organized Crime Section, Vancouver Police Department, personal communication, September 17th, 2014)

LAW ENFORCEMENT

2013 91,169 289 (12) 2884 4297 115 208510 31491 978

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0 Comparison CDSA Offences BC and Vancouver When comparing drug crime in Vancouver and in BC overall, there are some substantial differences (Figure 7.8). Cannabis was involved in the great majority (70%) of CDSA offences at

Figure 7.8

the provincial level compared to only 40% of drug offences in Vancouver; thus a larger proportion of drug offences involved heroin and cocaine in Vancouver compared to BC.

Comparison between CDSA Offences in BC and Vancouver, 2012134,137

Heroin 3%

Other drugs 10%

Other drugs 8% Heroin 15% Cannabis 40%

Cocaine17% Cannabis 70% Cocaine37%

BC

VANCOUVER

0 Alternatives to Incarceration Despite the reductions in property crime and drug offences, Vancouver rates are still among the highest in Canada and in BC. A large proportion of property crime is associated with substance use, which is prominent in the Downtown Eastside (DTES) and there are a high number of chronic offenders. In 2004, the Vancouver Police Department created the Chronic Offender Program (COP) to better understand socioeconomic and health issues that led to their criminal behaviour. They found that 379 individuals had more than 12 charges in the past 12 months and 78% of them had drug and/or alcohol addictions. In the follow-up period from 2001 to 2006, one hundred of them (more than 25%) had more than 54 convictions each.138 Chronic offenders with a range of health and socioeconomic problems represent a challenge to the justice system and a different approach to address their complex needs and interrupt the so-called “revolving door phenomenon” (imprisonment-> discharge from prison-> involvement in street crime-> conviction-> CHAPTER 7

imprisonment) was needed. Addressing the root causes of criminal behaviour, namely addiction, homelessness, low education level, unemployment and mental health, is thought to have more sustainable effects on rehabilitation of chronic offenders. Frequent re-offending creates a backlog of adult

Revolving Door Phenomenon Imprisonment Discharge from Prison Involvement in Street Crime Conviction

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criminal cases in the Provincial Court, so it may take from six weeks to six months for an offender to appear in court. This can lead to a termination of cases due to extensive delays, which further reduces chances for an offender to access treatment and social services and start the path towards recovery.139 Problem-Solving Courts were developed with the main goal to reduce recidivism and drug use through offering specialized programs instead of imprisonment. Repeat offenders are dealt with in a timely manner and provided with addiction treatment, healthcare, and social support. Of five problem-solving courts in BC, two operate in Vancouver and will be described in the following sections. These are the Drug Treatment Court of Vancouver (DTCV) and the Downtown Community Court (DCC).

DRUG TREATMENT COURT OF VANCOUVER Drug Treatment Courts (DTCs) were developed based on the integration of addiction treatment services with justice system case processing. The first DTC opened in the US in Florida (1989), and the first Canadian court opened in Toronto in 1998, followed by Vancouver in December 2001. The Federal Department of Justice, through partnership with Health Canada, subsequently provided funding for an additional four sites in Edmonton (2005), followed in 2006 by Winnipeg, Ottawa, and Regina. There are also DTCs in Calgary (AB), Moose Jaw (SK), London (ON) and Durham (ON), which are funded by their municipal governments.140 The common objectives for all DTCs are reducing substance use, offending and re-offending through the rehabilitation of persons who commit crimes to support their drug addiction. The Crown prosecutor determines eligibility after reviewing applications submitted by offenders. Individual assessment is conducted by treatment personnel who put forward an admission plan to the DTC team. The interdisciplinary team consists of provincial and federal Crown prosecutors, trained judges, court registry staff, defense counsel, psychologists, addiction therapists, case managers, financial assistance workers and probation officers. An offender can start the program after pleading guilty, but has 30 days to withdraw the guilty plea and enter the traditional court system. The program requires intensive participation, including weekly court attendance and counselling sessions, and respecting the strict bail conditions. Over 14 months participants receive 265 clinic hours of addiction treatment that is tailored to their individual needs. Random urine drug testing, incentives and sanctions are used to ensure compliance. Program graduation criteria include abstinence from drugs for three months preceding graduation, no new offences for the last six months, and evidence of social stability

