For the purposes of IDPC’s regional work, North America includes: Canada, Greenland and the United States of America (USA).
North America is a substantial producer of drugs for illicit consumption within the region. The USA produces amphetamine-type stimulants (ATS), mainly methamphetamines. Ecstasy production is also on the rise in both the USA and Canada. Cannabis is extensively cultivated in the USA and Canada mainly for domestic consumption. Though the World Drug Report suggests that Canada has an increasing role in the world-wide production of ATS, in-country estimates suggest that Canada produces as little as 0.6% of the world’s supply or as much as 4.6%. Based on the estimates produced in this report, Canada is no more and no less of a player today than it was five years ago. In 2010 nearly 500,000 plants were cultivated in the USA, the majority in Florida and California. California also recorded an increase in cultivation on public land i.e. national forests. (2012 World Drug Report)
North America is the world’s largest illicit consumer of drugs and, as such, is both a producer and a recipient for drugs trafficked into the region.
Cocaine and heroin are mostly imported through its southern border with Mexico and from other South American countries such as Colombia. Heroin seizures in the USA rose by almost 50% between 2009 and 2010, from 2.4 tons to a record level of 3.5 tons. In contrast, seizures in Canada considerably decreased in this period from 213 kg to just 98 kg. (2012 World Drug Report)
Canada seized 51 tons and 1.9 million cannabis plants in 2010. However, export of Canadian cannabis to the USA appears to be decreasing with cannabis production shifting to the USA side of the USA-Canada border.
Whilst ecstasy-group substance seizures recently declined the trend was reversed in 2009 when they increased by 124 kg corresponding to the increase in ecstasy production in the region. The USA is the most common destination for ecstasy shipments seized in or en route from Canada, followed by Australia, Malaysia and Peru. (2012 World Drug Report)
Cannabis and cocaine are the most widely used drugs in the region and although heroin is not as common as these drugs it is the most commonly injected drug in both the USA. Recent estimates of the number of people in Canada who use non-medical prescription opioids (NMPO) suggest that injection of these drugs is on the increase and may have replaced heroin as the most commonly injected drug in some cities. In Canada, the use of NMPO is now the fourth most prevalent form of substance use behind alcohol, tobacco, and cannabis. Some 500,000 to 1.25 million people are estimated to use PO’s non-medically in Canada surpassing heroin and cocaine in prevalence.
In the USA, annual prevalence of cannabis use among people aged 15-64 years continued to increase in 2010 to 14.1%. The use of prescription drugs is ranked second after cannabis (2012 World Drug Report). It also remained a major market for cocaine use although evidence suggests a marked decline between 2006 and 2010. Ecstasy use has also been on the rise in the region especially among young people, with 2.5 million users aged 14-34 (2010).
In Canada, recent data on cannabis, the most popular of illegal substances, suggest that its use remains high. Average use for individuals over 15 years of age and over was 39.4% for lifetime use, and 9.1% for past year use. Other data suggest that since the 1990s use of stimulants such as crack or methamphetamine among street based users has increased, primarily due to their easy availability. Local studies of high-risk populations also reveal high levels of drug use including alcohol, cannabis and MDMA among club goers.
An emerging trend in 2010 was the consumption of legal highs such as mephedrone which is often sold as ‘bath salts’ or ‘plant food’ as a substitute for other controlled stimulants. In Canada, Salvia divinorum, a naturally occurring psychoactive plant also not internationally regulated, has seen a rise in recent years particularly amongst young people with an estimated 1.6% of Canadians aged 15 years and over having tried the plant in their lifetime.
The use of synthetic prescription opioids and tranquilizers such as benzodiazepines is also increasingly common in the region. In 2010 it continued to stay at a stable level having a knock on effect resulting in a reduced the demand for heroin.
Regional Drug Policies
In 1971, President Nixon launched the “war on drugs” strategy. To a large extent, this strategy relied on the legal pursuit of drug suppliers and drug users. In the following years, President Reagan tripled supply reduction funding from $437 million to $1.4 billion, concentrating heavily on domestic law enforcement but with limited focus on international efforts to prevent trafficking in the region.
In contrast, President Bush focused heavily on international initiatives by providing economic and military assistance to aid illicit drug-producing countries, notably in South America and the Caribbean. Prohibition efforts were concentrated on preventing drugs from reaching the USA by increasing law enforcement in the air, land and sea. Whilst the Obama Administration in 2012 implied a shift in its new national drug strategy from a law enforcement focus to a new strategy aimed at enhancing treatment and prevention, in terms of federal funding, 58.8% of the budget ($15.062 billion) continues to be used for supply reduction efforts. Obama’s strategy also includes more than $5.6 billion for interdiction and overseas supply-control efforts, and US international policy on drug control remains largely unchanged.
