Pubdate: Tue, 21 Jan 2003
Source: Canadian Medical Association Journal (Canada)
Copyright: 2003 Canadian Medical Association
Contact:  http://www.cmaj.ca/
Details: http://www.mapinc.org/media/754
Authors: Evan Wood, et al

IMPACT OF SUPPLY-SIDE POLICIES FOR CONTROL OF ILLICIT DRUGS IN THE FACE OF 
THE AIDS AND OVERDOSE EPIDEMICS: INVESTIGATION OF A MASSIVE HEROIN SEIZURE

Evan Wood*, Mark W. Tyndall*, Patricia M. Spittal*, Kathy Li*, Aslam H. 
Anis*, Robert S. Hogg*, Julio S.G. Montaner*, Michael V. O'Shaughnessy* and 
Martin T. Schechter* *British Columbia Centre for Excellence in HIV/AIDS, 
St. Paul's Hospital, Vancouver, BC; Department of Health Care and 
Epidemiology, University of British Columbia, Vancouver, BC; Department of 
Medicine, University of British Columbia, Vancouver, BC; Department of 
Pathology and Laboratory Medicine, University of British Columbia, 
Vancouver, BC

Correspondence to: Dr. Martin T. Schechter, Department of Health Care and 
Epidemiology, University of British Columbia, 5804 Fairview Ave., Vancouver 
BC V6T 1Z3; fax 604 806-9044; Abstract

Background: More than 93% of the nearly $500 million spent annually on 
Canada's drug strategy goes toward efforts to reduce the illicit drug 
supply. However, little is known about the effectiveness of this strategy. 
On Sept. 2, 2000, Canadian police seized approximately 100 kg of heroin in 
one of the nation's largest-ever seizures of this drug. An ongoing 
prospective cohort study of injection drug users afforded an opportunity to 
evaluate the impact of this seizure.

Methods: The Vancouver Injection Drug User Study is a prospective cohort 
study of injection drug users that began in 1996. The present study relied 
primarily on data acquired from participants who were seen during the 
30-day periods immediately before and after the seizure. We compared drug 
use and behavioural characteristics, heroin and cocaine prices, and 
participants' reports of whether law enforcement had affected their source 
of drugs or the types of drugs available on the street, as well as 
overdoses, in these 2 periods.

Results: The 138 participants seen before the seizure were similar to the 
123 participants seen after the seizure with respect to age, sex, ethnic 
background, education, HIV serostatus, neighbourhood residence, instability 
of housing, employment status, use of methadone maintenance therapy and all 
other measured potential confounders (all p  0.10). We found no difference 
in the extent to which participants in the 2 groups reported daily use of 
heroin, frequency of nonfatal overdoses, or whether law enforcement had 
affected their source of drugs or the types of drugs available on the 
street (all p  0.10). Although we detected no difference in the price of 
cocaine, the median reported price of heroin went down after the seizure (p 
= 0.034), which suggests that other shipments compensated for the seizure. 
External evaluations of deaths from overdoses and heroin purity indicated 
that the seizure had no impact, nor was any impact seen when the periods of 
analysis were extended.

Interpretation: The massive heroin seizure appeared to have no measurable 
public health benefit. Closer scrutiny of enforcement efforts is warranted 
to ensure that resources are delivered to the most efficient and 
cost-effective public health programs.