(stable housing, school enrolment, employment or volunteer work). The graduate returns to court for sentencing – usually a suspended sentence and a term of probation. Participants are removed from the program if there is a pattern of repeated positive drug testing and lack of compliance with the program. If an offender is not successful in completing the program, he/she is sentenced as part of the regular court process.140 The first evaluation of the DTCV was carried out in 2006 by the National Crime Prevention Centre. From December 2001 to March 2005, 322 individuals participated in the program, but only 43 (14%) completed it. After six months, among those who completed the program, 30% tested positive for drugs and 10% had new charges; among those who did not complete the program, all had positive urine drug test and 35% had new criminal charges. Results for a comparison group consisted of 166 offenders with a history of drug addiction and were in custody for various reasons, not only drug offences, were not reported.141 The study was criticized for the lack of randomization, poorly selected comparison group and failure to provide an intention-to-treat analysis.142 In 2006 Vancouver Coastal Health took charge of the treatment component and full-time staff members providing Aboriginal care, housing, and financial support were added to the team. A subsequent evaluation looked at 180 DTCV participants enrolled between December 2001 and March 2008, regardless of whether they graduated from the program compared to 180 propensity score matched participants sentenced through the Provincial Court between April 2003 and March 2009. A ‘before-after’ analysis showed a significant decrease in the percentage of offenders who committed a new offence in both groups, but no differences between the DTCV (78% to 51%) and the matched comparison (72% to 49%) groups. CDSA offences pre-treatment (pre-sentencing) differed between groups (DCTV was 63% and matched comparison 21%); new CDSA offences were 28% and 14% respectively. 143 Drug use in the follow-up period and costs associated with DTCV enrolment versus traditional sentencing were not reported. Debate continues regarding the effectiveness and costs of DTCV. Allared et al. present a comprehensive analysis of methodological issues in DTC evaluation studies, as well as legal and ethical concerns that arise from DTCs in general. Introduction of DTCs as an alternative to incarceration represents an important step forward in the reform of the Canadian justice system, but there are still many opportunities to improve their functioning in order to reduce drug-related crime and improve public safety.144 LAW ENFORCEMENT

Y DOWNTOWN COMMUNITY COURT While DTCs focus primarily on offenders whose chronic reoffending is perpetuated by substance use, community courts focus on the integration of the justice system with the local social and health care services within clearly defined geographical boundaries. They apply problem-solving approaches to the street-level crime and safety matters in a neighbourhood, with emphasis on addressing the crime where and when it happens. An offender has the opportunity to see the consequences of his/her behaviour and make immediate compensation to the community in the form of community service. This model was developed in New York City at the Midtown Community Court, which opened in 1993. In the next 15 years community courts sprang across the US and were introduced in other countries such as the UK, Australia, New Zealand, and South Africa.145 The first Canadian community court opened in September 2008 in Vancouver DTES. It is funded by the BC government and represents the partnership between the Provincial Court of BC and 15 agencies and organizations, including Ministry of Social Development, BC Housing, Legal Services Society, Public Prosecution Service, Vancouver Coastal Health, Vancouver Police Department, Elizabeth Fry Society of Greater Vancouver, Vancouver Aboriginal Transformative Justice Services Society and Watari Counselling and Support Services Society.145 The team includes a defence lawyer (available at all times), a Provincial Court judge, a case manager, a Crown counsel, court clerks, police officers, probation officers, an occupational therapist, a licensed practical nurse, social workers, employment and income assistance workers, a BC housing support worker, native court workers, and forensic liaison workers. A victim service worker is also available onsite to assist victims through the community court process. Community partners include local residents, merchants, faith groups and schools.146 The court now processes about 2,500 cases per year, addressing various low-profile offenders in the central business district, Chinatown, Coal Harbour, Downtown Eastside, Gastown, Strathcona, Yaletown, the West End and Stanley Park.139 DCC operates based on three guiding principles: - Timeliness – reduction of time from charge to conviction

(offenders are heard within 2 to 14 days and if assigned to do community service, they start within 24 hours) - Integration – partnership between the justice system, health-

care and social services and the community to address the complex needs of offenders - Connection to community – local businesses and organiza-

