A message from Dr. Réka Gustafson
This report invites you to engage in meaningful conversations about psychoactive substancesi - alcohol, tobacco, cannabisi, and unregulated substances - using our collective experience and evidence as a foundation. Together we can work to improve the health of our communities.
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Contextbutton, consider the historical and social factors behind these avoidable and unfair health differences. These differences are rooted in the context in which people live their lives. "Nobody knows more about drug addiction than we ourselves do. We are the ones doing the drugs, living the life. Most people don’t understand it. A lot of us have been through pretty horrible traumas. For me, drugs were a way to numb out so I didn’t have to feel."
- Beth Haywood, a person with lived experience
"It is my experience that people’s vulnerability to problematic use of substances, including the use of illicit drugs is exacerbated by their prevalence to poverty, homelessness, mental illness and racism. I believe having access to regulated drugs, (like what is available for people who use, rely on alcohol, cigarettes, cannabis, etc.), is essential to reducing and preventing drug related crimes, accidental overdose and deaths."
- Louise Takhar, a person with lived experience
In the 1990s, the "paradox of prohibition" concept emerged. It illustrates that drug policies exist on a spectrum, and influence the health and social well-being of populations. The concept highlights that policies at either end of the spectrum —both illegal not regulated and legal not regulated—cause the most harm. The middle of the continuum is where effective regulations minimize harms.
Alcohol sits at the right of the policy continuum. It is the only psychoactive substance with addictive potential that isn’t controlled by international laws, despite its significant impact on public health.
In B.C. and across Canada, alcohol is fully legal with few restrictions.
Tobacco is a legal substance that is regulated at the federal, provincial, and local levels. It is closer to the middle of the policy continuum, where population-level harms are minimized.
Decades of regulation have successfully reduced tobacco consumption.
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Across Canada, overall reported consumption has increased moderately since legalization.
Cannabis is now a fully legal substance, regulated at the federal level via the Cannabis Act and in some provincial provisions.
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Illegally manufactured substances like opioidsi and stimulantsi are on the extreme left of the policy continuum. Since these substances are illegal, there are no regulations in place for their manufacturing and distribution.
Opioids in the unregulated market have become increasingly potent and contaminated over the past decade.
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There is a long and complex history of policies related to psychoactive substances in Canada.
The following timelines outline some of the significant events in the history of policies pertaining to psychoactive substances in Canada. The timelines illustrate how policies, laws, industry influence, and dominant social narrativesi and norms have shaped the current landscape of substance use.
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"I saw alcohol and tobacco use as a rite of passage, from teenage to adulthood."
- Gordon Harper, a person in very long-term recovery
"My family was happy to see me drinking alcohol, because it meant I wasn’t using drugs."
- Aran Wilson, in recovery
Alcohol is a legal, weakly regulated substance causing increasing harms in our population.
There is no international or national alcohol control strategy, and provincial policies over the past decade have largely promoted greater access to alcohol. These policy changes correlate with a steady increase in alcohol consumption and related harms. Alcohol consumption is higher in Island Health than in the province as a whole, including among youth.
"Alcohol is a social and cultural lynchpin in our society."
- Chris Edwards, a person with lived experience
Decades of regulatory approaches, including taxation, advertising restrictions, and smoking bans, have resulted in a substantial decline in tobacco smoking, particularly among youth.
Despite this progress, the decline has recently plateaued and smoking rates are still higher than the Canadian target of 5%, indicating the need for continued efforts.
The success in tobacco regulation serves as a model for other substances, demonstrating how sustained policy efforts can lead to significant public health improvements.
"When it’s difficult to smoke, I smoke less."
- Aran Wilson, in recovery
Cannabis became a legal, regulated substance in Canada in 2018. Between 2018 and 2023, the number of youth in Island Health reporting ever having tried cannabis declined slightly.
Now that cannabis is legal, we can better monitor consumption patterns and trends, in order to ensure that current and future policies maintain the goal of minimizing health harms.
