Drug History Canada

Musings on the history of drugs in Canada.

Category: legislation

Fentanyl crisis and historical perspectives

Over the past month or so I’ve been mulling over the current opioid crisis and what it means, and of course what history can tell us about it.  It culminated in an op ed in the Globe and Mail entitled “Why is everyone talking about painkillers, but not about pain?” I felt that this article in its 700 word format was a decent introduction to the complexity of the current opioid crisis, but of course there is so much to say.

Having written op eds before, on cannabis legalization and liquor control, I don’t think I was prepared for the type of attention this article received.  I guess it was the timeliness and the national scope, but also the emergent nature of the crisis. I will in the next few days try to capture some of the response without betraying any confidences. Suffice it to say when dealing with pain and medical treatment, people have a lot of stories to tell, and they need to tell them.  As the recipient of these stories, I’ve been humbled and saddened but also enlightened. Moreover, it has reinforced my resolve that the current painkiller crisis has much deeper roots and needs more concerted efforts to address its origins.

Reflections on a “road” trip

I visited the United Kingdom in February, as I often do, to attend conferences and talks. There is always a lot going on in the medical history and booze and drug policy/history area, so I am always finding myself quite stimulated intellectually by these trips.

This time I added the title of “unofficial university ambassador” to my credentials, since I met the director of internationa student exchanges at University of Kent and paved the way for what looks like adding another university for our students to visit on exchange. And this one in Canterbury, so they’ll get lots of our students there.

But more properly for the topic of this blog, I spoke at three universities, delivering three very different papers to three unique groups and also got to participate in an undergraduate class.

The first was at University of Leicester. There I explored, in more detail than I have on this blog, the connections between post-prohibition liquor control and the advocacy for and advent of marijuan licensing in the United States and (possibly in the future) Canada.  I’ll do a new blog post on that at some point in the future.

Also while at Leicester, I got to sit in on a class on liquor control in North America (mostly in the USA) run by my friend and colleague Deb Toner.  We did a session on the origins of prohibition in the USA, and she had students read the intro to my book Try to Control Yourself as a primer on theoretical framing of this topic.

After class, I was confronted by a student afterwards, who had a pointed question about what I wrote in my preface to that book. The preface was a reflection on my personal intersection with liquor and liquor control. In that reflection I noted that I benefitted from my parents modeling a “healthy relationship” with alcohol. This student asked: “Do you really think an academic can have a healthy relationship with alcohol?” Her stern face took me aback until she assured me she was kidding.

Two days later, at the School of Geography at University College, London, I presented a revised paper on the spatial rationalities of liquor control in Ontario.  This drew somewhat from my chapter on the organzation of the public drinking space, which looked at community layout and internal layout of beverage rooms.  But in the presentation I also used powerpoint to consider the geography of liquor control. I mapped the location of hotel spaces on a Toronto street, and looked at how the nature of those businesses shaped and was shaped by liquor control board decisions. I’m going to work this into a proper academic paper, but suffice it to say that my simple thesis was “you can’t make simple conclusions about a process as complex as liquor control in a diverse province,” which is also a general theme in the book.

Finally, I attended and was a guest speaker at a conference in Bristol on public drinking in the Victorian period.  This brought together historians, geographers, literature folks, art history scholars, and political science types.  They looked at the various ways of viewing and managing the pub in Victorian Britain.

I finished the conference with a paper that was, really, sort of out of place in that conference. My paper, entitled “The half-life of the Victorian saloon” looked at how the gradual transformation of liquor laws in Victorian Ontario was the foundation upon which post-prohibition liquor control was built. So instead of completely reconstructing a new system, the post-prohibtion liquor regulatory system imposed a new bureaucracy upon an older structure. Moreover, I argue that the post-prohibition liquor regulation system was more flexible and designed to be more responsive to the needs of individual communities than the system immediately before prohibition, which had grown increasingly restrictive over half a century.

That is all I’m going to write at this point. I love these visits; I have some good and brilliant colleagues and friends in the UK, and their engagement with liquor and drug regulation is different enough from what we have in Ontario (and Canada more generally) that it always stimulates interesting and thought-provoking discussion.

(And usually this happens at a pub.  It may seem cliched, but it is entirely accurate.)

(c) 2014, Dan Malleck

Wherefore medical history

Before I begin, a little Shakespeare tutorial. When Juliet says “Wherefore art thou Romeo?” she’s not asking “where are you?” but “why are you?” In other words, “why are you a Montague?” Her concern was, of course, that he was the child of her family’s arch enemies.

I say that because I’m being snooty humanities guy, and using clever word structures to suggest a depth of understanding. It may be a ruse to seem deep.  Although I do think I stopped trying sometime in second year undergrad, since, contrary to the messages of 1980s high school films, depth was not getting me a girlfriend.

Ok, that’s way more information than I intended to give here.  Let’s move on.

The question of the day is: what use is medical history.

I was talking about this recently with some colleagues who were asking me  what value can medical history provide to health professions.  I was a little preoccupied at the time, and gave a rushed answer.  The even more rushed answer is “plenty.”  But time did not permit me to get into it in more depth.

There has been a big push for medical humanities to be added to medical training recently. The Canadian Medical Association Journal (CMAJ) had an article a few years ago asking why Canadian med schools lag behind the US in this innovation.  The CMJ (which sounds deceptively like the CMAJ but is actually the Croatian Medical Journal) had a great issue on the implementation of medical humanities, mostly focused on initiatives in Eastern Europe. Indeed, there is actually a Journal of Medical Humanities, too.

The evidence generally points to the development of what are often (inappropriately, to me) called “soft skills”: interpersonal interaction, sensitivity to patient needs, awareness of the broader social and cultural issues affecting a patient, etc.  This all goes under the “quality of care” or “professional acumen” or “professional competencies” label. It’s important, affects patients directly, and is certainly not “soft” in its outcome.