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service helping them gain new skills and work experience and develop pro-social behaviour, which increases offender accountability A person charged with an offence discusses the case with a defence lawyer and has an interview with a community court staff. If the accused pleads guilty, the case can be dealt with in the DCC. The judge has several options depending on the severity of the current offence, history of re-offending, and personal history. For minor offences, an “alternative measure” in the form of community service may be appropriate or an offender may be referred to addiction/mental health treatment or employment programs. For more serious offences, an accused might be sentenced to probation, a fine, time in jail or any combination of these.145 The effectiveness of DCC was evaluated by researchers from the Faculty of Health Sciences and School of Criminology at Simon Fraser University and by an independent evaluator, R.A. Malatest & Associates. The evaluation focused on three areas: 1. DCC efficiency. Implementation of DCC had neither positive nor negative effect on several measures of efficiency (the average number of appearances per concluded case, the median time to disposition, the proportion of individuals dealt with through alternative measures, the number of post-sentence court appearances, the number of cases awaiting trial, etc.) 147 2. Offender outcomes were evaluated only on the subset of DCC participants who were assigned to the Case Management Team (CMT) because of their higher risk of re-offending and high needs (n=279, which is 9.5% of total DCC cohort processed between 2008 and 2011). The comparison group consisted of individuals sentenced through the Provincial Court in the same time period (n=4,377). A total of 249 individuals were selected in CMT group and the same number was selected in the matched comparison group (MCG). The greater reduction in total number of offences and property offences was seen in the CMT group compared to MCG, but drug offences were not reported.148 3. Community engagement was assessed through a series of qualitative studies, focus group discussions and surveys. The results showed that representatives from the community service agencies were supportive of the vision and goals of the Downtown Community Court, but many expressed concerns regarding the commitment of stakeholders, decision-making process within DCC, long term support for clients after their court obligations finish, and transparency about the court’s impact in the community.146

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0 Drug Thefts From Pharmacies According to Health Canada, all people involved in legal distribution of controlled substances must take appropriate security measures by providing designated space for storage of such substances (i.e. the pharmacy narcotic vault and locked cabinets) and keeping prescriptions and orders for Schedule I, II and III drugs in a secure space, inaccessible and invisible to the public.149 Each case of theft, loss or forgery must be reported to the police immediately and to the Health Canada, Office of Controlled Substances within 10 days. The College of Pharmacists of BC has collected this information since 2009; however data from 2009, 2010 and 2011 are inconsistent and unreliable (for example, there are only 3 entries for all 2010). In the first six months of 2014, there were more robberies/break-ins than in the whole previous year (36 vs. 32). Opioids (oxycodone, Percocet, methadone) were involved in 126 out of 135 cases. When sold on the street, these substances can cause serious problems for people who use who are not aware of the drug content or potency. From March 2009 to July 2014 there were 135 events; -

53 armed robbery

-

42 robbery

-

30 break and enter

-

10 attempted robbery or break and enter

About half (68) of the events occurred in Fraser Health: Surrey (24); Burnaby (10); Langley (7); Maple Ridge (5); Coquitlam (5); Abbotsford (4) Vancouver Coastal Health had 51 reports: the majority were in Vancouver (46) and two each North Vancouver and West Vancouver and one in Richmond VIHA had 4 reports –Victoria (2), Nanaimo (1) and Qualicum Beach (1) Interior Health had 11 reports; 4 of these were in Kelowna and the rest distributed across the health authority. Northern Health had 1 report which was in Fort St John. DOAP collaboratively developed recommendations to respond to pharmacy break-in or robberies. If the police have concerns about the pharmaceuticals stolen and possible action or interactions they are advised to contact the BC Drug and Poison Information Centre which has a 24-hour phone line with pharmacists available. As on all occasions when it is determined necessary to issue a media

release or local alert, it is suggested the police (or other alerting authority) discuss with the corresponding medical health officer who in turn may seek input from service providers and PWUD to ensure the wording is appropriate.

0 Drug Trafficking Drug trafficking is a lucrative business on an international scale. Distribution of plant-based substances follows well-established drug-trafficking pathways from their geographical region of cultivation to the consumer markets around the world, including Canada. An important part of law enforcement at the national, regional and international level is to interrupt these trade pathways, including eradication of cultivating crops, dismantling of manufacturing labs and seizure of shipments at international borders. UN Office on Drugs and Crime (UNODC) collects data about cultivation, production, distribution and sale of illicit drugs, which is published each year in the World Drug Report. Data presented in this section are from the latest report published online in 2014.24 The Canada Border Services Agency reports drug seizures and estimated value of drugs arriving from other countries through air, sea and land routes. Drugs that are trafficked across borders are usually concentrated to reduce the volume necessary to transport.