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The primary response to the spread of HIV among injection drug users (IDUs) 
has been to intensify law enforcement in an effort to limit the supply and 
use of illicit drugs. Locally, the enforcement budget for Vancouver's 
Downtown Eastside district has doubled since 1995, with no observed benefit 
with regard to drug supply or public order (Vancouver District 2 total 
budget figures for 1995­2001; Vancouver Police Department, Financial 
Services, unpublished data), and reports of police misconduct in the 
neighborhood have recently raised major concerns. At the national level, a 
recent report from the Canadian auditor general estimated that of the $454 
million spent in 1999/2000 to deal with illicit drugs in Canada, $426 
million (93.8%) was devoted to reducing supply. Despite the expenditures on 
supply reduction, high HIV incidence rates persist in many Canadian cities, 
and overdoses of illicit drugs have been a leading cause of death.,

Few studies have attempted to evaluate the impact of the supply-reduction 
strategy on community drug-use patterns. An Australian study found no 
evidence that heroin seizures affected the price, purity or perceived 
availability of heroin. Similarly, despite spending of over US$18 billion 
annually on supply-reduction efforts in the United States, the most recent 
heroin availability report from the US Office of National Drug Control 
Policy stated that the price of heroin in that country decreased 3-fold 
between 1988 and 2000, while purity has reached an all-time high.

On Sept. 2, 2000, Canadian law enforcement officials seized approximately 
100 kg of uncut heroin soon after its arrival in the port of Vancouver, in 
what was reportedly the nation's largest-ever seizure of the drug. To put 
this seizure in perspective, the US Drug Enforcement Administration's 
10-month Operation White Horse resulted in the seizure of 6.5 kg of heroin, 
and the total amount of heroin seized by the US Customs Service along that 
country's southwest border during the entire year 2000 was 113 kg.

In the wake of the Vancouver seizure, it was suggested that the removal of 
this quantity of heroin from the market could substantially limit the 
supply of the drug and could keep prices beyond the range of youth at high 
risk for experimentation, and that it was responsible for a decline in the 
city's overdose rate. We sought to determine if the seizure had a 
measurable effect on the price of drugs, injection drug using behaviour, 
the incidence of overdoses or the supply of heroin to Vancouver's IDUs.

Methods

Beginning in May 1996, IDUs were recruited into the Vancouver Injection 
Drug User Study, a prospective cohort study that has been described in 
detail previously., Over 1400 study subjects have been recruited through 
self-referral and street outreach, and we have previously reported that the 
cohort appears to be highly representative of IDUs in the Vancouver area.,

At baseline and semiannually thereafter, subjects provided blood samples 
and completed an interviewer-administered questionnaire. The questionnaire 
elicited demographic data including age, sex and place of residence, as 
well as drug use, risk behaviour and attendance at drug treatment. In 
addition, since the cohort's inception several general questions have been 
added to evaluate the effect of law enforcement efforts on the supply of 
drugs and patterns of drug use. Participants were also asked to report the 
current street price per "point" (single shot) of injection heroin and 
injection cocaine.

For the primary analysis in this study we assumed a priori that acute 
street-level impacts would be measurable within a month starting the day 
after the seizure., Therefore, pre-seizure and post-seizure participants 
were defined as those seen for follow-up within 30 days before and 30 days 
after Sept. 2, 2000, respectively. In addition, because of uncertainty 
concerning the appropriateness of the 30-day period for observing any 
impact of the seizure, we conducted several sensitivity analyses. First, we 
compared participants seen during the 60 days before Sept. 2, 2000, with 
those seen during the 60 days after this date. Second, we evaluated 
participants seen in 6 successive 2-week periods after Sept. 2, 2000.

Statistical analyses were applied to compare pre- and post-seizure 
participants. Categorical explanatory variables were analyzed with 
Pearson's 2 test and Fisher's exact test, and continuous variables were 
analyzed with the Wilcoxon rank-sum test. In addition, to adjust for 
potential confounding due to differences between the IDUs seen before and 
after the seizure, we conducted a logistic regression analysis in which the 
dependent variable was the period (before v. after).

Results

In the 30 days before Sept. 2, 2000, 138 participants visited the study 
site for follow-up; 123 participants visited for a follow-up visit in the 
30 days after this date. The 2 groups were similar with respect to age, 
sex, ethnic background, education, HIV serostatus, neighbourhood residence, 
instability of housing, employment status, methadone use and all other 
measured potential confounders (all p 0.10).

