Drug History Canada

Musings on the history of drugs in Canada.

Month: January, 2014

Whose control is it, anyway?

So those upstart pharmacists and nurse practitioners want to edge in on doctors’ business!

Recently, across the country, various health practitioners have been seeking to expand their scope of practice. This is the legally defined range of activities they are allowed do. In the health system, especially, it is a highly contentious issue. Because unlike other professionals, whose work is also restricted and protected by law, when health professionals do stuff, it affects people’s health.  And just ask any health ethicist. Unlike buying a car, or getting your house painted, or even renovating your bathroom, the transaction you have with your health professional affects you in a way that can affect your well being,  quality of life, and sense of self.

We can understand scopes of practice by looking at history.

The scopes of practice for health professionals have been developed over decades, if not centuries.  In Ontario, in the middle of the nineteenth century, doctors and pharmacists, argued over what activities should be their specific areas of authorities.  Generally physicians won these arguments, since the pharmacy laws which gave pharmacists legal right to compound and distributed a specifically listed set of substances, normally exempted physicians from those rules (docs often carried drugs with them and it was often, in a rural country as ours was, much more efficient for them to sell or give drugs during treatment then to require a patient to head to the local pharmacy).

Some physicians exploited this loophole.  Some opened their own pharmacies, finding these were much more lucrative than a medical practice. A pharmacy could sell other goods that it might not be so expedient for a physician to carry in his saddle bags, so if you could build a good solid mercantile business, you were in the money.

At the same time, some pharmacists also infringed on the physicians’ domain. A customer comes in and has a cough and is looking for  a remedy.  What do you do?  Send them to a doctor to get a ‘scrip for a cough medicine? Or compound some simple syrup, cherry flavour and opium and voila, cough medicine (this would probably be what the doc would prescribe anyway)?  Well, to the docs, this was a violation of the legal scope of practice. To the pharmacists, it was just serving their customer. The courts were divided, but most saw selling something to a patient to deal with a simple symptom was not the same as diagnosing and prescribing.

There were other issues of intersection, and I’m currently exploring them in more detail.  I’ll try to post more information and thoughts when I find more great examples.

The point, though, in respect to current debates about scope of practice, is complex.  

Scopes of practice were contested, debated, lobbied for, and not always established with 100% control.  When doctors in Ontario saw the legislation passed that gave them professional status and control over who would be allowed to practice medicine, they had to share this responsibility with homeopaths and practitioners of a few other types of alternative modalities.  Homeopathy was popular, especially among elites, and the idea of an absolute monopoly over any single occupation rubbed our laissez faire-ist ancestors the wrong way.

So these current debates are part of a process of evolution and change

But when it comes to drugs, there is another historical process at work: the construction of danger embedded in the prescription.

When pharmacy laws were passed they had two purposes. The first was to control access to “poisons” which were being used purposely or mistakenly to kill.

Suicides, murders, accidents. These were sometimes linked to drugs.

Strychnine, arsenic, opium. These were the poisons.

Taken in high enough doses, they’ll kill you. But they were also medicines.  

So the pharmacy law was designed to place control over highly dangerous drugs in the hands of professionals who knew how to use them. And since usually pharmacists were also compounding remedies (a doctor would send a recipe and the pharmacists would mix it) there was some skill in the actual process of assembling, measuring, etc. 

But what happens when something becomes controlled? Well, the idea that medicines should be controlled by professionals expands the scope of that control. By the end of the century, there were more arguments for more control over substances that, while not poisonous, might in some ways cause some damage to a patient.  The range of “controlled substances” expanded as the pharmacopoeia did. Why is an antibiotic a prescription drug?  It’s not likely going to kill you. But if you take it too often, it will become ineffective. How about oxycontin?  Well, it is an opiate, so it might kill you, but it will more likely addict you.  Both of these, of course, carry their own dangers, and some very significant ones, but they are not poison in the traditional sense. They are, however, controlled.

So when docs, nurses, pharmacists and others begin to talk about who should control the prescription and administration of certain drugs, pay attention to the way the idea of danger emerges.  What is dangerous?  How dangerous? How much risk is there in a different professional administering an antibiotic or a vaccine?  And is that danger so severe that the practice should be strictly controlled to one professional? And should one profession have that much authority?

It’s worth considering.  Because these ideas of danger, control, abuse, misuse, and professional authority are infused with complex meanings. The meanings are historically grounded, and evolve and even transmogrify. As these debates continue, ask what is really being discussed.

And then look to an historian to unpack it for you.

(c) 2014, Dan Malleck

Pot-ty mouth

Last year I was contacted a few times by some AM Talk radio stations after Justin Trudeau made his audacious announcement about legalizing pot.  The reason they contacted me was that I am a type of expert on this topic. (Interestingly, they all seem to think I smoke the stuff.) And they all have this tendency to want me to have a strong opinion for or against legalization. Then they want me to make big predictions based upon my research in drug and alcohol history about what might happen if it were legalized.

Below I’ve put what I normally tell them.  But before that I want to make sure we’re on the same page.

Legalization is significantly different than decriminalization. You’d think they’re the same, because if something is not criminal, how can it not be legal?  But decriminalization basically reduces the weight of the legal system that comes down on you if you’re found to possess or be smoking pot.

Think of it like driving a car. If you speed and are caught, you might get a ticket and a fine, and lose a few “points” on  your record.  You don’t get a criminal record; you don’t normally go to jail.