OPIUM AND HEROIN Heroin (diacetylmorphine) is manufactured from raw opium. In order to produce 1 kg of heroin, 7-10 kg of raw opium is needed. Afghanistan continues to be the world’s largest producer of opium with an estimated production of 5,500 tons in 2013 (about 80% of global opium production). The second largest producer of opium is Myanmar, with an estimated production of 870 tons of opium (12.6% of global production) in 2013. In recent years, Mexico has emerged as the third largest producer of opium.24 The latest available data about drug seizures in Canada are from the RCMP Report on the Illicit Drug Situation-2009.150 In 2009, a record of 213 kg of heroin was seized in Canada, plus an additional 6 kg seized abroad en route to Canada; 339 kg of opium and 17 tons of dried opium poppy pods were seized. Despite unavailability of forensic profiling to determine the geographical origin of the seized opiates, it is believed that the majority of shipments originated in Afghanistan and only 2% from Southeast Asia and Latin America.150 LAW ENFORCEMENT

Y COCAINE The three South American countries – Colombia, Peru and Bolivia – are the world’s largest producers of cocaine. According to the UNODC World Drug Report 2014, the cultivation and production of cocaine are in decline due to eradication of coca bush plantations and seizures of illicit laboratories that manufacture cocaine. In Colombia, the area under the coca bush cultivation decreased from 135,000 ha in 2012 to 89,000 ha in 2013, and also decreased in Peru and in Bolivia. Consequently, the estimated production of cocaine chlorohydrate fell from 405 tons in 2012 to 331 tons in 2013 in Colombia. Along with the decline in cocaine production, the decline of cocaine purity was noted in major consumer markets of North America and Europe. Commonly used adulterants are levamisole (anti-parasitic), lidocaine, procaine, benzocaine, caffeine, hydroxyzine (antihistamine) and phenacetin (analgesic). Levamisole has been associated with severe neutropenia and other harms as described in the morbidity section. Trafficking of cocaine flows through the Pacific and Caribbean maritime routes to Mexico and then to the US and Canada. Smaller quantities are transported by air cargo, commercial trucks and private vessels. In 2009, law enforcement agencies across Canada seized 2,373 kg of cocaine and 15.6 kg of crack cocaine.150

CANNABIS Cannabis can be cultivated indoors or outdoors and the scale ranges from a few plants for personal use to thousands of plants intended for exploitation and drug trafficking. There are several varieties available on the market: herb, resin, plant, oil and seed. Cannabis is the most frequently used substance in the majority of countries in the world, including Canada. Cultivation in Canada happens mostly in BC, Ontario and Quebec, predominantly in indoor marijuana grow operations (MGOs). Despite domestic production exceeding demand, different cannabis preparations (marijuana herb, hashish, hash oil) continue to be imported into Canada from Jamaica, the US, the Netherlands, Thailand, Pakistan, Afghanistan, Morocco, Lebanon, South Africa, Mozambique and Kenya. 150 Organized crime groups use mostly air cargo and passenger flights to bring cannabis into Canada, while hashish is usually smuggled concealed in containers on large commercial boats. Canada is also a source country for cannabis intended for trade in the US market. 24 CHAPTER 7

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In 2009, Canadian law enforcement agencies seized 34,391 kg of marijuana, 1,845,734 marijuana plants, 9,666 kg of hashish and 241 kg of hash oil.

SYNTHETIC DRUGS ‘Synthetic drugs’ refers to psychoactive substances synthesized in the laboratory from precursor chemicals that are normally used in the production of legitimate industrial and household goods. In general, synthetic drugs are classified into two major groups: 1.

Amphetamine-type stimulants (ATS) include amphetamine, methamphetamine, methcathinone, 3,4-methylenedioxymethamphetamine (MDMA, i.e. ecstasy) and its analogues (3,4-methylenedioxyamphetamine (MDA) and N-ethyl-α-methyl-3,4-methylenedioxyphenethylamine (MDE).

2.

New psychoactive substances (NPS) are substances “that are not controlled by the 1961 Single Convention on Narcotic Drugs or the 1971 Convention on Psychotropic substances, but which may pose a public health threat”.151 They are often referred to as “legal highs”, ”herbal highs”, “bath salts”, “research chemicals” or “designer drugs” and are marked with labels ‘not for human consumption’ in order to avoid detection and control.

Virtually endless possibilities exist for the alteration of chemical structure and synthesis of new molecules. This is supported by the fact that the UNODC identified 348 NPS by 2013, although this number does not take into account substances that are on the market but are not reported. 152 The growing demand for ATS and NPS has led to the expansion of ATS trafficking routes and manufacturing labs to all six continents. Of all ATS, amphetamine and methamphetamine remain the most commonly manufactured substances worldwide, while the manufacture of ecstasy and its analogues is less widespread. Since 2008, seizures in ATS have increased globally. This prompted UNODC to initiate the Global Synthetics Monitoring: Analyses, Reporting and Trends (SMART) Programme, which now monitors the synthetic drug situation all over the world. Globally, seizures of ATS reached almost 140 tons in 2012. Although the highest number of dismantled ATS-manufacturing laboratories was reported in 2004 (19,799), in 2009 10,598 labs were dismantled. 153