For illegal, unregulated substances, we are unable to use the evidence-informedi policy and regulatory mechanisms that can ensure that they are less toxic and accessed in ways that cause less health and societal harm.
Unregulated opioids are the substances causing the greatest number of potential years of life lost in Island Health. The very high death toll of unregulated opioids is directly related to the toxicity of the drug supply. A public health emergency was declared in B.C. in 2016 in response to the increased deaths after the emergence of fentanyl in the illegal supply. Interventions such as overdose prevention services, take-home naloxone, and opioid agonist therapy resulted in a decline in mortality.
In 2020, pandemic restrictions disrupted services for people who use unregulated substances, resulting in an immediate increase in deaths. In the following months and years, unregulated substances became more highly concentrated and contaminated. Mortality related to unregulated opioid toxicity is now more than two times higher than when the public health emergency was declared.
Identify and address health care system contributors to higher-riski substance use, such as inadequate pain management...
i"Abstinence is not for everyone. We need to make sure that we have the services available for people no matter where they are in their relationship with substances.”
- Beth Haywood, a person with lived experience
"Stimulants are my whole story of substance use. I couldn’t get help because I was ‘only’ a stimulant user.”
- Aran Wilson, in recovery
Psychoactive substances are causing significant harm to people. These harms are preventable and we have the power to influence policies to improve the health of our communities.
The data and opportunities for action outlined here are not the end of this work. This is not a comprehensive report about all substances and all experiences, but a resource that is intended to serve as an engagement tool to support conversations to bring about meaningful change.
With this report, we are armed with data and evidence-informed actions that can start to turn the tide and improve the collective health of our communities. We encourage you to read the full report and share the findings.
Let’s continue the conversation about opportunities that can make a difference for our Island Health communities.
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All references are included in the downloadable report.
Psychoactive Substances
Psychoactive substances are legal or illegal substances that affect mental processes and range from caffeine and nicotine products to illegally manufactured fentanyl.
Prohibition
Prohibition refers to policy approaches to substance use that forbid possession, distribution, and production of substances, unless authorized. Those who break the laws face criminal penalties. This approach was used for alcohol in the past and is currently in use for heroin, cocaine, methamphetamine, and others.
Evidence-informed
The process of gathering and sharing the highest quality evidence from research, practice, and experience, and using that evidence to guide and enhance policy and practice.
Stimulants
Stimulants are drugs that increase activity in the body, causing it to speed up. Stimulants include cocaine, amphetamines, crystal meth, MDMA (Ecstasy), Ritalin and caffeine.
Higher risk substance use
Substance use that is harmful and negatively impacts a person, their family, friends and others, such as impaired driving.
Dominant Social Narratives
Dominant (social) narratives are widely accepted stories, perspectives and frameworks within a society that shape and influence collective understanding, beliefs, and behaviors. These narratives often reflect the values, norms, and interests of dominant groups or institutions, reinforcing their power and status while marginalizing alternative viewpoints. Dominant narratives permeate various aspects of life, including media, education, politics, and culture, and can impact how individuals perceive and interact with the world around them.
Vaping
When referred to in the report, vaping is the inhaling of an aerosol or vapour created by an electronic cigarette, vape pen, or personal vaporizer (known as “mods”). All legally sold vapes in B.C. contain nicotine.
Health inequities
Health inequities are unfair and avoidable systematic differences in the health status of different population groups. Examples include lower life expectancy and high rates of disease.
HSDA
For planning, reporting and assessment purposes, the regional health authorities in B.C. are divided into Health Service Delivery Areas (HSDA), which then are sub-divided into Local Health Areas (LHA).
Cannabis
Cannabis, also known as marijuana, pot, or weed, is a plant. The cannabis plant contains a number of chemical compounds called cannabinoids that may affect the brain and other parts of the body’s nervous system.
