Introduction

It is not possible objectively to understand an existing situation without a knowledge of the basic history leading up to this situation.  While it is only a hundred years since substances that are now classified as illegal became subject to the criminal law system, others were under the control of doctors and pharmacists and were prescribed widely and quite lawfully.  Despite the fact that some drugs that are currently classified as illegal are subject to a certain form of medical control, these substances are, in the first instance, subject to the criminal law as a result of an approach designed to suppress their use and we are all aware of the results of that approach.  How did this situation come into being?  How did the control of drugs in Canada end up in the hands of agents of a bureaucracy devoted to their suppression, who even exerted a certain power over doctors, whereas in England, for example, doctors had greater freedom of action than their Canadian colleagues in prescribing the same substances?  While this document cannot claim to provide a comprehensive explanation of the reasons why only some of the many psychoactive substances are now banned while others are prescribed by doctors, we shall examine in greater detail the role of medical professionals in Canada in the early days of control of legal and illegal drugs.

The appearance in the 1980s of a high incidence of HIV/AIDS among intravenous drug users (IDUs) and the recent controversy concerning the medical use of cannabis for some patients who prefer this substance to more traditional medication has reopened the debate about the role of members of the medical profession at the beginning of the century in Canada and especially the early days of the implementation of the drug regulatory system in this country.  We believe that increased knowledge of the origins of these controls will give us a better idea of the current situation and eventually perhaps lead to a more careful organization of actions to be taken in the future.

1– THE C.–N. Robert MODEL

C.–N. Robert (1989) has devised an explanatory model that clearly illustrates the role that may have been played by members of the medical profession and workers from the criminal law system in the prohibition of drugs.  According to this model, the law alone cannot dictate a policy of prohibition; it is rather a popular instrument that can be used by various interest groups in society for the purpose of imposing their values, their beliefs and their professional interests on others.  It will be seen therefore that any group must have access to adequate legal resources if it wants to use the law for its own benefit, which is obviously not the case for all groups of individuals, especially of certain consumers, as opposed to the professional governing bodies which are generally influential, have a wide audience and are respected by the authorities and well organized (Mitchell, 1990).   Robert (1989) indicates, however, that the xenophobic argument is almost always present when there is a question of controlling drugs.  He also points out in this regard that in both China in the 19th century and the United States in the 20th century, the xenophobic argument was a key factor in the development of the first controls over drugs.

Thus, according to Robert, the medical profession presents two faces to some extent when drugs are at issue in that it is responsible for increased use of drugs by the public – as a result of the prescription of medications – but, at the same time, its utterances are resolutely anti-drug – or of certain drugs – in order to consolidate its control and its authority in the field.

The five stages of this model are accordingly summarized below.  They constitute an interesting program of reading for anyone attempting to understand the complex relationship between health and criminal law aspects of drug regulation by society:

(a)      Integrated cultural consumption of a product by a particular civilization.  Socialization is perfectly accepted and more or les well controlled.

(b)      Appropriation of the product by certain health professionals (healers, witches and warlocks, doctors etc.).  The circle of users and opportunities for use expand.  The indications and effects of the products are inaccurate and prescriptions are uncontrolled.

(c) The product becomes part of scientific progress.  A legal network is created and this reduces the price.  There are increasingly precise medical indications.  The product is appropriated by “specialists” and its association with popular culture is lost.  Tight control is exercised by specialists.

(d) A ban is imposed on use of the product outside normative controls.  The product is criminalized as a result of therapeutic use.  Legal status is then combined with medical status.  The law alone is not able to impose a ban: it merely supports the other sciences that are particularly powerful with respect to assertions of the social, health and therapeutic use of a substance.  This explains the creation of a  major medical discourse on prohibition, swinging between the medicalization of a substance in the name of its social usefulness and its prohibition on the ground that it poses a danger to health.  Thus, medical discourse and practice appear simultaneously to be responsible for a substantial increase in the use and abuse of drugs under a therapeutic pretext but are also strongly creative of a consensual anti-drug ideology by denouncing the harm they cause with supporting evidence.

(e) The final stage: the natural (or more or less crudely processed) product has invaded entire markets.  Control and prohibition are considered, violated and it becomes impossible to have any debate based on political traditions, which are all marked by the prohibitionist model.

1.2 – The medical monopoly

One vision of the world of the professions suggests that the laws and regulations establishing the specific status of any profession are presented by the representatives of these professions as guaranteeing quality service, promoting access to services, favouring health promotion, justice and security as well as fair pricing.  A number of authors[3] still object to this interpretation, however, and criticize such an assertion with respect to public protection.  They maintain that the characteristics of this professionalism tend rather to serve the professional interests of the members of the group to the detriment of their clients (Mitchell, 1990).

Olson (1982) states that he has noted a tendency in professional groups wishing to organize themselves into professional organizations.  In his view, it is various public interest groups looking for incompetent practitioners that have advanced the ideal argument for those wishing to establish professional governing bodies.  Again according to Olson, members of the medical profession have clearly displayed monopolistic characteristics since the beginning of the century; in fact, the medical profession is often viewed as the ultimate model of professional hegemony.

Professional governing bodies attempt in various ways to exclude competition from members of related disciplines and doctors are no exception in this respect because they compete in various areas with nurses, midwives, pharmacists, homeopaths, chiropractors, psychologists and other practitioners of natural medicine.

According to Mitchell (1990), doctors have hitherto succeeded in dominating all other health professionals, whether in the fields of psychotherapy, counselling, birthing or addiction, even though they have never established their superiority in those fields.  A key factor testifying to this domination by doctors lies, according to the author, in the coverage by insurance companies of doctors’ activities.  The fact that these medications prescribed by doctors are covered by insurance when some of the products sold by pharmacists are not may provide evidence of this domination, in Mitchell’s view.  In addition to their dominance over other health practitioners, doctors have constantly broadened the definition of what constitutes a medical problem and Mitchell refers in this regard to the example of alcoholism and tobacco use.

In order to establish the relevance of the Robert model to the situation in Canada, as well as some of the characteristics that Mitchell attributes to the powers of the medical authorities, we shall now take a historical approach and examine the involvement of doctors and pharmacists in the early days of formal legal regulation of drugs in Canada.  We shall examine the competition that may have existed between these two groups of professionals and their interactions with the agents of stricter regulation in the early days of the implementation of laws governing drugs at the beginning of the century.  In order to take an in-depth look at a segment of history rather than simply skimming the surface of the overall situation in the 20th century, we shall restrict our review to the early days of the implementation of the legislation, the period from the beginning of the century to the 1930s, because this period seems to have been particularly significant and revealing of the positions taken by each group with respect to the initial application of controls.  Although the sequence of events is certainly interesting and enlightening with respect to certain factors leading up to the current situation, that situation nevertheless appears to be a direct result of the controls that were initially put in place in the first thirty years of the century.