In Canada, the federal government has renewed its “Anti-Drug Strategy” for another five-year period (2012-2017) at a proposed cost of $527.8 million. The majority of resources in this strategy are allocated to the criminal justice system and reinforce Canada’s prohibitionary approach to drug policy focusing on law enforcement and incarceration. In 2012, federal legislation came into effect that introduced mandatory minimum sentences for some drug crimes. Canada is also escalating its involvement in drug interdiction efforts in Latin America signalling its intention to participate more fully in the war on drugs.
Even conservative estimates of the costs of these new provisions suggest that the federal government would bear about $8 million and the provinces another $137 million in costs.
Criminal justice system
Over the past 25 years, governments in the region have pursued a law enforcement-based approach to drug use which included mandatory minimum sentencing laws for drug offences at the state and federal levels, resulting in a massive increase in the size of the prison population and the number of non-violent offenders incarcerated for drug offences. In the USA alone, the numbers of incarcerated adults for drug offences increased by 1,000% between 1972 and 2002 and over 1.5 million people were arrested for drug offences in 2011, with nearly 45% being for cannabis possession. In 2011, police reported more than 113,100 drug crimes, an increase of 14% since 2001. Of thes, more than half (54%) were for the possession of cannabis. Between 2010 and 2011, the rate of drug crime increased slightly following an increase of 10% between 2009 and 2010. These increases continue a general trend that began in the early 1990s. The increase in drug crime in 2011 was driven by a 7% rise in the rate of police reported cannabis possession offences. However, the rate of police reported incidents of trafficking, production and distribution of cannabis declined 11%.
In Canada, expenditures on federal corrections have increased to $2.375 billion in 2010-11, a 43.9% increase since 2005-06. It costs $578 per day to incarcerate a federally sentenced woman inmate and just over $300 per day to maintain a male inmate. In contrast, the daily average cost to keep an offender in the community $80.82. Canada’s federal prison system is overcrowded leading to increasing volatility behind bars. In the two-year period between March 2010 and March 2012, the federal in-custody population increased by almost 1,000 inmates or 6.8%, which is the equivalent of two large male medium security institutions. As of April 1, 2012 more than 17% of people in Canada’s prisons are double-bunked.
As of April 2011, 21% of federal offenders were serving a sentence for a drug crime. 55% have problems with substance use. Prison-based substance use programming is also in decline; the Correctional Service of Canada budget for these programs fell from $11M in 2008-09 to $9M in 2010-11. Access to programs and other services inside prison that help inmates transition to life after prison is also either in decline or plagued by lack of available resources.
This law enforcement approach also led to racial discrimination in the legal system. The most glaring example of these laws was the legal response to the emerging crack cocaine epidemic in the mid-1980s. The USA Congress passed laws that created a 100 to 1 sentencing disparity for the possession or trafficking of crack when compared to penalties for trafficking of powder cocaine. Individuals convicted in federal court of possession of 5 grams of crack cocaine received a minimum mandatory sentence of 5 years in federal prison. On the other hand, possession of 500 grams of powder cocaine carries the same sentence. The policy led to far more black and other minorities being incarcerated for drug offenses and receiving far stiffer penalties and sentences than white offenders. In 2010, the Fair Sentencing Act cut the sentencing disparity to 18:1, the first roll-back of compulsory minimum sentences at the federal level in 40 years. Whilst this was a progressive step in the US criminal justice system, recent evidence suggests that racial disparities persist. Whilst only 10% of the adult black population use drugs in the USA, compared to 9% of adult white population, black people are nine times more likely to serve a prison sentence for drug offences. From 1980 to 2007 about one in three of the 25.4 million adults arrested for drugs were African American.
Since the mid 1990’s there has been a growth in the use of drug courts in the USA and Canada, which aim to divert those arrested for low level drug offences out of the prison system and into treatment. According to the Obama administration, drug treatment courts have successfully diverted 120,000 offenders a year since 2009 into treatment instead of incarceration. There are now 2,600 courts across the country. In Canada, results from drug courts have been mixed. Because of a lack of follow-up research on the experiences of participants, and the low retention rates in many DTC programs, it is difficult to conclude at this stage whether or not drug courts result in decreased drug use and/or recidivism. More alarmingly, these authors found that women are less likely to apply to DTC’s and less likely to graduate at comparable levels to men, partly due to a lack of gender specific programming and program flexibility that accommodates parenting responsibilities. Indigenous women and men are also less likely to complete drug court programs due in part to the lack of Indigenous-specific treatment services.