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Seven main categories of NPS Controlled Substance (natural or synthetic)

Category

Street Names

Synthetic Analogues

synthetic cannabinoids

tetrahydrocannabinol (THC) aminoalkylindoles

synthetic cathinones

cathinone

4-methylmethcathinone (mephedrone) and 3,4-methylenedioxypyrovalerone (MDPV)

‘m-cat’, ‘meph’, ‘drone’, ‘top cat’

ketamine

phencyclidine

ketamine

‘special K’, ‘kit kat’, ‘vitamin K’, ‘cat valium’, ‘super K’

phenethylamines

mescaline

piperazines

N/A

1-benzylpiperazine (BZP), m-chlorophenylpiperazine (mCPP), 1-(4-fluorophenyl) piperazine (pFPP)

‘legal E’, legal X’, ‘pep X’, ‘Benny Bear’, ‘Flying Angel’, ‘party pills’

plant-based substances

cathinone

Khat

‘Arabian tea’, ‘chat’

N/A

Kratom

‘ketum’

N/A N/A

Salvia

‘magic mint’, ‘sallyD’

Aminoindanes

‘pink champaigne’

rolicyclidine (PCPY), eticyclidine (PCE)

Phencyclidines (PCPs) 3-methoxyeticyclidine (3-MeO-PCE)

‘research chemicals’

psilocybin

Tryptamines

‘foxy-methoxy’, ‘alpha-O’

miscellaneous substances

benzodifuranyl aminoalkanes, p-methoxymethamphetamine (PMMA), p-methoxy-alpha methylphenethylamine (PMA)

It is estimated that Canada produces 0.6-4.6% of the global ATS supply.154 Besides domestic production and distribution, organized crime groups in Canada are involved in international MDMA and methamphetamine trade. In 2009, the RCMP reported seizure of 954,929 units of MDMA, 78.79 kg /62,307 tablets of methamphetamine, 36 kg of ketamine and 210,151 tablets of BZP.

Figure 7.9

‘spice’, ‘K2’, ‘moon rocks’, ‘Mr. Smiley’

‘methyl-MA’

Data about ATS lab seizures (45 labs in 2009) indicate that the majority of them are located in BC and Ontario, in urban areas of Metro Vancouver and Greater Toronto. Figure 7.9 shows the number of clandestine labs seized in 2009 by province and type of manufacturing process. 150

Number and type of clandestine labs seized in Canada, 2009150

20

Labs seized in 2009 by Province and by Process Type

15 10 5 0

British Columbia Alberta

Manitoba

Ontario

Quebec

LAW ENFORCEMENT

Amphetamine Cannabis Extraction Ephedrine GHB MDMA Methamphetamine PCP Tablet Extraction Tabletting

Y CANADA BORDER SERVICES AGENCY The Canada Border Services Agency (CBSA) was created in 2003. Details regarding prosecutions can be found at http:// www.cbsa-asfc.gc.ca/media/prosecutions-poursuites/ pac/2013-12-16-eng.html this includes individual’s body packing small amounts of heroin and methamphetamine, larger seizures for example 130Kg of cocaine was seized from a large marine container from Russia in September 2013; and precursor chemicals.

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Data regarding seizures for 2008 to 2013 was obtained from the CBSA, Pacific Region. This data includes estimated monetary street value of the drugs seized. Where drugs are reported as grams and as dosage e.g. ecstasy and methamphetamine and amphetamine or as solid, liquid or residue events are summed but no weight or volume amounts are included. See Table 7.5. In 2013 the total street value of drugs seized was estimated as $47 million.

Canadian Border Services Agency, Pacific Region, Drug Seizure Report

COCAINE (gm) Seizure events Estimated value $CDN CRACK (gm) Seizure events (incl. residue) Estimated value $CDN ECSTACY* Seizure events Estimated value $CDN HASHISH** Seizure events (incl. residue) Estimated value $CDN HEROIN (gm) Seizure events Estimated value $CDN KETAMINE (gm) Seizure events Estimated value $CDN MARIJUANA (gm) Seizure events (incl. residue) Estimated value $CDN METHAMPHETAMINE & AMPHETAMINES*** Seizure events Estimated value $CDN OPIUM (gm) Seizure events Estimated value $CDN PSILOCYBIN (dosage) Seizure events Estimated value $CDN TOTAL SEIZURE EVENTS TOTAL ESTIMATED VALUE

