Canada's Health Case System: Its Funding and Organization

The Canada Health Act of 1984 set out an agreement between the provinces and the federal government that emphasized five basic principles for health services: universality, comprehensiveness, portability, public administration and accessibility.⁴ This may be seen to have influenced Canada's response in two ways. First, in principle, injection drug users are linked into the Health Care System. Second, in Canada there is a will and an interest in protecting this system, and prevention of hospitalizations is a major component. This is seen further in a general trend to conceptualize drug problems in terms of lifestyle rather than as a disease.

Canada's Drug Strategy

In 1987 Canada's Drug Strategy was inaugurated with new funding allocated in roughly equal amounts to a wide variety of enforcement, treatment and prevention activities. Although the overall predominant focus on illicit drugs might have been criminal prohibition, in fact, the philosophy behind the Canadian Drug strategy represented a tentative first step toward a harm minimization approach, and an increase in emphasis on demand (the user) versus supply reduction (the seller) strategies.⁵ The national focus provided a catalyst for programme action at the provincial level where the expertise and jurisdictional authority exist. While the Canadian Drug strategy was influenced by the American ''War on Drugs", it attempts to achieve a balance between the supply and the demand sides. Although smaller in scope, the Canadian strategy was more comprehensive than the American in terms of substances targeted (i.e. alcohol is included), and further, placed greater emphasis on prevention and treatment.⁵

Canadian Drug Laws

In Canada the most important legislation dealing with illicit drugs are within the federal governments' jurisdiction, namely, The Narcotic Control Act and The Food and Drugs Act. In brief, these acts deal with possession, trafficking, importing and exporting and "prescription shopping." Further, in 1989 amendments were made to the Criminal Code to make it illegal to knowingly import, export, manufacture, promote, or sell illicit drug paraphernalia or literature. (Bill-264 , September, 1988). The provision or distribution of needles by the medical profession as a "medical device" as opposed to an "instrument for use" is not an offence under the criminal code. Interestingly, the amendment is generally interpreted to suggest that the supplying of needles and syringes for safer injection is not illegal.^{6, 7}

Canada's National AIDS Strategy (1990)

In 1990 the Federal government provided funding and a comprehensive statement of need and directions that should be taken which encompassed AIDS prevention, treatment and research. This National AIDS Strategy committed to support research initiatives to address the issue of HIV infection among people who use injection drugs.⁸ It is through these initiatives that many of the early outreach programmes for injection drug users were funded.

Pharmacy Accreditations and Pharmacists Licensing

In the absence paraphernalia laws, provincial pharmaceutical associations and colleges (regulatory of and licensing bodies) have been largely responsible for setting policies that govern the actions of the pharmacists and the operations of pharmacies in their jurisdictions. For the most part, the sale of needles and syringes for illicit drug use has been discouraged by licensing bodies and in the professional education of pharmacists until recently. Yet, individual pharmacists in some jurisdictions have for some time sold needles and syringes in packages of one to non-diabetic drug users. During the AIDS epidemic the "no sale" policy has been repeatedly examined and an incremental change in policy has occurred. For example in the Province of Ontario in 1987 the sale of needles and syringes to injection drug users was opposed (although recognized as both a moral and public health issue), in 1988 sales were permitted with "professional discretion" because it was seen to be a public health issue and in 1992 the policy was further changed to promote sales of needles by permitting the open display and self-selection of needles and syringes, with professional discretion.⁹ In all provinces except British Columbia there has been movement towards more liberal practices. In British Columbia a policy was embedded in Bylaw B19(9) which indicates ''that no pharmacist shall (a) store hypodermic syringes and needles in an area of the pharmacy accessible to the public, (b) sell hypodermic syringes and needles unless he has established to his reasonable satisfaction that they are required for a lawful purpose, and (c) advertise, by any means, hypodermic syringes and needles." In 1988 the British Columbia Council of the College of Pharmacists recommended to the Provincial Ministry of Health that this bylaw be amended by the deletion of paragraph (b). However, the amendment has never been promulgated.

To summarize for the purposes of this paper, the current provincial regulatory body policies regarding sale of needles and syringes to non-diabetic drug users fall into four categories:

(a)

No Sale (Illegal)

(b)

Sale with Professional Discretion

(c)

Sale with Self-selection possible. (Open display with discretion)

(d)

No written policy.

The current policies of the provinces/territories are shown in Figure 2.