2– Involvement of members of the medical profession in prescribing drugs in Canada at the beginning of the century[4]

2.1 – Situation before 1908

Murray (1988) reports that in Canada, several editorials in the medical and pharmaceutical journals in the early part of the century indicated that pharmacists and doctors were more concerned about controlling the trade in patent medicine[5] for their own benefit than about the potential dangers of these products.  The professional and economic interests of doctors and pharmacists came into direct competition with those of the patent medicine industry.  The author argues that change came to this field so slowly because the contribution made to the economy by patent medicine was substantial.  It was not until 1904 that discussions began in the Senate concerning the enactment of legislation by one Senator Sullivan, who also happened to be a doctor (Murray 1988).  What he was originally seeking was a requirement that all the ingredients of the preparations sold be indicated on the containers of these preparations.  Between 1904 and 1908, there were a number of negotiations with the aim of enacting legislation that would have satisfied all the parties involved, namely pharmacists, doctors and the representatives of the pharmaceutical companies.  While the pharmacists did not agree with certain forms of legislation, they were particularly worried that a tax would be introduced on the sale of medications as well as registration charges.

According to Murray (1988), the substantial growth in the patent medicine industry during the 19th and early 20th centuries was very closely linked to the development of advertising, especially in newspapers, for the profits of which this market was particularly important.  Patent medicines were popular at the time because they were an effective and inexpensive remedy for many health problems and also because they could be obtained from doctors, pharmacists, at the general store and by mail or home delivery.  While the advertisements apparently described them as risk-free, these medications nevertheless caused frequent problems because under the general label of nostrum, they contained substances such as codeine, morphine, opium or large amounts of alcohol, without the quantities being clearly indicated on the container (idem.).

According to Giffen et al. (1991), the growing trade in patent medicines posed a threat to the medical profession.  In fact, doctors and the large companies that manufactured patent medicines found themselves in competition with each other in certain regards.  While doctors at first merely expressed their doubts about the quality of these preparations, the tone grew harsher later and doctors even went so far as to openly ridicule these products.  Following a campaign to alert the public to the potential dangers of patent medicine and the mendacious advertising of the manufacturers, some provincial doctors’ associations, including those in Ontario and British Columbia in particular, agreed to take part in the application of stricter regulations governing medicines.  The Vancouver Medical Association accordingly submitted a resolution in 1906 to the then-Prime Minister, Sir Wilfrid Laurier, informing him of the potential dangers associated with the consumption of patent medicines and asking him to ensure that a commission of inquiry was established to examine the trade in these preparations in depth (idem.).

In the early part of the century, a distinction was made between two main types of drug consumption: on the one hand, there were the Chinese on the west coast of Canada and their specific habit of smoking opium and, on the other hand, there was widespread use of patent medicines among the Canadian public and, according to the authors consulted (Murray 1988, Giffen et al. 1991, Mitchell 1990, Small, 1978, Solomon and Madison, 1976), the latter caused many more health problems than the use of opium by the Chinese.

2.2- 1908: the earliest drug legislation

1908 saw the first step taken to enact legislation to control drugs in Canada.  In fact, that year witnessed the adoption of two acts respecting drugs in the country, two separate statutes even though they were passed in the same year.  The first, the Opium Act, which was designed primarily to regulate the opium trade, was definitely not promulgated for medical reasons but rather for union and racist reasons (Beauchesne, 1992, Solomon and Green, 1988, Boyd, 1984).[6]  The Proprietary or Patent Medicine Act was also tabled in 1908 but did not come into force until the following year.  Small (1978) has argued that this Act was passed to regulate the widespread use of drugs that could be dangerous.  It provided in particular that:

No proprietary or patent medicine shall be manufactured, imported, exposed, sold or offered for sale.

a)       if it contains cocaine or any of its salts or preparations;

b)       if it contains alcohol in excess of the amount required as a solvent or preservative, or does not contain sufficient medication to prevent its use as an alcoholic beverage;

c)        if it contains any drug which is included in the schedule to this Act but the name of which is not conspicuously printed on, and an inseparable part of, the label and wrapper of the bottle, box or other container.

Finally, when it was promulgated in 1909, the Proprietary or Patent Medicine Act did not satisfy the expectations of the doctors or the pharmacists.  The government had taken good care to calculate all the political consequences this legislation could have with respect to the two professional groups, not to mention the powerful pharmaceutical companies (Murray, 1988).  Thus, following the implementation of the Proprietary or Patent Medicine Act, it was still possible to sell products containing heroin, morphine, opium and other substances as long as the presence of these drugs was indicated on the container.  In fact, these substances did not even have to be indicated on the container when they were present only in small quantities, which were to be determined by the Department of Revenue!  Murray (1988) argues that undeniable evidence of the weakness of this Act can be found in the fact that there was no penalty for any misrepresentation in advertising and the penalties provided in the Act were not very serious.  Depending on the offence committed, the maximum sentences were fines of $100 and/or 12 months’ imprisonment.  Anyone who contravened the Act was liable to a maximum fine of $100 and the loss of the registration of the product in question.  In comparison, the Opium Act provided for maximum sentences of 3 years’ imprisonment and/or a fine of $1,000.[7]  Despite the prevailing consensus at that time, not all political players agreed with the criminalization of the Chinese and the lesser degree of intolerance shown to doctors, as can be seen in the following quotation from Senator Wilson, who was himself a doctor:

The indiscriminate use of opium is a very deleterious habit, yet that is no justification for making the use of it a criminal offense.  This habit is principally among the Chinese.  Have we the right to make criminals of people, because they have learned the habit in their younger days and now desire to continue it? They give no offense except by injuring themselves.  Much of the habit of using opiates, morphine or cocaine has been brought about by its indiscriminate use as authorized by physicians… Why not punish the physicians? (House of Commons Debates, 1910–1911 :399, in Small, 1978)

While heroin, cocaine and cannabis were included in the schedules to the Proprietary or Patent Medicine Act, along with such substances as carbolic acid and strychnine, morphine and opium were not included since the latter was covered by the Opium Act.  The sentences imposed for offences under the Proprietary or Patent Medicine Act were initially $50 for a first offence and $100 for subsequent offences.  If we compare these penalties with the maximum sentences imposed by the Opium Act – which were much harsher and applied primarily to opium smokers (especially the Chinese and a few rare whites) and a handful of dealers of Chinese origin on the west coast – the racism argument seems plausible and greater tolerance appears to have been shown to health professionals than to the Chinese (Small, 1978).