Aboriginal persons are overrepresented in Canada’s justice system. In 2011, approximately 4% of the Canadian population was Aboriginal, 21.4% of the federal incarcerated population is Aboriginal. A 2004 study of incarceration in Canada found that visible minority offenders are incarcerated more often for drug related offences than white offenders despite having less extensive criminal histories than white offenders.
Both the USA and Canada have high levels of people who inject drugs (PWIDs) and are home to one-tenth of all people who inject drugs worldwide. After China and Russia, they have one of the highest estimated populations of PWIDs, with 286,987 in Canada and 1.857.345 in the US. The HIV prevalence among PWIDs is 5.8% in Canada and 15.57% in the USA. Drug-related deaths are highest in North America. They account for approximately 1 in every 20 deaths among persons aged 15-64. Overdose deaths involving prescription opioids increased by 175% in the period 2001-2006. (2012 World Drug Report. –Note: ‘North America in WDR’12 includes Mexico).
Of the 2,358 new HIV infections reported in Canada in 2010, 16.8% were attributed to injection drug use. In 2010, 30.4% of new infections in women versus 13.5 % of new cases in men were attributed to injection drug use. Cases of HIV attributed to injecting drug use among Aboriginal persons have gone up to more than 50 per cent in the period spanning 2001 to 2008 from 18 per cent before 1995. Further, the majority of hepatitis C virus (HCV) cases in Canada are found among people who inject drugs. As of 2009, injection drug use was associated with 61% of newly acquired HCV cases.
Both Canada and the USA have needle and syringe exchange programs (NSPs) and opioid substitution therapy (OST) measures in place. In 2003, Vancouver, in Canada, opened North America’s first (and only) medically-supervised drug consumption room called Insite, which has had an estimated 1.8 million visitors since its opening. Since 2003, Insite has proven its effectiveness in reducing drug-related harms, crime and social exclusion. Insite reduces HIV risk behaviour, preventing more than 80 HIV infections per year. It has also promoted access to drug dependence treatment and reduced deaths from overdose.
As of October 2010, 50 community-based opioid overdose prevention programmes distributing naloxone were functioning in the USA. Since the first opioid overdose prevention programme began distributing naloxone in 1996, kits with naloxone have been distributed to 53,032 persons, and programmes received reports of 10,171 overdose reversals. These 50 programmes operate in 15 USA states and the District of Columbia and include nearly 200 sites where naloxone is distributed in the community to people who use drugs (PWUD), their friends and family.
In Canada, community–based overdose prevention and treatment programs were pioneered in Edmonton, Alberta. Since 2011, Ontario has also started a scale-up of similar services and British Columbia is currently pilot-testing its own provincial program. Considerable work remains on addressing the overdose situation in Canada.
Due to fragmented reporting systems, comprehensive Canadian statistics on overdose fatalities are only available for some jurisdictions. What we do know, is that prescription opiate related deaths have risen sharply and are estimated to be about 50% of annual drug deaths. Overdose deaths from illicit drugs and prescription drugs are a leading cause of death among drug users in Ontario and nationwide. The annual rate of fatal overdoses for drug users who inject is estimated to be between one and three per cent per year. Between 2002 and 2010 there were 1654 fatal overdoses attributed to illegal drugs in B.C and between 2002 and 2009 there were 2,325 illegal drug-related overdose hospitalizations. Increases in the use of prescribed medications like Oxycodone have also precipitated increases in overdose. In Ontario, prescriptions of oxycodone increased by 850% between 1991 and 2007, and each year between 300 and 400 people die from overdose involving prescription opioids -- most commonly oxycodone. Research found that in Ontario the addition of long-acting oxycodone to the drug formulary was associated with a 5-fold increase in oxycodone-related mortality and a 41% increase in overall opioid-related mortality. People are also at higher risk of overdose if they initiating or tapering opioid therapy, have difficulty accessing primary care, have a period of non-use, or when drugs are delisted or suddenly made unavailable.