I did not talk about that stuff.  I had read a lot of that material, and could have gone on at length, but I wanted to talk about something else, something closer to my research and experience.

Medical history, as medical historian and hematologist Jacalyn Duffin has noted, has the potential to teach health practitioners the value of life-long learning and healthy skepticism. That is, history shows us that we exist on a continuum between the past and future, and that all of our knowledge, techniques, innovations, and assumptions about health are driven by our social and cultural values, economics, politics, and processes that have gone before.  Rather than see what we do as “true” and what people did in the past as “wrong,” rather than looking at the past and saying “how could they have been so stupid?”, medical history encourages us to see that what we believe is a product of our current reality, and that this may change. No, this will change.

The example I often provide to students is the double-blind, placebo-controlled trial (DBPCT). This is considered the “gold standard” of health research. Basically, it emerged from pharmaceutical assays.  You get a bunch of people.  Give half of them a new drug, and half of them a sugar pill. That is the “placebo control.” But it gets better. You make sure the people who are administering the drug, and the people receiving the drug, do not know whether they’re giving/getting the real pharmaceutical or the placebo. that is the double blinded.

The results are considered to be air tight proof of a substance’s effectiveness.

This seems perfectly reasonable, and is to us. as long as you believe the assumptions behind this process.

Assumption 1:  All bodies function basically the same.  This is the foundation upon which modern “western” medicine is based. It underpins the way medicine operates.  If all bodies were not essentially the same, we would need to find unique treatments for each person.  That is time-consuming, and undermines a particular way of doing science.  It introduces subjectivity into a system that strives for evidence-based objectivity.  It is also both a relatively new idea (since subjective interpretation of individual patient conditions was a hallmark of medicine until the early nineteenth century) and also based upon seventeenth century mechanistic physics that has been mostly overturned by modern quantum and string theory physics.

The problem with this assumption is that it is pretty easy to contradict.  The very existence of the idea of a placebo, some kind of unexplainable effect that means sometimes people who think they’re getting a drug actually get better even if they’re not getting the drug, undermines the “all bodies work the same” assumption. All bodies do not work the same.

In fact, the limits to this assumption has driven additional medical knowledge gathering, and spawned my second favourite word in the english language: psychoneuroimmunology. It is the science of understanding the placebo. Like the DBPCT, it assumes all bodies function the same, but we need to understand more discretely the way they function, and the inputs that affect the output (health or illness). This is normal.  We usually surround a problem with a wall and try to contain it.  This is the very reason for the placebo control  And for psychoneuroimmunology. (I love to say it; hate to type it)

Assumption 2.  Sickness is standardized.  Along with all bodies function the same, there is this assumption that all bodies get sick the same way.  You can see the falseness of this assumption when you ask a group of friends what makes them feel better when they have a cold. Some feel better in warm rooms, some in open air, some in the morning, some at night.  If one illness entity, “the common cold” has so many different manifestations (and we’re talking almost all the time in almost all cases) then how can we conclude that a) all bodies are the same and b) all illness manifests itself the same way.

So medical history helps us to explore these ideas. It shows us how our assumptions are rooted in our culture, just as the explanation about blood letting or leeching or using mercury to treat syphilis was also rooted in a complex physiological understanding of the place of the body in society.  BTW, recent research has shown that mercury does have some effect on the syphilis bacillus, further suggesting that they weren’t idiots.  But also suggesting that we need recent research done properly through condoned scientific methods to convince us of this fact.

Moreover, medical history does give perspective. It permits physicians to understand their social role along with their medical role.  A number of important books underscore this, none less impressive than Susan Sontag’s Illness as Metaphor.  A critical literary scholar, Sontag was diagnosed with cancer in the early 1970s. She was surprised and offended by the way physicians and the general public layered metaphors on cancer patients, and argued that the metaphorical construction of cancer as an embarrassing illness that was probably the fault of the individual, caused way more damage and impediment to treatment than just the straight facts.  She compared the metaphors of cancer to the very different metaphors of consumption/phthysis/tuberculosis/TB of the past.  It’s a great read, and a detailed humanist view of medical history informing today. Well, informing the 1970s.  Ten years later she published AIDS and its Metaphors and explored the topic in more detail, and from a less angry perspective. It was no less influential.

I teach using such texts, and it allows health science students to understand the cultural forms we place on top of biological processes.  As an historian, it is tremendously satisfying to see lights go on when students begin to understand how our ideas are a reflection of a moment in time.

The other thing I like to note is how the stuff I study specifically can inform medical practice. Here is that argument.

People often look to health practitioners, especially physicians, as “experts in life.”  That is, we look to them for a range of answers far beyond the biological and physiological function or dysfunction of our bodies.  Health policy, public health intervention, broader issues of population health, these are the sorts of things that policy makers, media, and everyday people look to physicians (and increasingly nurses and pharmacists, but still usually physicians) to help to address.

Understanding policy, its formation, the politics and economics that underpinned the change, is important.  If we look at a current issue of allowing pharmacists and nurses and nurse practitioners to prescribe controled drugs, we can see the way the idea of drugs as bad came about, and how it was as much a political as a biomedical issue. Indeed, as I’ve argued elsewhere on this blog, it was mostly political and economic.  This understanding can help us question the assumptions behind both resistance to the change, and the advocacy for the change.

Terms like of “danger” “poison” “control” “knowledge” “experience” and “authority” abound.

So wherefore medical history?  Because it helps to excavate the foundation of our current knowledge, gives context to what health practitioners do, and can answer many questions about today that some may not even think to ask.

(c) 2014 Dan Malleck

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