In their research on the origins of drug controls, Giffen et al. (1991) report that they found few sources indicating the existence of parties opposed to the enforcement of the Opium Act (1908 and 1911 versions) because, in reality, opposition to this statute was practically non-existent aside from a few opium dealers of Chinese origin.  The situation was altogether different in the case of the Proprietary or Patent Medicine Act, the numerous bills leading up to which were opposed by doctors, pharmacists and the pharmaceutical companies.  These authors also found little evidence that clearly indicated that health professionals had played a crucial and essential role in instigating the ban on narcotics in Canada.  According to these authors, while the Proprietary or Patent Medicine Act was designed to protect the public interest, its designers did as little as possible to harm commercial interests.  Moreover, the original Bill was substantially  changed in order to meet the concerns of health professionals and drug companies.  In addition, a few years before the Proprietary or Patent Medicine Act became law, some provinces had already attempted to introduce measures to regulate patent medicine but resistance from the manufacturers had prevented them from making much headway.  Moreover, Giffen et al. attribute the acceptance of this legislation in 1908 by the manufacturers of patent medicines to their fears that there would eventually be a plethora of provincial laws on the subject.

2.3 – Doctors

For Giffen et al. (1991), it is clear that the corporate interests of the doctors, pharmacists and drug companies inevitably influenced the enactment of the Proprietary or Patent Medicine Act.  On the other hand, however, it would seem that the Opium Act of 1908 (as well as the 1911 version) is also directly linked to the fate of the medical profession as a result of strict regulatory measures that initially applied only to opium but that later included cocaine and morphine (1911), cannabis and heroin and other opiates (1923) (Giffen et al. 1991, Murray, 1988).  Furthermore, it was in the Opium and Other Drugs Act that the requirement that only one renewal of prescriptions containing opium be permitted was introduced in 1911.  With this amendment, Parliament attempted to legislate that prescriptions would now be controlled solely by doctors in order to ensure that patients would not use the same prescriptions repeatedly, which had often happened in the past, it would appear.  Despite these measures, Giffen et al. (1991) assert that Parliament’s primary objective was not to interfere with the traditional independence given to the medical profession but rather to limit the overconsumption of opiates.  It was only later, in the 1920s, when Canadian officials responsible for the enforcement of the drugs legislation were more firmly established in their control functions that stricter and more precise controls over prescriptions were implemented with the openly stated objective of imposing controls on doctors.

It is worth noting that it was in connection with narcotics more than any other type of substance that we find such regulation of doctors’ power to prescribe drugs by the controlling authorities.  This situation came about primarily as the result of the consensus that existed in Canada concerning a ban on narcotics from the beginning of the century to the 1950s, a consensus that was then questioned with greater vehemence by people involved in the social and medical services in the Vancouver area.  In fact, this subordination of the powers of doctors to the legislature and the regulatory authorities was first challenged by the Canadian Medical Association only toward the end of the Second World War (Giffen et al., 1991).  Doctors were unable to discipline their colleagues in the profession and, on the other hand, this situation was made easier by the desire of the medical authorities to eliminate the practice of some doctors who over-prescribed such substances, an activity that was causing great harm to their professional image (idem.).  This lack of opposition also resulted from the fact that few patients demanded medication over the long term.  Finally, another reason for the weak opposition put up by doctors to state control over prescriptions lay in the fact that these administrative directives did not in themselves constitute a major public issue and, what is more, the possible penalties did not involve criminal prosecutions but only written warnings.  Furthermore, very few doctors were apparently subject to criminal prosecutions for unlawful prescribing in the early part of the century (idem.).

In the United States, on the other hand, as is true today with respect to drugs, much greater vigour was devoted to suppression than was the case in Canada.  Under the Harrisson Act, thousands of doctors were prosecuted during the 1920s for selling drugs and many of them were even imprisoned for doing so (Szasz, 1974).  In our southern neighbour, the development of the situation between doctors and the regulatory authorities was different from that existing in Canada.  As the users of drugs became more stigmatized, the positions taken by the doctors were more clearly demarcated.  By diagnosing these users as “sick deviants”, American doctors obtained the support and co-operation of the very powerful federal regulatory authorities.  On the other hand, if they had claimed that users were Americans like other people and required free access to drugs of their choice, doctors would have drawn the fire of those same federal authorities.  In fact, if they continued to prescribe those substances, they could well lose their licences or be prosecuted (Mitchell, 1991).  In the face of this threat, it is easy to understand why most of them chose the government’s approach.  It is appropriate to note that like many other social phenomena, the whole debate concerning measures to regulate narcotics in the early 20th century in Canada was strongly influenced by the situation in the United States.  The coming into force of the Harrisson Act in the United States in 1914 was a major event with respect to the development of this phenomenon in the Americas as a whole, because Canada had become the entryway for many pharmaceutical products to the United States, where controls were much stricter (Giffen et al., 1991).

To come back to the Canadian scene, Giffen et al. argue that 1919 and 1920 witnessed major steps in the tightening of the controls on drugs introduced in 1908 because in those were years there was lively debate about the amendments to the Proprietary or Patent Medicine Act.  The doctors, who had organized themselves in a professional association as long ago as 1871, should normally have played a pivotal role in these amendments but in fact they played only a secondary role in the negotiating process.  In the view of these authors, this lack of involvement on the part of the doctors resulted from the fact that they were not sufficiently organized at the time, because in 1920, the Canadian Medical Association (CMA) was fighting for survival after a narrow brush with bankruptcy during the First World War.  Moreover, the CMA had not yet found goals around which to rally its members that would have enabled it to counteract the decentralization caused by the fact that the issuance of licences to practise was a provincial responsibility.  Thus, contrary to what was happening in Great Britain at the same time (which we shall consider later), Canadian doctors did not play a decisive role in the early years of regulation of the medical use of drugs in this country.  This was due in part to the fact that the power to discipline members who broke the rules was the task of the provincial colleges, which served to weaken the national association, while the federal government had jurisdiction to enact legislation on drugs.  These two factors helped to ensure that the representatives of the Drugs Division gained control over the doctors (Giffen et al. 1991).

2.3.1 – First signs of maintenance doses

While the question of maintenance doses is still a hot topic, it is not new.  In fact, it was a popular topic of conversation at the beginning of the century, at least among some doctors, because it directly affected their professional independence (Giffen et al., idem.).  Some Canadian doctors believed that providing maintenance does of drugs was the most humane form of treatment that could be provided in some cases, although this practice was made difficult by the many administrative controls.  However, as indicated earlier, it was only after the Second World War that the Canadian Medical Association – which by then was better organized and more powerful – began publicly and more vigorously to oppose the controls imposed by the Drugs Division.

In 1924, the Department of Health sent a questionnaire to 8,300 Canadian doctors asking how many patients required narcotics.  The 4,319 replies received indicated that only 777 patients were in that situation.  While the majority of these patients were considered to be “medical cases”, some were in fact users who were being given maintenance doses by certain doctors.  However, as long as the drug was administered in the doctor’s office, they felt that their actions were justifiable and legal.  This ambiguous situation was a result of the very wording of the Opium and Other Drugs Act of 1911, which contains the following provision in Part 2, section 5:

Any physician who signs any prescription or order for the filling of which any drug is required, unless such drug is required for medicinal purposes or is prescribed for the medical treatment of a person who is under professional treatment by such physician... shall be guilty of a criminal offence.