In univariate analyses of drug use and behavioural characteristics (), we 
found no difference in the proportion of participants who reported that law 
enforcement had affected their source of drugs (p = 0.55) or the type of 
drugs available on the street (p = 0.73). Similarly, we found no 
differences in overall drug-use pattern (p = 0.60), injection drug-use 
pattern (p 0.13), current heroin use (p = 0.57), frequency of heroin 
injection (p 0.52) or frequency of cocaine injection (p = 0.42). In 
addition, we did not detect any difference in the proportion of 
participants reporting a recent nonfatal overdose (within the previous 6 
months) (p = 0.12). Although the seizure was not associated with a change 
in the per-point price of cocaine (p = 0.36), we did detect a statistically 
significant decrease in the per-point price of heroin, from a median of $20 
before the seizure to a median of $16 after the seizure (p = 0.034). After 
adjustment for all combinations of potential confounders, the decrease in 
the price of heroin remained independently associated with the post-seizure 
period in logistic regression analyses (p ( 0.05)

Furthermore, our findings were unaffected when we doubled the length of the 
pre- and post-seizure periods and compared the 317 participants seen during 
the 60 days before Sept. 2, 2000, with the 259 participants seen during the 
60 days after this date. In this analysis, the median post-seizure 
per-point price of heroin was higher than for the 30-day period, at $18 
(interquartile range $14 to $20), but it was still lower than the 60-day 
pre-seizure price, which remained unchanged at $20 (interquartile range $15 
to $20).

The percentages of participants reporting current heroin use, methadone 
maintenance therapy and recent nonfatal overdose during the period from 28 
days (4 weeks) before Sept. 2, 2000, to 12 weeks after this date are shown 
in . For all 3 variables, comparisons of periods were nonsignificant except 
for the comparisons of period ­2 and period ­1 (the two 2-week periods 
before the seizure) with period 2 (the second 2-week period after the 
seizure) for nonfatal overdoses (p = 0.08 and p = 0.001 respectively); this 
variable was moderately greater during period 2 than during periods ­2 and 
­1. Not shown in the figure is the percentage of participants who reported 
that law enforcement had affected the types of drugs available on the 
street. On average, 22.2% of participants reported that law enforcement had 
affected the types of drugs available during the 4 weeks before the 
seizure, whereas 19.5% of participants reported that law enforcement had 
affected the types of drugs available during the 12 weeks after the seizure 
(p = 0.19).

Interpretation

The data presented here indicate that the record seizure of heroin in 
autumn 2000 appeared to have no impact on injection use of heroin or on 
perceived availability of heroin. Furthermore, we detected no difference in 
the extent to which drug users reported that enforcement had affected their 
drug source, the types of drugs available or their pattern of drug use.

Several factors may explain our observations. First, we must accept the 
possibility that the results can be explained by chance or confounding 
factors. Although we detected no evidence of a significant difference 
between the 2 study groups, it is possible that unmeasured confounding 
persisted. In addition, we recognize that the reduction in the price of 
heroin that we observed was probably due to random fluctuation or 
compensatory shipments and was not causally connected to the seizure. With 
regard to the possibility that compensatory shipments explain our findings, 
previous studies have found that heroin seizures tend to correlate with 
times of high production and supply of drugs., We do not believe that 
interview bias played a role because the interviews were not conducted to 
assess the effect of the seizure but rather constituted the data instrument 
for an ongoing HIV incidence study; thus the interviewers and participants 
were in effect "blind" to this eventual use of the data. We should also 
note that although 148 (56.7%) of those considered in the present analyses 
were active heroin injectors, only 75 (28.7%) injected heroin daily. 
Nevertheless, the results were unaffected when we restricted the analysis 
to current heroin users (data not shown).