2008 244,440 20 30,554,969 2 9 320

2009 362,567 51 45,320,918 13 21 2,648

2010 628,784 44 78,597,809 0 20 64

2011 156,323 71 19,540,432 40 20 7,903

2012 52,249 46 6,531,148 142 23 28,440

2013 193,782 24 24,222,744 12 13 2,301

8 8,885,531

59 2,866,646

46 1,829,157

63 1,926,031

22 35,925

36 73,871

14 3,185 4,964 12 1,985,633 26 1 1,305 5,406 225 108,123

45 27,707 18,449 18 7,379,592 1,507 6 75,373 26,188 727 523,755

34 5,532 20,983 23 8,393,449 1,808,131 6 126,569,191 85,397 680 1,707,955

48 153,531 6,495 19 2,598,016 33 5 2,338 35,363 863 707,243

79 9,531 5,640 20 2,255,960 103,391 8 7,237,341 62,963 1,186 1,237,713

64 22,570 48,643 36 19,457,502 46 8 3,217 14,263 711 285,261

13 994,850 130,247 10 6,512,366 9 9 2,672 321 49,048,954

47 507,451 3,442,531 28 172,126,437 13 13 3,426 1,015 228,833,953

46 9,459,059 304,402 51 17,696,085 18 18 6,426 968 244,264,727

94 1,859,972 188,543 41 11,307,119 22 22 2,690 1,246 38,105,275

119 1,558,995 77,903 33 4,674,183 17 17 4,449 1,553 23,573,685

119 3,042,958 3,403.43 24 204,206 23 23 66,971 1,058 47,381,601

*Ecstasy includes dosage and grams **Hashish and hashish liquid including residue ***Methamphetamine and amphetamine include dosages and grams (Canada Border Services Agency, Pacific Region Enforcement and Intelligence Division, Intelligence Section, September 24, 2014) CHAPTER 7

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The estimated value of selected drugs seized is shown in Figure 7.10. It shows cocaine seized peaked in 2010 and consistently has the greatest value of drugs seized each year by CBSA. In 2013 although the number of seizures of cocaine

Figure 7.10


was less than the previous year the value was higher as larger volumes were seized. Heroin also increased in 2013. Methamphetamine and amphetamine together and ecstasy have remained consistently below $10million per year.

Value of Canadian Border Services Agency, Pacific Region, selected drug seizures ($CDN) 200,000,000 180,000,000 160,000,000 140,000,000 120,000,000 100,000,000 80,000,000 60,000,000 40,000,000 20,000,000 0

2008 2009 2010 Cocaine 30,554,969 45,320,918 78,597,809 Ecstasy 8,885,531 2,866,646 1,829,157 Heroin 1,985,633 7,379,592 8,393,449 Opium 6,512,366 172,126,437 17,696,085 Meth and amphetamine 994,850 507,451 9,459,059

2011 19,540,432 1,926,031 2,598,016 11,307,119 1,859,972

2012 2013 6,531,148 24,222,744 35,925 73,871 2,255,960 19,457,502 4,674,183 204,206 1,558,995 3,042,958

(Canada Border Services Agency, Pacific Region Enforcement and Intelligence Division, Intelligence Section, September 24, 2014)

PRECURSOR CHEMICALS The 1988 UN Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances regulates the trade of chemicals that can be used in the process of manufacturing drugs (plant-based or synthetic). Health Canada implemented the Precursor Control Regulations in January 2003. In 2011 amendments were made to the CDSA to include possession and trafficking of precursor chemicals and/or equipment as a new violation code. Currently only 23 chemicals are under strict international control, although the list is constantly monitored and updated. Controlled precursor chemicals are classified as Table I (substances that become incorporated into a new drug at the molecular level during the manufacturing process) and Table II substances (reagents and solvents used in the process of production which do not become incorporated into the newly synthesized molecule). The list is shown in Table 7.6.