In this provision it is worth noting the problem for the prosecution of defining the expressions “medicinal purposes”, “for medical treatment” or “under professional treatment”.  To remove this ambiguity, the Act was amended in 1923 on the recommendation of the Head of the Drugs Division, Mr. Cowan, and the onus of proof was reversed.  Following this amendment, the Act read as follows:

If any person charged with an offence under section 6 of this Act pleads or alleges that the drug in question was required for medicinal purposes or was prescribed for the medical treatment of a person under professional treatment by the accused... the burden of the proof thereof shall be placed upon the person so charged [emphasis added].

In order to reassure doctors with respect to this amendment, the federal Minister of Health asserted that the measure was merely designed to divide drug-dependent users into two groups: for the first, those who were sick and required medical care, doctors could prescribe any quantity of drugs they considered necessary, while for the other group, those who were not “sick” except for this dependence, doctors were not authorized to prescribe any drugs (Giffen et al., 1991).  It will be seen, therefore, that already at that time, some doctors were questioning the appropriateness of treating patients who were dependent on drugs by means of a maintenance dose.  Until 1922, doctors were required to provide very precise information to the Department of Health concerning the drugs they obtained, dispensed or prescribed.  In that year, an amendment to the Opium and Other Drugs Act made a written prescription mandatory – which had not previously been the case since a simple phone call to the pharmacist was sufficient.  In 1925, controls became even tighter and all orders for drugs had to be recorded by the authorities in the province where they were prescribed.

2.3.2 –  The Drugs Division and doctors

The appointment of Colonel Sharman to head the Drugs Division in 1927 was marked by an increase in and substantial tightening of the control measures imposed on doctors.  Although he was not able to obtain detailed changes in the Act, despite many attempts, the constant pressure and intimidation exerted by Colonel Sharman on doctors nevertheless succeeded in achieving significant changes in prescribing practices, which meant that these were now more closely monitored (Giffen et al.:1991).  While some doctors admitted that prescribing drugs for a patient over the long term might not be legitimate in some cases, Colonel Sharman felt that this was quite simply illegal, regardless of the circumstances.  Giffen et al. (idem.) report that in order to fill the legal vacuum left by the Act, the regulatory authorities, specifically the Drugs Division and the RCMP, apparently used various means to prohibit the prescription of drugs over a long period.  For example, during the 1930s, the RCMP went so far as to send certain dependent users as informers to doctors who were suspected of issuing repeat prescriptions in order to catch them prescribing in flagrante delicto.

Later, in the early 1930s, at a time when Colonel Sharman was extending his power over doctors even further, it was reported that there was a secret list of all the doctors who were suspected of prescribing drugs illegally or unnecessarily (Giffen et el., 1991).  These doctors were investigated discreetly and if they could establish that their prescriptions were legitimate, that was the end of the matter.  However, if the Division felt that large quantities of drugs were being used without justification and that the doses were prescribed for long periods or, if maintenance doses were being prescribed on an outpatient basis, the offending doctors were reprimanded and had to stop such practices immediately or be subject to penalties.  Giffen et al. feel that this clearly shows the power the Drugs Division had in its ability to encroach upon the professional judgment of doctors in the first half of this century.  It was as a result of such practices that Colonel Sharman succeeded to some extent in changing the enforcement of the Act, even though the Act in question did not clearly prohibit some of the actions taken by the doctors.  Those doctors who did not bring their practices into line with the Division’s standards were placed on a secret list and were prevented from obtaining drugs from wholesalers or pharmacists.

2.3.3 –Question of treatment

While the treatment of people who were dependent on drugs played a relatively insignificant role in public discussions of drug use in the early part of the century, it was not completely absent from those discussions.  A meeting of all the provincial health ministers to devise a formal policy on the treatment of “drug habitués” took place in 1923 but did not produce any concrete results (Giffen et al., 1991).  Dr Amyot, a public-health advocate of long standing, said that he was in favour of implementing medical detoxification programs.  There is an interesting statement by her in the Canadian Medical Association Review in 1927:

Why should not hospitals treat these cases [drug users] as they do tuberculosis and venereal diseases?  The remedy would seem to be the establishment, under provincial control, of special institutions, psychiatric institutions for their treatment, where the addict could be held for treatment.  (Giffen et al., 1991 :330)

As far as internment of drug addicts was concerned, various documents referred to by Giffen et al. (1991) indicate that while some psychiatric institutions and hospitals occasionally accepted patients who were acknowledged to be dependent on drugs, there were no clear directives on the subject and each institution could adopt different policies.  A general attitude of prejudice against drug addicts by some members of the medical profession[8] is not therefore new if we can rely on the following quotation:

…the ordinary hospital does not care to admit this class of patient, owing to the fact that they are as a rule very noisy and require male attendants, and also in view of the fact that the treatment takes time and not the financial means of paying for such treatment (Sessional Papers, Health Canada, in Giffen et al. 1991:326)

It is interesting to note that already at that time, some doctors were dealing with concerns that are still very much with us today at the dawn of a new century.  In fact, while the authorities in the City of Vancouver have since 1990 decided to purchase a number of hotels on the East Side in order to house HIV positive and AIDS-infected IDUs, traces of a similar practice can be dated back to 1920 in this country.  In fact, Dr. R.J. MacDonald stated at that time:

I could not obtain admission for him [a patient dependent on narcotics] in the hospital here and was forced to treat him in one of the poorer class hotels here and instituted as best I could the reduction treatment for his addiction. (Archives of the Drugs Division, 1920, in Giffen et al. 1991:325). 

2.4 – Pharmacists and drug manufacturers

According to Giffen et al. (1991), the efforts made by the federal government to regulate the distribution of drugs encountered greater resistance from pharmacists than from any other group involved in the development of the drug control system in Canada.  As professionals, pharmacists enjoyed a doubly favourable reputation: namely that of professionals who were a full part of the health system as well as that of respectable businessmen capable of providing remedies without the mandatory use of doctors.  The Canadian Pharmaceutical Association could easily mobilize its members in defence of their interests through its national publication, which contained many editorials criticizing some of the government’s restrictions. 