Rationale for the Canadian Pharmacy Survey

This study was designed to describe the variations in current practice in pharmacies across Canada with respect to HIV prevention and to explore the factors that influence these. A related purpose was to assess whether the role of pharmacists might be expanded, and to determine what organizational, educational, or policy changes might be required to accompany any change in role. This study was modelled on an earlier study conducted as part of the evaluation of the City of Toronto's Injection Drug Use Programme. For the 1989 study the sampling unit was the pharmacist rather than the pharmacy. Results were difficult to analyze because of this sampling frame and inability to determine the denominator (number of pharmacists in full-time and part-time employment was unknown, and several pharmacists may have worked in several pharmacies). As well, a low response was obtained. The study responses received reflected that there was a potential role for pharmacies. Data from interviews with injection drug users, another aspect of the evaluation, suggest that 30% of injection drug users experienced difficulty obtaining needles and 47% indicated that pharmacies and drug stores were their most important source of needles and syringes.¹⁰

Knowingly Served a Person with HIV

Nationally, 29.5% of the respondents indicated that they had served a client who was HIV antibody positive or who had AIDS. Twenty-two percent indicated that they did not know if they had served a person who had tested positive for the HIV antibody. Across the country this ranged from a high of 49.5% in British Columbia to a low of 14.8% in Saskatchewan as shown in Figure 4. The three provinces with the greatest proportion of respondents reporting that they had served an HIV positive individual were British Columbia, Quebec and Ontario which corresponds to the known prevalence of AIDS.

Requests to Sell Needles and Syringes

Nationally, 7.9% indicated that they had received no requests to sell needles or syringes (in the past year); 33.8% estimated that they received 20 or fewer requests a year, 18.9% reported receiving 21-100 requests and 21.9% reported more than 100 requests. These rates varied across the country as shown in Figure 5. The provinces receiving the greatest proportion of requests were British Columbia, Ontario, Prince Edward Island and the territories. (Note: As the number of respondents in the eastern provinces and territories are small the graph may misrepresent. Many of the community pharmacists in smaller communities may know their drug using clientele and be prepared to sell. A single user who regularly obtains needles or syringes may inflate this. Further, because of the knowledge a pharmacist may have of their customers in smaller communities they may be prepared to sell needles and syringes for many uses-from basting food to injecting earthworms to keep them buoyant for fishing!)

Comparison of Requests for Needles and Syringe Sales to Knowledge of Serving Persons Living With HIV

Comparison of the proportion of respondents within each province/territory who knowingly have served a person living with HIV as shown in Figure 4 with Figure 5 reflecting requests to sell needles and syringes, shows that there is considerable correspondence between these two variables, except in the provinces with smaller populations. The province of Quebec shows a further variation. This may be a result of the fact that in Quebec many of the pharmacy services may be provided through specific community pharmacies designated as serving injection drug users and through community health centres.

Comparison of "Pharmacy Response" with "Requests to Sell"

A comparison of the two graphs, requests to sell (Figure 5) and response to requests (Figure 6) does not show complete congruence between requests and response within all provincial jurisdictions. This comparison suggests that the decision to sell may relate to both policy and to discretionary factors. To assist in the interpretation of these data two analyses were conducted; one relating provincial/territorial policy to sale of needles and syringes, and another examining factors considered by pharmacists when exercising discretion.

Pharmacy's Response to Requests to Purchase

Nationally, 17.0% of the owner-managers indicated that they would not sell needles and syringes to non-diabetic drug users, 29.1% would sell in some cases, 29.2% would sell in most cases and 24.6% indicated that they would sell in all cases.

Figure 7 shows the proportion of pharmacies within each province/territory agreeing to sell. The highest proportion reporting that they would not sell was 30.5% in British Columbia where sales are illegal. In that same province 31.4% would sell in some cases, 21% in most cases and 17.1% in all cases. The second highest proportion not selling was in Newfoundland (25.9%) where there was no policy. The highest proportion selling in all cases was in the Yukon and Northwest Territories (42.9%), followed by Manitoba (28.4%) and New Brunswick (27.1%).

Discretion in Sales

Of the pharmacies that indicated that they would sell, 69.8% indicated that they would use some discretion in their decision to sell (i.e. would sell in some or most cases).

This subgroup were asked whether various aspects relating to the client and practice influenced their decision to sell. Figure 9 presents the proportion indicating each of five aspects to be a "very important" reason. In order of importance these were the sobriety of the client, characteristics of the client, familiarity with the client, presence of other customers and time of day.

Pharmacy-Based Services for Injection Drug Users

Figure 10 reflects the respondents' willingness and support for specific pharmacy-based services for injection drug users. The respondents were most willing to provide counselling and literature (including information on safer needle use) followed by sale of needle and syringes. They were least supportive of being part of a needle and syringe programme based in their pharmacy.

Agreement with Interventions to Prevent the Spread of HIV

With regard to various measures to prevent the spread of HIV, the respondents were most prepared to endorse control and compulsory measures (e.g., Compulsory HIV antibody testing), followed by punitive measures (e.g., abstinence should be goal of treatment, and possession of needles should be made a criminal offence) (see Figure 11). They were least likely to endorse to more relaxed legislation regarding drug use.

Perceptions of Factors Contributing to Injection Drug Use

The respondents perceived peer pressure to be the greatest contributing factor to injection drug use, followed by personal and social values and personal traits, as shown in Figure 12.

Endorsement of Future Preventive Interventions

In order of preference respondents were prepared to endorse first, environmental and technological measures (e.g., disposal units in parks and non-reusable needle and syringe technologies); second, exchanges in selected pharmacies; third, mobile drug needle exchange units; and finally, the legalization (prescription) of illicit drugs and methadone (see Figure 13).