Table 7.6

The list of internationally controlled precursor chemicals24

Table I

Table II

Acetic anhydride Alpha-phenylacetoacetonitrile N-acetylantranilic acid Ephedrine Ergometrine Ergotamine Isosafrole Lysergic acid 3,4-methylenedioxyphenyl-2-propanone Norephedrine Phenylacetic acid 1-phenyl-2-propanone Piperonal Potassium permanganate Pseudoephedrine

Acetone Anthranilic acid Ethyl ether Hydrochloric acid Methyl ethyl ketone Piperidine Sulphuric acid Toluene

LAW ENFORCEMENT

Y The International Narcotics Control Board (INCB) monitors the legal and illegal trade of precursor chemicals. The Precursor Incident Communication System (PICS) was implemented in 2012 as an international monitoring system and source of information about trends, amounts and types of precursors legally and illegally transported around the world. In response to stricter control measures and amendments to legislation, drug traffickers and clandestine lab operators continue to introduce new chemicals (precursors and pre-precursors) into the market and move their operations into countries previously unaffected by synthetic drug trade.152

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Land cross-border routes are the primary ways of transportation of precursor chemicals and/or lab equipment to and from Canada. The RCMP launched a Synthetic Drug Initiative in 2008 and, with partners from the industry, developed a program called ChemWatch to monitor and investigate incidents of diversion and theft and develop preventative measures. In 2009, most commonly seized chemicals in Canada were ephedrine (92 kg), pseudoephedrine (118 kg) and gamma-butyrolactone (GBL) (close to 2,000 litres), but considerable amounts of other chemicals, such as safrole and L-phenylacetylcarbinol (L-PAC) were seized as well. 150

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~Glossary Attributable Morbidity/Mortality

Rate

The theoretical proportion of the number of cases of hospitalizations/death that can be attributed to a given risk factor. 20 For this report, the values for the attributable fractions (AF) for tobacco and illicit drugs were taken directly from the report “The Costs of Substance Abuse in Canada 2002” by Jurgen Rehms et al. 20

a measure of frequency with which an event occurs in a specific population in a defined time period. Rates enable comparisons between geographic areas by taking into account different population sizes and changes to these populations over time.

Incidence The risk of developing a condition within a specified time period. The incidence rate is obtained by taking the number of people who have been diagnosed with a particular condition (new cases) within a stated period of time, divided by the number of people at risk for the condition.

Life expectancy at birth This is the average number of years a person may expect to live assuming mortality rates remain stable for each age, usually aggregated over five year periods.

Ratio A comparison between two numbers, usually separated by a colon.

Risk The probability that an event will occur.

Standardized Mortality Ratio (SMR) based on the age- and sex-specific rates in a standard population and the age and sex distribution of the study population. If the ratio of observed to expected deaths is greater than 1.0, there is an "excess of deaths" in the study population.10

Morbidity Another term for a disease state or illness. Incidence and prevalence are two measures used to describe the occurrence of morbidity in a population.

Mortality Rate The number of deaths due to a condition divided by the number of persons in the population.

Opiate Naturally occurring alkaloids found in the opium poppy e.g. morphine and codeine

Opioids (or narcotic analgesic) Psychoactive chemicals which relive pain include natural opiates and synthetic opioids; methadone, oxycodone, hydrocodone, hydromorphone, morphine, pethidine, fentanyl, buprenorphine.

Prevalence The proportion of people that have a condition at a specified time. Prevalence is calculated by taking the number of people with a particular condition and then dividing that number by the total number of people who are at risk for the condition.

GLOSSARY

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~Data Sources ~BC Stats

, The AIDS Care Cohort to Evaluate access to Survival

The central statistics agency for BC; it provides population estimates and projections.

Services (ACCESS) follows HIV-positive people who use illicit drugs , The At-Risk Youth Study (ARYS) began in 2005 and

~BC Vital Statistics Agency

follows street-involved youth aged 14-26 years

Registers all births and deaths in BC. It provides mortality (cause of death) data for the general population using the World Health Organization International Classification of Diseases version 10 (ICD-10).

~Homeless Counts provide snapshots

- 2014 Metro Vancouver Homeless Count was conducted on

March 11/12 2014. includes data provided by BC Housing; methods and implementation was overseen by the Greater Vancouver Regional Steering Committee on Homelessness and the Aboriginal Homelessness Steering Committee

- The Victoria homeless count – provided by the Greater

Victoria Coalition the End Homelessness; drawn from a count conducted on February 2, 2011

- The Prince George homeless count - drawn from a May 16th

and 17th 2010 survey conducted by the Community Partners Addressing Homelessness.

- 2013 URHI data contained in this report was extracted from i)

ARYS cohort, and ii) combined VIDUS and ACCESS cohorts .

~BCCDC’s Survey of Harm Reduction Distribution Site Clients

Harm reduction distribution sites across BC participate in the annual survey which commenced in 2011. Clients complete a survey which asks about drugs used, access to harm reduction supplies and risk.

~McCreary Centre Society’s Adolescent Health Survey (AHS)

The survey is administered every five years to BC public school students in grades 7 to 12; in 2013 there were 259,138 participants.