It was in 1871 that pharmacists gained legal recognition of their profession, although it was not until 1907 that they established a national association.  At the beginning of the century, this association attempted on many occasions – without success – to force the manufacturers of pharmaceutical products to register the ingredients of their preparations.  According to Clark (1983, in Murray, 1988), the trade in patent medicine left little room for the sale of compounds prepared by the pharmacists; in fact, some pharmacists invented their own medications, an activity that sometimes paid better than the sale of preparations manufactured elsewhere.  Thus, pharmacists who owned their own businesses in which they could sell their own preparations also enjoyed growth in the market for patent medicine  because they sold the most popular of such products.  It was specifically those pharmacists who engaged in these particular activities who objected to some of the provisions of the Proprietary or Patent Medicine Act as it was enacted.  For most pharmacists, however, although they strove to distinguish themselves from the manufacturers of patent medicine and despite their reservations concerning such products, the sale of patent medicine was to some extent a service they wished to offer to their customers.  On the other hand, some pharmacists refused to sell patent medicine and, on some occasions, the Canadian Pharmaceutical Association even recommended that its members sell the products they had prepared themselves rather than promoting the most popular patent medicines because they could guarantee the composition of their products but not that of the patent products, which contained some potentially dangerous substances and the content of which was unknown (Giffen et al., 1991).  Despite these practices, pharmacists nevertheless had to remain on good terms with the representatives of the pharmaceutical companies because they kept the pharmacists supplied.  On some occasions, moreover, when their interests coincided, pharmacists enjoyed the support of the pharmaceutical companies, with which they co-operated closely despite the fact that their views diverged in certain respects.  According to Giffen et al. (idem.), the major manufacturers often agreed to place the pharmacist’s name on popular products sold in the pharmacies.  In fact, the role of the manufacturers of products based on narcotics is key in the initial development of policies on drugs.  For the manufacturers, in fact, it was essential to maintain harmonious relations with the pharmacists in order to promote the sale of their products.  On the other hand, however, it was just as important for them to maintain good relations with doctors because they prescribed the products of the pharmaceutical companies as well as with the regulatory agencies responsible for controlling the use of drugs as the powers of those agencies grew. 

2.5–  Relations between pharmacists and doctors

The relationship between doctors and pharmacists was rather ambiguous throughout the period of the debates about the initial development of drug controls (Giffen et al., 1991).  In some cases, pharmacists could count on the support of the doctors but only when limitations with respect to the controls caused them problems as well because the doctors wished to retain their own access to drugs since they regarded these products as medications.  Moreover, it was the doctors who sat in the House of Commons during the debates on the amendments to the Proprietary or Patent Medicine Act in 1919 who raised arguments designed to prohibit the manufacture and sale of medications containing opiates (Giffen et al., idem.).

At the beginning of the century, in fact, doctors and pharmacists were concerned about the great popularity of patent medicines but the reasons of each of these groups were different.  While the doctors, for their part, were afraid that the sale of medicines would cause them to lose their patients, thus depriving them of income, the sale of these products would also harm the pharmacists who sold their own preparations directly in their own businesses.  Furthermore, some pharmacists were reluctant to accept the idea that they should sell patent medicine because alongside the competition this would provide for their own products, they could not guarantee the composition of these preparations the nature of which was sometimes dubious and unknown.  These two groups of professionals were therefore in vehement disagreement with each other on certain points – including the role to be played by each of them in the renewal of prescriptions – and they were even in competition with each other in sharing a market that was limited at the time.  On the other hand, the players in each of these groups maintained ambivalent business relations with the pharmaceutical companies.  As mentioned earlier, however, while the doctors and pharmacists clearly expressed their doubts and sometimes even their disapproval with respect to the effectiveness of patent medicine, they nevertheless had to maintain good relations with the major pharmaceutical companies from which they obtained their supplies (Giffen et al., 1991).  According to these authors, it was immediately after the First World War that the competition between doctors and pharmacists reached its height.  In 1919, there were between 5,000 and 6,000 pharmacists in Canada and 8,500 doctors.  At the time, pharmacies were retail operations where only products relating to the promotion of health or for pain relief were to be found and not the supermarkets that they have since become.  The pharmacies sold medicinal preparations under their own name and they were often consulted on an informal basis on the subject of medications.  Before 1919, these products could contain opiates but the amendments made to the Proprietary or Patent Medicine Act  in that year prohibited the use of such substances.  However, that prohibition did not apply if the medicine was sold in a container that bore the original formula or a full list of the ingredients; in that case, the preparation was not considered in law to be a patent medicine. 

In 1920, other amendments to the Proprietary or Patent Medicine Act further restricted the sale of certain medicines.  The pharmacists were opposed with such vehemence to the initial legislation, which would have required a prescription for the sale of any preparation containing opiates (regardless of the quantity) that the government withdrew the amendments;  thus, only preparations that contained a limited quantity of opiates could be sold without prescription.  Giffen et al. (1991) asserted, moreover, that the first draft of the 1920 version of the Act shows the wide range of reasons that motivated the Department of Trade, which was responsible for the first legislation concerning patent medicines and the Department of Health, which was newly created at that time and which was responsible for administering the controls on drugs.

In fact, since 1911 the question of prescriptions had raised many questions as well as many arguments between doctors and pharmacists.  While the 1911 Opium and Other Drugs Act permitted the renewal of prescriptions, there was no indication as to the number of times they could be renewed or whether the consent of doctors was absolutely essential.  In order to remove this ambiguity concerning the renewal of prescriptions, the Act was amended in 1920 to add a provision indicating that any pharmacist [TRANSLATION] “who, without the authorization of a doctor, veterinarian or dentist, uses a prescription to sell a drug on more than one occasion, is guilty of an indictable offence”.  At the same time, the maximum sentences applicable to pharmacists who breached the prescription requirements were increased from $200 and/or 2 months’ imprisonment to $1,000 and/or one year’s imprisonment with a minimum fine set at $500 (Giffen et al., 1991).

Another source of unhappiness among pharmacists lay in what they viewed as an intrusion by doctors into their area of jurisdiction, more specifically when doctors directly prescribed for their patients their own medicines purchased in bulk rather than issuing prescriptions that had to be filled at a pharmacy.  The confusion of roles between the two professions at that time indicated that the pharmacists viewed doctors not only as adversaries with respect to national controls but also as competitors on the local level.  In the short term, it was this rivalry with doctors that would have made it possible to mobilize pharmacists with a view to amending the attempts at control originally proposed by the representatives of the Department of Health, which placed the pharmacists at a disadvantage.  In the long term, however, this rivalry with the doctors would, on the other hand, permit those who were in favour of criminal penalties to enjoy success on certain points to the detriment of a medical profession that was divided on more than one issue.  Again according to Giffen et al. (1991), by combining the authority given to the medical profession with the popular support enjoyed by the pharmacists in the public, the representatives of the health professions could have constituted a much firmer opposition than they posed at the time to the representatives of the law and thus have secured more power for themselves in this area.  However, this common front was limited by conflicting interests in certain issues.

From the perspective of the authorities responsible for enforcing the law, stricter supervision of the pharmacists would have facilitated controls over the distribution of drugs and, at the same time, this would have made controls of prescriptions written by doctors even easier to apply.  Thus, for the regulatory authorities the ideal solution in legal terms would have been to require each player responsible for handling drugs – doctors, manufacturers and pharmacists – to have a permit and to report any transaction or at a minimum keep all the evidence so that it could be checked.  The Hague Convention of 1912 also required such controls in all the signatory powers.