There are significant barriers hindering the provision of these services, and harm reduction coverage therefore remains relatively low compared to Australasia or Western Europe. It was estimated that in 2009 there were just 186 NSPs operating with only 0.1 NSP sites per 1,000 people who inject drugs in the USA (http://www.ihra.net/files/2012/07/24/GlobalState2012_Web.pdf). In Canada, the federal government eliminated support for harm reduction in its National Anti-Drug Strategy as of 2007. It continues to be openly hostile to these services. Because health care is a provincial/territorial responsibility, harm reduction programs are supported by a patchwork of provincial and territorial policy frameworks though there are significant barriers to the provision of these services including lack of public support in some areas and underfunding of current services. Canada faces similar challenges related to scaling up programs like safer consumption services and the distribution of safer crack use supplies.
Barriers to accessing harm reduction services include stigma, discrimination and fear of the involvement of law enforcement. The ban on federal funding of needle exchanges in the U.S., which left individual states to decide on the extent to which they would allow NSP provision, left many areas without coverage and has only recently been overturned. Some states also have stricter regulations over methadone prescribing, which has an effect on the availability of OST in those areas. In addition, many of these programmes have recently closed down or reduced their services due to budget cuts.
In Canada, services vary considerably from province to province. Even within the same jurisdiction, services can vary considerably between urban and rural areas. In rural areas, lack of transportation to services, few pharmacies that dispense methadone, and shorter pharmacy hours may affect the success of MMT treatment. Retention rates in treatment can vary considerably both within and between jurisdictions. Unlike other health care services in Canada, in most jurisdictions MMT is offered through a mix of public and private settings meaning that some people must pay for this essential health services. In many cases, private providers are not integrated with other important services and supports in the health care system and beyond. But in some areas, private providers are the only source of services.
Finally, although OST is provided in both Canadian and USA prisons, NSPs are not available. In the USA, drug-related harms in prison are exacerbated by overcrowded prison conditions, and the incarceration of a large number of PWUDs, leading to relatively high levels of HIV. In early 2012, the Obama Administration released a new drug control strategy providing funding (over US$ 10 billion) for prevention and treatment programmes. In Canada, the Canadian HIV/AIDs Legal Network has initiated litigation against the federal government because of lack of needle supply programs in federal prisons.
Although the USA Federal government lists marijuana as a Schedule I substance (i.e. high potential for dependence and no recognised medical use), 18 states have made marijuana available for medical purposes.
In 2010 Californians voted on Proposition 19 also known as the Regulate, Control & Tax Cannabis Act. The bill did not pass, but showed a clear sign of change in public opinion with regards to cannabis regulation, beyond medical use.
As cannabis laws in the US are being reformed at a state level there are a variety of different models, from unregulated distribution in parts of California to the recently approved recreational use in Colorado and Washington In November 2012, during the US elections, voters in Colorado and Washington approved initiatives to legalise the recreational use and commercial production of marijuana. In that sense, Colorado and Washington have become not just the first USA states – but the first political jurisdictions anywhere in the world – to approve regulating, taxing and controlling cannabis in a similar way to alcohol. The legal implications of the differences between state and federal law are difficult to predict. However, it is expected that having approved recreational use of cannabis will protect users from the harmful effects of the criminal justice system, particularly with regard to prison sentences; it should also contribute to reducing the violence related to the illegal market. At the federal level, a bipartisan group of legislators has introduced the first bill ever to end federal marijuana prohibition. Fourteen additional states have reduced or eliminated criminal penalties for personal possession of marijuana.[i]
At the international level, the move will impact the global movement for drug policy reform, particularly in countries like Uruguay, which is refining its proposals for the establishment of a regulated market in cannabis.
Rights of indigenous people
Certain indigenous communities in North America have the right to legally use specific substances according federal laws in the USA and Canada. For example, in the USA, members of the Native American Church are able to legally use peyote, a cactus containing psychoactive alkaloids, in the context of their traditional religious ceremonies.
- America’s plague of incarceration, The Lancet, 2012
- The 2012 National Drug Control Strategy: Building on a Record of Reform, Executive Summary, The White House, 2012
- State by State Update to Marijuana Decriminalization, Legalization and Reform
- Marijuana Regulation in the US, HCLU, 2011
- The US multi-site adult drug court evaluation, The Urban Institute, 2011
- IDPC Briefing Paper Drug consumption rooms: Evidence and practice, IDPC, 2012
- Just How “New” is the 2012 National Drug Control Strategy? WOLA, 2012
- America’s War on Cocaine: The National Drug Control Supply Reduction Strategy, Commander Gary C. Rasicot, 2004
 Bouchard, M., Morselli, C., Gallupe, O., Descormiers, K., Turcotte, M., Boivin, R. (2012). Estimating the Size of Canadian Illicit Meth and MDMA Markets: A Multi-Method Approach. Canada: Public Safety Canada.