~East Kootenay Addiction Service Society (EKASS) This survey is administered every two years to Kootenay area students in grades 7 to 12; in 2013 there were 3,462 participants .

0 DRUG USE DATA ~Canadian Alcohol and Drug Use Monitoring Survey (CADUMS)

0 MORBIDITY DATA

An annual telephone survey of Canadians aged 15 and older, led by Health Canada. It was discontinued in 2012.

~BC Alcohol and Other Drug Monitoring Project

~The High Risk Populations Surveys A component of CARBC’s Alcohol and Other Drug Monitoring Project. It consists of a convenience sample of about 50 participants every 6 months in three study groups: street involved adults, recreational drug users and street involved youth, in Vancouver and Victoria. Currently 2013 data for Vancouver are not available.

~The Urban Health Research Initiative (UHRI) of the BC Centre for Excellence in HIV/AIDS

- The latest URHI report (Drug situation in Vancouver)

combines three longitudinal Vancouver based open cohorts which interviews participants every 6 months , The Vancouver Injection Drug Users Study (VIDUS) is

UHRI’s longest-running cohort study which started in 1996 and follows about 1,500 participants who are HIV-negative DATA SOURCES

(AOD monitoring)

Run by Centre for Addictions Research of BC has 10 research components which include the high risk population surveys, hospitalizations and deaths attributable to substance use, emergency department study.

~Hospitalizations attributable to substance use (a component of BC AOD Monitoring Project)

The most responsible diagnosis code (ICD-10) for 70+ conditions is obtained from the Ministry of Health Discharge Abstract Database by quarter, by 5 year age group and sex and local health area; hospitalizations related (attributable) to alcohol, tobacco, and illicit drug are calculated using attributable fractions adjusted for prevalence of substance use (alcohol and tobacco). All rates are age- and sex-standardized using the 2001 BC population over 15 years of age as the standard.

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~Emergency Department Study

(a component of BC AOD Monitoring Project) Vancouver General Hospital and Royal Jubilee Hospital in Victoria survey patients who come into the emergency department on one Friday and one Saturday evening per month between 9 p.m. and 4 am and assess substance use through administration of the Alcohol Use Disorders Identification Test (AUDIT) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

~Public Health Surveillance Unit, Vancouver Coastal Health

The unit was established in 2007 in preparation for the 2010 winter Olympics with a mandate to support VCH’s overall goal of promoting better health for its communities, through disease surveillance, health assessment, epidemiologic investigations and knowledge transfer.

~BC Ambulance Service (BCAS), BC Emergency Health Services

BCAS provide BCCDC with weekly dispatch call data coded as ingestion poisoning by geographic regions. BCAS also provides naloxone administration events by ambulance crew.

~BC Drug and Poison Information Centre (DPIC) DPIC provides advice to the public and health professionals regarding poison exposures through a 24-hour phone line. Call information including drug categories and health authority is provided to BCCDC weekly.

~HealthLink BC 811 Trained nurses provide free health information and advice over the phone to the public .

0 COMMUNICABLE DISEASE DATA

~BC Public Health Microbiology and Reference Laboratory

Is the primary public health and reference diagnostic testing facility for BC. It performs about 95% of hepatitis C virus testing in the province and therefore provides testing volumes and seroconversion data.

0 MORTALITY DATA ~Deaths attributable to substance use

(a component of BC AOD Monitoring Project) The underlying cause of death code (UCOD) from BC Vital Statistics enables substance-attributable deaths to be calculated. See hospitalizations attributable to substance use above.

~BC Coroners Service Provides monthly illicit drug overdose deaths in BC and also ad hoc reports regarding specific substances e.g. fentanyldetected deaths. The Coroner’s regions differ from the health authority areas. Data for past 12 months is subject to change as cases are closed.

0 HARM REDUCTION ~Harm Reduction program at BCCDC The HR program tracks harm reduction supplies distributed to 300 sites throughout the province. It also coordinates and collates the data for the Take Home Naloxone Program .

0 LAW ENFORCEMENT DATA ~BC Ministry of Justice and Vancouver Police Department Data about criminal code and CDSA are collected using the Uniform Crime Reporting Survey.

~Integrated Public Health Information System (iPHIS) Clinical and confirmed case reports of reportable diseases in persons residing in BC are entered by public health.

~Clinical Prevention Services at BCCDC Compiles HIV case data with risk factor information. Are provided in collaboration with the BC Centre for Excellence in HIV/AIDS if provides AIDS case reports.

DATA SOURCES

Y

BC DOAP REPORT 2014

Y 107

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