Drug History Canada

Musings on the history of drugs in Canada.

Tag: pharmacy

Good drugs and their bad tendencies

After several decades of working on this (ok, worked on it in the 90s then took some time away) my book, When Good Drugs Go Bad: Opium, Medicine, and the Origins of Canada’s Drug Laws has been released.

You can order a copy of the hardcover here.

And for reference, here is a picture of the cover.  Below I will tell you more about it.

Malleck - Good drugs - cover image

In this book I look at the origins of Canada’s drug laws, the century or so before the creation of the Opium Act, 1908, and the Opium and Drugs Act, 1911.

My main question was simple: where did the idea come from that some drugs were bad and needed to be regulated. It may seem simplistic, but beneath this question are a bunch of related issues: Why is addiction considered a problem?; what is wrong with recreational drug use? How did the idea that government should be involved in the regulation of drugs come about?

These may seem odd questions, but they really are fundamental to our understanding of current debates over drug laws and drug use.

For example, we seem to have this idea that recreation is an illegitimate application of chemicals.  That is, you can take drugs for pain killing, to heal, to allow children to focus, to reduce coughs, and to get rid of the sniffles, but once you enjoy them purely for the sake of enjoyment, you are misusing drugs.

Here we get this idea of “drug abuse” which is linguistically connected to things like child abuse and spousal abuse, but in this way we’re really considered to be abusing ourselves by using drugs in a way other than one medically acceptable.

Why was medicine the only legitimate use of such substances?  How did physicians get that kind of power?  Why are pharmacists the ones who should be managing the sale of drugs?

The book takes a long view, stretching back to pre confederation, to look at the various uses of drugs, and the different ways that people began to suggest there are legitimate and illegitimate uses of them. It traces the creation of provincial pharmacy laws, which I argue are Canada’s first drug laws.  Here the idea emerged that the trade in certain substances should be governed by small groups of educated men rather than allowing the free market to do its thing.  Once you establish the idea that some things should be controlled by government pronouncement, and you deputize groups of professionals to do the controlling, that scope of control can be broadened. The idea of controlling drugs that could kill you broadens to include controlling drugs that could hurt you. Then the idea of “hurt” expands to include not just maim or debilitate, but perhaps just make you need them all the time (habituation, or addiction).

It’s a complex story, and one that needed to be told for Canada.

I hope you enjoy it. Buy multiple copies.  Christmas is coming, after all!

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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

Why do pharmacists control access to certain drugs?

I had a student who is diabetic come to speak to me today, and in the meandering way conversations I get into with students go (usually my fault), she ended up asking the rhetorical question “why do I have to get my insulin from a pharmacist?”

It is a good question.  As I noted in the last post, the issue of the “dangerous”ness of drugs drove the construction of control of access to some drugs.  But what about insulin?  It’s not addictive; it’s not really poisonous (at least no less so than non-drugs you could surreptitiously administer and kill someone, like antifreeze) and it’s an essential substance for some people to receive artificially.

To be honest, I’m not sure.  I told the student that she could do a directed reading with me and we could explore the idea. I love it when I have motivated students like that, and questions I can’t answer.

I do have some guesses, though.  They are really nothing more than suppositions based upon my thin knowledge of the process

  1. Insulin, when it was first isolated, was relatively difficult to get your hands on.  Controlling access through a pharmacist or doctor would allow its use to be judicious.
  2. Controlling access to insulin was easy to justify because diabetes itself had to be diagnosed.  Without such a diagnosis, you’d not know you had diabetes. So there was no real way to self-diagnose, and no need in the market to have it available for over the counter sale.
  3. By the time insulin had been isolated and seen to be an important medical tool, the idea of expanding medical jurisdiction over access to such technology was sort of a given. Maybe it was just natural that new important substances like insulin would be available only by prescription.
  4. It made it more expensive. Big pharma loves something that makes drugs more expensive (I doubt this was the case).
  5. It needs to be injected, which makes the hormone insulin need to be administered by docs.  See #2.
  6. None of the above
  7. Many of the above.

I really have no idea.  I will look into it though.  It’s a compelling thought, and will fill out the complexity of my narrative on the relationship between legislation that controls access to medicine, and the authority and social role of the medical industrial complex.

Interested in this question?  Have some ideas?  Post a response.  Share thoughts.  I have to come up with a reading list at some point, so you’d make my job a lot easier.

Your responses are copyright: you.

My post is (c) Dan Malleck. 2012.