 Fischer, B., Argento, E. (2012). “Prescription Opioid Related Misuse, Harms, Diversion and Interventions in Canada: A Review.” Pain Physician, 15, ES191-ES203.
 CADUMS, 2011. Available at: http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/_2011/tables-tableaux-eng.php#t2
 Centre for Addictions Research of BC. 2012. High Risk Populations. Available at: http://carbc.ca/AODMonitoring/ProjectComponents/HighRiskPopulations.aspx.
 Treasury Board of Canada, Department of Justice Supplementary Tables, Horizontal Initiatives, 2007/08 and 2012/13. Data on budgets for the 2007-12 period can be found at: http://www.tbs-sct.gc.ca/hidb-bdih/plan-eng.aspx?Org=37&Hi=28&Pl=164. Data for the 2012-2017 period can be found here: http://www.tbs-sct.gc.ca/hidb-bdih/plan-eng.aspx?Org=37&Hi=28&Pl=447.
 Government of Canada. 2012. National Defense and the Canadian Forces: Operation Caribbe. Available at: http://www.cjoc.forces.gc.ca/cont/caribbe/index-eng.asp.
 Canadian HIV/AIDS Legal Network. 2006. Mandatory Minimum Sentences for Drug Offenses: Why Everyone Loses. Toronto. Available at: www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=1455.
 Brennan, S. (2012). Police Reported Crime Statistics in Canada, 2011. Canada: Statistics Canada.
 CIC, 2012, p. 3.
 CIC, 2012, p. 3
 Ibid., p. 16.
 Impaired Judgment: Assessing the Appropriateness of Drug Treatment Courts as a Response to Drug Use in Canada from the Canadian HIV/AIDS Legal Network. Available at: http://www.aidslaw.ca/publications/publicationsdocEN.php?ref=1302.
 Trevethan, S., Rastin, C. J. 2004. A Profile of Visible Minority Offenders in the Federal Canadian Correctional System. Research Branch, Correctional Service of Canada. Available at: www.csc-scc.gc.ca/text/rsrch/reports/r144/r144_e.pdf.
Public Health Agency of Canada. 2012. At a Glance - HIV and AIDS in Canada: Surveillance Report to December 31st, 2011. Available at: http://www.phac-aspc.gc.ca/aids-sida/publication/survreport/2011/dec/index-eng.php
 Fischer, B. and Keates, A. 2012. “’Opioid Drought’, Canadian Style? Potential Implications of the ‘Natural Experiment’ of delisting Oxycontin in Canada.” International Journal of Drug Policy, 23, p. 495-497.
 Milloy MJS. et al. (2008) ”Estimated drug overdose deaths averted by North America’s first medically-supervised safer injection facility.” PLoS One 3(10): e3351
 Vallance, et al., 2012. Overdose Events in British Columbia: Trends in Substances Involved, Contexts and Responses. Victoria: Centre for Addiction Research of BC. Available at: http://www.carbc.ca/Portals/0/propertyagent/558/files/180/carbc_bulletin8.pdf
 Ontario Public Drug Programs Division. Ministry of Health and Long Term Care. Notice from the Executive Officer. February 17, 2012. Available at: http://www.health.gov.on.ca/english/providers/program/drugs/opdp_eo/notices/exec_office_odb_20120217.pdf
 Dhalla, I. A. et al. 2009 “Prescribing of Opioid Analgesics and Related Mortality Before and After the Introduction of Long‐Acting Oxycodone.” Canadian Medical Association Journal, 181(12).
 Luce, J., Strike, C. 2011. A Cross-Canada Scan of Methadone Maintenance Treatment Policy Developments. Ottawa: Canadian Executive Council on Addictions. Available at: http://www.ccsa.ca/ceca/activities.asp; Reist, D. 2011. Methadone Maintenance Treatment in British Columbia, 1996-2008. Victoria: Centre for Addictions Research of BC. Available at: http://www.health.gov.bc.ca/cdms/methadone.html.
[i] Alaska, California, Connecticut, Maine, Massachusetts, Minnesota, Mississippi, Nebraska, Nevada, New York, North Carolina, Ohio, Oregon and Rhode Island.