If you speed, drive recklessly through a city, and smash into a building, you will likely go to court and if convicted, it won’t be for speeding, but for reckless driving, or something more severe.

Decriminalizing pot has its conditions.  Normally it’s something like a possession of a certain small amount of pot for personal use will result in perhaps a fine and confiscation, but no criminal record.  That punishment is saved for those who might be selling it.  (All they assume when you have pot on you is you’re either going to use it or sell it.)

Legalization makes pot legal. Normally, these days it also requires a system of legal distribution to be established. Legalization usually means it’s not illegal to grow it, sell it, or use it. The product is legal.  However, any of these activities may require a license.  Just like making booze, or running a casino

After voters in Colorado and Washington State agreed in a referendum to legalize, not just decriminalize, pot, the states had to create some kind of system of control.

This is where I come in.  At least in the eyes of the radio stations.

Since I study post-prohibition liquor control, and also study drug regulation, the radio station producers and interviewers want to know what it would look like when and if pot were legalized.  Wouldn’t it just be like the end of alcohol prohibition?

I usually say: not entirely.  Alcohol prohibition and drug prohibition have their similarities.  Both were made illegal to possess at some point.  Both were resisted by a certain group of people. Both were considered by many people to be immoral and a harbinger of social doom.

But alcohol was illegal only for a few years, relatively.  In the USA, national prohibition was in effect from 1921 to 1933. In Canada, national prohibition began in the First World War, but since it was a provincial matter, prohibition was deployed differently, and didn’t last very long. (Except in Prince Edward Island, which kept prohibition in effect in some form until the 1940s).  Although it is true that a massive temperance movement was pushing for several generations to see alcohol as bad, immoral, and a social scourge, the law took a long time to satisfy the urges of the prohibitionists.

Pot has been illegal in Canada since the 1920s.  It was prohibited under national legislation.  It was generally not even very popular until the 1950s, and in the 1960s of course its popularity really took off.  A lot of people wonder why it was even made illegal in the 1920s, given that so few people were even using it.

Yet its illegality was not just a matter of being illegal or not. Illegality creates all sorts of myths and contexts for a substance.  If you want it, you need to conspire with criminals.  Criminals need to use certain methods that are sometimes less than savoury to do their business.  Whereas other businesses use patents and copyrights to protect their product, criminals might use intimidation and violence. Whereas other businesses, competing in the open market, might try to strategically place their products so as to undermine competitors, criminals might establish their turf and violently remove competitors. At the same time, if you are hooked on it (the addictive nature of pot is highly debatable) criminalization also makes it more difficult to seek help.  Because you’re a criminal and ostracized or risk conviction if you admit it. (I wrote about this in one of my first posts, by the way).

Criminalization, then, creates a sort of ripple effect of crime and criminality.

At the same time, such a system, which is in fact embedded in an underground system of crime, also creates some stereotypes and impressions of immorality.  Not only does taking illegal drugs mean, to an observer, that you are now flaunting the law (what other laws might you flaunt?) but also it can be seen as an indication of some kind of depraved moral state. You’re an anti-establishment type, who can trust you?

(Of course this works both ways.  People who want to be seen as anti-establishment might start smoking weed precisely because it’s anti establishment.  I wonder what will happen when it’s made legal).

One question I was asked on a Niagara radio station, which is pretty conservative, is “well, if someone is making a lot of money selling booze in prohibition, what would stop them from continuing to sell when it’s legal. So wouldn’t we have many nefarious characters selling pot if it’s legalized.”

At the time, I had a flip and dismissive answer, and I regret it now.  That answer was “Hey, there are a lot of nefarious characters in the banking industry!” (Full disclosure: my dear elder sister works in that industry)

What I should have said was more historically grounded.  The short answer is yes. But the longer answer is this: many people who ran hotels or hospitality services of some kind really just wanted to make money.  They did it with booze, but when prohibition ended, at least in Ontario (where I do my research), many of these people continued to run hotels, and opened up legal beverage rooms.  Some of them had some trouble at first, selling after hours, selling spirits (which weren’t allowed) selling to people who were not allowed to buy it.  And I’m sure some of them continued to break the laws.

But more of them just began to follow the law. It was lucrative, and even with some pretty tight restrictions on what you could do in a beverage room (couldn’t play music, couldn’t lean on the bar, couldn’t buy whisky, couldn’t go in alone as a man looking to hook up with women unless you came with a  woman) many people, for the sake of order, or money making, or just because it was legal, began to do the right thing.

It is partly for this reason that I called my book “Try to Control Yourself” because it was about instilling self control on citizens. And it was about asking them to try their best to control themselves. It was not, as some argue, a stalinist state.  It was an attempt to control something that was in fact considered very socially problematic, and politically dangerous, too.

So in response to the “nefarious characters” comment, I could have given a more nuanced answer: for many people, it was the law that made them nefarious, not some kind of inner moral corruption.  When that law changed, they could then profit legally from selling what people wanted to buy.  They were no more nefarious than, well, bankers.  Maybe even less so.

How will legalization of pot unfold? Well, it’s tough to say.  But although it might take on the characteristics of early alcohol legalization, there are enough differences, and our society is technically and culturally different enough to create a whole different context for this process.  Keep an eye on this. It will be fascinating.

(c) 2014 Dan Malleck