2.6 – Summary of the situation in Canada from 1900 to the 1930s

Thus, before 1908 very few restrictions were imposed on the distribution and consumption of drugs, whether for medical or for recreational purposes.  In fact, tons of raw opium and large quantities of processed opiates were imported into Canada every year in the late 19th and early 20th centuries.  Various preparations sold at low cost were available from doctors, travelling patent-medicine sellers, the pharmaceutical companies, pharmacies, general stores as well as the opium dens run by the Chinese.  Viewed as a medical misfortune or as a personal vice, drug dependence was not associated with moral weakness until the 1920s, as well as subsequently (Solomon and Green, 1988).  Self-medication by means of these products was thus the most widespread form of treating pain in the late 19th and early 20th centuries in Canada.  However, many of the medicines sold could pose certain dangers because they contained varying amounts of cocaine, heroin, morphine, opium or even excessive quantities of alcohol (Murray, 1988).  Since the composition of most of these products was unknown, many Canadians were addicted to them without really knowing it whereas some individuals may have been seeking precisely this euphoric effect.

According to Murray (1988), various interests led to the enactment of the Proprietary or Patent Medicine Act.  The rapid growth of the patent medicine trade was at the time a threat to the professional recognition only recently acquired by doctors and pharmacists.  Self-medication with patent medicines deprived these professionals of a major source of income.  As a result, these two groups worked, each in its own way, to create a social problem with respect to the use of patent medicines.  The problem was highlighted and defined by the members of these two groups in the editorials of their respective journals as well as in discussions at their annual general meetings.  In Murray’s opinion (1988), it was the pharmacists and doctors who urged Parliament to adopt the objective of regulating the trade in patent medicine for the benefit of these two groups.  However, the path was long and difficult for the representatives of these two groups and the outcome was not to the complete satisfaction of some pharmacists or of most doctors.  The pharmacists who profited from sales of patent medicines were fairly happy to be able to continue to sell these products without being too heavily taxed, which was their fear at the time of the initial reform projects (Giffen et al. 1991).  Other pharmacists, on the other hand, like most doctors, were annoyed because the sale of these products continued to deprive them of a large share of the market for health services and also hurt sales of their own in-house preparations.  Be that as it may, the players involved in implementing the Proprietary or Patent Medicine Act – be they doctors, pharmacists or the representatives of the pharmaceutical companies – were all closely associated with the patent-medicine industry and all had a great deal of influence within society (Murray, 1988).

While the demands of the doctors and pharmacists certainly contributed to the adoption of the Proprietary or Patent Medicine Act in 1908, the Act was in fact a fairly toothless piece of legislation following its enactment; the trade in these medications remained relatively intact during the decade following the coming into force of the Act in 1908 until the amendments of 1919 and 1920.  Far from capping the growth in excessive consumption of these medications, the Act merely marked the end of the initial cycle of the history of the use of, trade in and regulation of patent medicine (Murray, idem.). 

3– The British tradition: beginnings of the British System

England provides an interesting point of analysis in terms of the involvement of the medical authorities in the regulation of drugs; that country is in fact internationally recognized for its drug prescription system, which is referred to as the British System.  We therefore thought it would be interesting to trace briefly the history of developments in that country at the beginning of the century and to compare it with the situation that existed in Canada in order to note the main factors that may have led the two systems to diverge with the North American system focused primarily on criminalization and the other, the British system, focused more on medicalization than the North American model.

In fact, since the beginning of the century, the representatives of the medical profession in Great Britain have played a much more important role in implementing government controls on drugs than their Canadian colleagues.  This power can be attributed to the fact that it was represented by a strong central association better able to exercise strict disciplinary controls on its members (Whynes, 1991).  Moreover, the system of permits to practice medicine was centralized in Great Britain and various mechanisms existed to restrict access to prohibited substances to those practitioners who were not qualified (idem.).  South (1991), on the other hand, argues that the British System has often been presented in an idealized way and this approach is not altogether realistic.  In his view, it was the desire of the British medical profession to control its own members that formed the basis for their model because most addicts in Britain at the beginning of the century were in fact either doctors who engaged in substance abuse or patients for whom drugs had been prescribed in the course of medical treatment.

The first statute regulating medicine in Great Britain was the Pharmacy Act of 1868 (Mott and Bean, 1991).  That Act made it an offence for anyone to sell, dispense or prepare chemical substances unless he or she was a chemist working in the pharmaceutical industry.  It was also prohibited to sell these substances unless the container clearly indicated the name of the substance as well as the name and address of the person selling the product.  The act did not apply to dealing in large quantities or to doctors who prescribed these substances to their patients as part of their medical practice.  Until the outbreak of the First World War, parallel to what was happening in Canada, it was possible to obtain opium- and cocaine-based products fairly easily in British pharmacies.  Opium and preparations that used it and the opium poppy as a base were also subject to the Act and sales of them were permitted to the extent that the quantities of the substances concerned were indicated on the container.  Patent medicines containing opium were not subject to the Act whereas morphine-based preparations had been subject to regulation since 1869 (Whynes, 1991).  In 1908, the Act was amended and cocaine and opium were included in Division II (subject to the strictest regulation) although no new controls were added.  Although morphine and cocaine had already been included earlier in Division I of the 1868 Act, the government accepted the proposal of the British Pharmaceutical Society that these substances be included in Division II and that they also be included in the new Schedule (Mott and Bean, 1991). 

Although the British System is usually referred to in connection with the prescription of heroin, it is interesting to note that it was cocaine that led at the beginning of the century to stricter legislation concerning drugs in Great Britain.  In fact, during the First World War, there was widespread consumption of cocaine in that country (as elsewhere, in fact, including the United States), especially among prostitutes and Canadian soldiers who were in Britain because of the war.  While sales of intoxicants (sedatives, narcotics or stimulants) to any member of His Majesty’s forces was prohibited under the Defence of the Realm Act (DORA) of 1914, the sale and possession of intoxicating substances was not, paradoxically, prohibited by the 1908 Act  (Mott and Bean, idem.).

In 1916, an order of the Army Council prohibited the sale of cocaine – and all other drugs – to any member of the armed forces unless it had been prescribed by a doctor (the prescription was renewable only once).  Since this measure had very little effect, DORA 40B was enacted.  This special legislation, which tightened the existing control mechanisms, no longer permitted more than a few authorized persons (pharmacists, doctors, persons who received medicines from a doctor or individuals in possession of a special authorization from the Secretary of State) to have cocaine or other preparations containing more than 0.1% of cocaine in their possession (Mott and Bean, 1991).  The death of a well-known actress in 1918, which was attributed to cocaine consumption and led to a major uproar in the British media, was an important contributing factor to the government’s enactment of its first legislation prohibiting the use of drugs for non-medical purposes, the Dangerous Drugs Act, which was enacted in 1920.  The Act resulted from the ratification by the United Kingdom of the International Opium Convention of 1912 and this was given concrete form following the signing of the Treaty of Versailles in 1919 (Whynes, 1991).