Opioids
Opioids are a class of drug that can be prescribed by a doctor or nurse practitioner but are also found in the street drug supply. Common opioids include heroin, fentanyl, oxycodone, codeine, morphine, methadone and hydromorphone. Illegally manufactured opioids are sometimes made to look like prescription drugs.
Territorial Acknowledgement
The region Island Health supports is the traditional territory of the Coast Salish, Nuu-chah-nulth, and Kwakwaka’wakw cultural families, who have been caretakers and stewards of these lands since time immemorial. It is with humility we continue to work toward building our relationship.
Rights Acknowledgement
We acknowledge with respect the inherent rights of the First Nations whose ancestral territories cover the entirety of the region served by Island Health. These inherent rights include their unextinguished land rights and rights to self-determination, health, and wellness within these territories. Laws and governance systems rooted in the land have upheld the sovereignty of these diverse Nations for thousands of years. The rights and responsibilities of First Nations to their ancestral territories have never been ceded or surrendered, and are upheld in provincial, national, and international law.
We also acknowledge that many Indigenous Peoples (First Nations, Métis, and Inuit) from elsewhere in what is now known as Canada also call these lands and waters home, and we have obligations to uphold their rights to self-determination, health, and wellness. This includes Métis Nation British Columbia and its Chartered Communities across the region served by Island Health, as well as those whose ancestral territories lie elsewhere.
Island Health Medical Health Officers recognize the need for thoughtful and intentional work to decolonize the health system. In the spirit of the United Nations Declaration on the Rights of Indigenous Peoples, the Métis Nation Relationship Accord II, and the Calls to Action of the Truth and Reconciliation Commission, Island Health works with the First Nations Health Authority, Métis Nation British Columbia, and other Indigenous partners to make programs and services more culturally appropriate and supportive of Indigenous health and wellness.
Context: Alcohol
Remote and rural communities face higher rates of alcohol consumption and related harms, reflecting disparities in health and social conditions.
Context: Tobacco
The commercialization of tobacco and adoption of commercial products like cigarettes, cigars, and pipes leads to harmful outcomes. This does not include tobacco used by First Nations, Inuit, and Métis communities for traditional and sacred practices, which differs in composition, production, and usage.
Context: Cannabis
While cannabis use appears consistent across regions, the health outcomes and access to support services vary, potentially hiding disparities in how different communities are impacted.
Context: Unregulated Substances
First Nation communities face higher rates of toxic drug poisonings, driven by a complex interplay of historical trauma, social exclusion, and inadequate access to culturally safe health services. This disproportionate impact is a stark reminder of the ongoing effects of colonialism and systemic racism.
Thank you for your interest in this report about substance use and health in Island Health. It is important to talk about psychoactive substances because they are causing preventable health harm for people in Island Health, and there are tangible steps we can take to change that.
By exploring a range of psychoactive substances, from the illegal and unregulated to the legal, promoted, and celebrated, the report hopes to show that the way we talk about and approach substances is largely rooted in history and perception, rather than evidence. While substance use is a part of the human experience, the way we use substances and how substance use affects our health is also influenced by our biology, social circumstances, experiences of trauma, and public policies.
I am grateful for the Population and Public Health (PPH) team and the many colleagues who drafted, edited and provided advice on this report. I’m especially grateful for conversations with Beth Haywood, Gordon Harper, Aran Wilson, Louise Takhar and Chris Edwards, who shared the kind of wisdom, humour and insight that only those with lived and living experience can. I would like to thank Gordon for giving this report its title.
I hope that the information presented here will support constructive conversations among communities, organizations, and people who use substances in Island Health and help identify and bring about meaningful change for the better.
Sincerely,
Dr. Réka Gustafson
Vice President, Population and Public Health and Chief Medical Health Officer, Island Health
Island Health delivers healthcare in British Columbia to a large population across Vancouver Island, islands in the Salish Sea and Johnstone Strait, and mainland communities north of Powell River. Within the region there are 50 First Nations and 6 Métis Chartered Communities.
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