The Dangerous Drugs Act, which reproduced the main regulatory measures that existed in DORA 40B, prohibited the production, importation and exportation, possession, sale and distribution of opium, cocaine, morphine or heroin, except by authorized persons.  The availability of drugs was limited to doctors’ prescriptions and any possession outside this framework was regarded as illegal.  It was therefore at the beginning of the 1920s that English doctors, thanks to the Committee of members of the medical profession in the House of Commons, began to play a more important role in drug control in England.

Toward the end of the 1920s, the legislation was unclear on two points concerning the circumstances surrounding the prescription of drugs: 1. the doctors were unanimous concerning the main dispute as to whether the prescription of morphine or heroin to those who were dependent on these substances as being a legitimate treatment, and 2. the question arose as to whether doctors should be permitted to prescribe opiates for themselves (Mott and Bean, 1991).  In 1924, the Minister of Health appointed Sir Humphrey Rolleston, the President of the Royal College of Physicians, to head a Commission consisting of eminent doctors to consider the question of drug prescription in that country.

3.1– The Rolleston Commission

The Rolleston Commission, which submitted its final report in 1926, was thus the official starting point in the introduction of a change of attitude and a new conceptual framework for drugs in Great Britain.  It was, moreover, the Rolleston Report that confirmed the central role of English doctors in this regard.  The report recommended that doctors be given the power to use their professional discretion in treating drug-dependent users and they could even prescribe long-term maintenance doses.

This medical as opposed to criminal approach toward the users of drugs was possible primarily because English doctors demanded and were given a pivotal role in the drug regulatory system in Great Britain.  Before 1926, the main concerns of medical professionals with respect to drugs were to prevent overdosing as a result of recreational use.  Following the new social and medical theories, the Rolleston report redefined the use of drugs as a sickness based on the dependence model.  Thus, the prescribing of drugs became legitimate and even legal in certain cases: 1. if the addicts received a gradual withdrawal treatment,  2. where complete abstinence would have caused serious problems that could have been treated differently, or 3. where the dependent user could have led a normal life if he or she had received a stable dose (Whynes, 1991).  It was also the Rolleston Report that proposed a system of medical tribunals in order to regulate the practices of the medical profession.  Thus, when a doctor was suspected of abusing his or her discretion, a medical tribunal would have the authority and power to decide whether he or she could continue to write prescriptions and not a criminal court, as was the case in Canada.

The British System, which permitted doctors to prescribe a wide range of substances (heroin, methadone, cocaine, amphetamines, morphine) in their medical treatment of addiction, was in effect for a period of almost 40 years, that is from the 1920s to the 1960s.  It would seem that the prescribing of drugs by doctors went on without too many abuses over this period (Whynes, 1991).  Starting in the 1960s, however, the occurrence of a number of scandals involving over-prescribing by some doctors at the same time as the arrival in England of large numbers of young drug-users from many other countries seeking free drugs led to the enactment of new legislation in 1967.  According to this new legislation, only doctors with a special permit issued by the Home Office in Britain could now prescribe such substances.

According to Lart (1991), the British System has been defined in various ways over the years: as a medical treatment designed to help stabilize addicts and make them functional, as a cause of increased addiction or even as a way to short-circuit the illegal market for drugs.  It includes both a flexible legislative tradition and also an opportunity for concerted local initiatives, a phenomenon that was particularly marked in the 1980s in the Merseyside area in northwestern England, the focal point of which is the city of Liverpool.  Brisson (1997) also indicates that the Merseyside model, which received widespread media coverage in the early 1990s and which is taken to be true of the whole country, is more unique to that particular region than to the country as a whole.  In fact, the British System has been subject to much harsh criticism, even in Britain itself.

4– Conclusion and discussion

Generally speaking, this brief historical overview has allowed us to expand our knowledge and understanding of the role of medical practitioners in the implementation of regulatory policies relating to drugs in Canada, and to a lesser extent in Britain.  According to the authors consulted, the market for patent medicines was an important sector of the Canadian economy at the beginning of the century.  Furthermore, various commercial interests were also involved at that time while many complex corporate agendas existed in the relations among doctors, pharmacists, the pharmaceutical companies, politicians and the representatives of the forces of suppression.  In fact, this document has enabled us to confirm that we over-estimated and idealized the power of the members of the medical profession.  We tended to see them as a unified coherent body above the political challenges, even dictating the actions of politicians in accordance with the Robert model, in which the law follows medical discourse and practice.  However, it now seems clear to us that the situation was infinitely more complex and that many divergent interests existed among pharmacists, doctors and the pharmaceutical companies, despite their shared points of interest.  These divergent interests seem to explain the relatively limited importance of the members of this group in the initial implementation of the provisions in the early drug legislation in Canada.

Unlike Great Britain, where the power of the doctors was centralized in a strong national association, Canada’s situation was different to the extent that each province had its own separate college of physicians and associations and pharmacists working against highly different backdrops imbued with different concerns and this had the effect of diluting their power on the national stage.  The fact that the professional associations of doctors and pharmacists were in their infancy also contributed to the predominance of repressive forces, which seemed to be better organized at that time.  It was only following the application of the first controls that doctors and pharmacists organized themselves into national associations and that consequently their political weight seems to have grown.  Since the drug legislation fell and still falls within the jurisdiction of the federal government, this lack of well-established organizations at the national level seems to have done a lot of harm to doctors and pharmacists in their relations with the government in Ottawa.  Despite their relative political weight at the time, it would seem that the demands made by these two groups to the government nevertheless made an impact to a certain extent on the politicians grappling with the initial attempts to change the mechanisms of control over patent medicines and prescriptions around the end of the First World War.  In fact, the proposed amendments to the Proprietary or Patent Medicine Act were changed many times in order to satisfy each of the groups involved.  Although the manufacturers of patent medicines seem to have been the winners in these negotiations, the politicians were nevertheless listening to the doctors and pharmacists.

Parallel to the specific role played by workers in the health field in the debate concerning regulation of drugs at the beginning of the century, a certain racist attitude toward the Chinese on the west coast seems to have ensured that the harshest measures would primarily affect that particular group.  At the beginning of the century, North America was basking in an atmosphere of moral reform widely supported by the clergy and a broad movement aimed to protect the white race and puritan values (Solomon and Madison, 1976).  Drugs were not the only thing that was affected by this moralistic attitude because the prohibition of alcohol in the United States and English Canada at the time also testifies to this general tendency.  The combination of these factors accordingly helped to tilt the nature of drug regulation toward the criminal approach and at the same time this deprived doctors and pharmacists of some of the power they had been granted, which made it easier for them to be subordinated to the representatives of the Drugs Division and to a lesser extent those of the RCMP.  Pressure from the influential US bureaucracy on Canadian authorities and the strict control they exerted on American doctors also seems to have made it easier for Canadian officials to take a repressive approach to the detriment of one that focused more on medical considerations.  Colonel Sharman’s presence at the head of the Drugs Division from 1927 to 1946 and his privileged relationship with Henry Anslinger, his American counterpart who strongly influenced the approach to strict regulation in the US, are other major factors that made it possible to consolidate responsibility and impose government control over drugs through the criminal law in Canada, which began to be formally implemented in 1908.

Application of the Robert model to the situation in Canada

In light of the information provided earlier, it would appear that the C.-N. Robert model presented at the beginning of this paper applies only in part to the situation in Canada.  First of all, according to some of the authors consulted (Beauchesne, 1991, Giffen et al. 1991, Murray, 1988, Solomon and Green, 1988), it is known that in terms of consumption patterns, many Chinese on the west coast of Canada smoked opium in the late 19th century and in the early 20th century.  Later, when this previously limited use expanded outside the Chinese community, a phenomenon that was to some extent tolerated by the regulatory authorities until the early 20th century when it expanded to certain groups in the white population, controls imposed on Asians became more widespread and even harsher (Solomon and Usprich, 1990).  Parallel to this use of opium and at essentially the same time, drug use became more widespread within the general public as the marketing of patent medicine increased.  This situation generally benefited from the fact that the pharmaceutical companies were selling patent medicines against a blaze of publicity and because sickness was widespread at the time and medical treatments somewhat limited.  Since this market was of considerable commercial interest, the government did not wish to harm this sector of the economy, which gave employment to a large number of workers and brought in large sums of money (Murray, 1988).  Robert’s model applies to the Canadian situation up to this point because it was under the pressure of doctors and pharmacists that the previously uncontrolled use of patent medicines was subject in part to regulation under the Proprietary or Patent Medicine Act in 1908.  We know that this legislation was designed to monitor sales and use of patent medicines that had previously been unregulated, a situation that had primarily benefited the manufacturers of these products.  Against all their expectations, after this Act became law, the members of the medical profession were subject to even closer controls and supervision by federal bureaucrats, which did not reflect their initial demands seeking an increase in power for their benefit.  As far as opium use among the Chinese was concerned, the Opium Act became law in 1908 and it was primarily the police and the criminal courts that were given responsibility for imposing the controls; we should note that there was little opposition to this Act, aside from a few opium dealers of Chinese origin.

Thus, contrary to Robert’s argument, at least in the Canadian situation, it would seem that it was not medical discourse and practice that dictated the use of the criminal justice system in the early part of the century but, on the contrary, medical practice and discourse that succumbed to the regulatory bureaucracy by which they were closely supervised and by which they could even be prosecuted.  The power enjoyed by the representatives of the regulatory bureaucracy, helped, as we have seen, by the disputes within the group of health professionals, favoured criminalization of the use of certain drugs rather than their medicalization in Canada.  The doctors had to comply and rigorously follow the application of the Act implemented by the federal bureaucrats who took the initiative in this regard, all on the basis of moral reform supported by the clergy.  Doctors and pharmacists were split among themselves and this appears to have greatly weakened their position against the other players involved, that is the supporters of regulation, who were close to the authorities, and the representatives of the large pharmaceutical companies that employed many people and invested large sums of money in and obtained extensive profits from this industry, as well as the government, which also secured its share through various taxes.  The Robert model seems therefore to reflect more accurately the situation in Britain, where the doctors played a major role in the debate on drug use because they were represented by a strong national organization.  In fact, as Whynes (1991) showed earlier, doctors were well represented in the British Parliament and were listened to and respected by politicians.  In both countries, however, despite the differences listed earlier, it can be said that Robert is right when he says that [TRANSLATION] “medical discourse and practice both appear to have been responsible for a substantial increase in the use and abuse of drugs, on a therapeutic pretext, that also firmly led to a consensual anti-drug ideology by competently denouncing the harm caused”.  This statement can be checked in particular against the efforts of the doctors and pharmacists who sought to influence the politicians in applying legal controls for the purpose of limiting the sale of patent medicines prior to 1908, because this situation deprived them of a share of the market for medical prescriptions.  The representatives of the medical profession contributed, from the very beginning of the century, to the increased use of some drugs, while denying or refuting the therapeutic virtues of other substances from elsewhere out of ignorance or interest.  It must be noted that alongside the contribution made by medical professionals, drug consumption habits changed on the basis of technological and scientific progress, including the discovery of new substances, not to mention the invention of the hypodermic syringe and tablets.

In conclusion, if we observe the current situation in the field of drugs, it will easily be seen that the supporters of regulation still dominate the debate in North America, although considerably less so in Canada than in the United States, it should be noted.  Although medical professionals may well be required to play a larger role in coming years with respect to drugs primarily because of the propagation of HIV/AIDS among intravenous drug users, the increasing distribution of methadone and the openness of political and medical authorities and public opinion concerning the medical use of cannabis, the regulatory tradition will continue to influence our understanding of the phenomenon for a long time to come.  On the other hand, it is also possible to ask to what extent a possible “medicalization” of drugs would be more beneficial than the criminalization that currently prevails because there is a risk that one will replace the other without any heed being paid to improving the conditions in which problem users live.  Would it really be preferable for a drug user to be under the supervision of a doctor who could easily impose his or her own values and decide on his or her own whim what the patient needed rather than running the risk of being prevented sporadically from continuing to obtain drugs on the black market?  We doubt this and of course the debate is not over.

However, the main question in our view remains the following:  how do we manage to reduce as far as possible the negative consequences – of whatever kind – associated with drug use and the control thereof by creating a situation that is more conducive to the use of public services by needy users.  In our view, this is where the crucial challenge lies in this area.  Regardless of the kind of controls that are put in place, it is essential to keep the debate going so that users will eventually become the focus of our concerns and of our social services.  Too often, drug users are merely the subjects of policies and practices that are tainted with ideology and a prohibitionist morality that are not suited to them in any way and which, in many cases and for large numbers of consumers, do not work in any event.

Has the time now come to explore other approaches?  Yes.  Although it is perhaps not the miracle solution to the problems caused by drug use, medicalization, which has been viewed with increasing favour over the last few years in the field of drugs and addiction, at least allows us to propose an alternative to the main focus of action, which is still based primarily on abstinence and immediate and complete cessation of use.  Medicalization takes greater account of the needs of users rather than attempting to force them into a uniform and unidirectional world.  The war against drugs can only result in a witch-hunt against drug users and this is far from being an inviting approach from their viewpoint.