It could be argued that a 30-day period after the seizure was insufficient 
to capture a reduction in supply due to the seizure. To address this 
possibility, we conducted additional analyses and detected no difference 
when we examined data for a full 12 weeks after the seizure. It could also 
be argued that the heroin shipment was never intended for the local market. 
Although the inability to determine with certainty the final destination of 
the heroin is a limitation of the present study, the circumstances of the 
seizure suggest that the heroin was destined for the Vancouver market. 
Specifically, the seizure was the result of a 20-month investigation by the 
Vancouver Royal Canadian Mounted Police Asian Organized Crime Unit, which 
led to the arrest of several Vancouver men. During the investigation, 
information was acquired that led officials to conclude that the heroin was 
destined for the local market.,, Nevertheless, had the heroin been destined 
for shipment away from the market created by the area's estimated 5000 to 
10 000 injection drug users, this would suggest that the local market was 
already saturated., Finally, it could be argued that the seizure led 
suppliers to reduce the purity of the heroin they sold so as to maintain 
the quantity of drug available. However, participants reported no 
difference in their source of drugs or the type of drugs available, and we 
found no decreases in overdoses or heroin use, nor any change in methadone 
use when the 12-week post-seizure period was examined (). All of these 
variables have previously been associated with fluctuations in the purity 
of street-level heroin.,,

Externally compiled data appear to support our findings. Specifically, 
there were 10 fatal overdose deaths in the month before the seizure, 
whereas there was an average of 13.3 overdose deaths per month during the 3 
months after the seizure (monthly illicit drug overdose statistics for 
2000; BC Coroner Service, unpublished data). In addition, data from Health 
Canada's Drug Analysis Services, a group that often tests the purity of 
heroin samples provided by police, showed no decrease in the purity of 
heroin samples tested during the 3-month periods before and after the 
seizure (Health Canada, Drug Analysis Services, Burnaby, BC, unpublished data).

Analyses conducted by the United Nations Office for Drug Control and Crime 
Prevention suggest that a maximum of 5% of the global illegal drug flow is 
seized by law enforcement agencies. For this reason, despite the 
expenditure of tens of billions of dollars annually on drug interdiction 
efforts in North America, heroin purity has increased and prices have 
markedly decreased since the late 1980s., In turn, high HIV incidence rates 
have persisted, and overdose is among the leading cause of death in many 
large Canadian and US cities.,,, In Baltimore, for example, overdose deaths 
increased by more than 425% between 1990 and 1997.

In the present study we observed no beneficial public health effects of 
Canada's largest-ever heroin seizure. In our view, the most plausible 
explanation is that the seizure had no significant effect on the supply of 
heroin in this locality. This conclusion is supported by a recent report by 
the World Customs Organization, which found that even post-September 11 
security measures have had a "negligible" impact on the influx of illicit 
drugs into the US. Given the size of the seizure relative to other large 
heroin seizures,, our findings raise serious questions about the potential 
for Canada's present drug policies to adequately control the drug use 
epidemic through supply-side interventions. It is critical to emphasize our 
view that fault does not lie with the front-line law enforcement officers 
who are involved in supply-side strategies at the operational level. 
Rather, the responsibility lies with the politicians and policy-makers who 
continue to direct the overwhelming majority of resources into failing 
supply-reduction strategies, despite the wealth of scientific evidence 
demonstrating their ineffectiveness.,,, Our findings support the strong 
consensus that curbing the HIV and overdose epidemics will require a shift 
in emphasis toward alternative strategies based on prevention, treatment 
and harm reduction, even if this shift necessitates a diversion of 
resources away from criminal justice interventions.,,,,,

Footnotes

This article has been peer reviewed.

Contributors: Evan Wood and Martin Schechter designed the study and 
prepared the first draft of the manuscript. All authors played central 
roles in the conception of the study and the interpretation of the data and 
contributed to various drafts of the manuscript.

Acknowledgements: Evan Wood is supported by the Canadian Institutes for 
Health Research and the BC Health Research Foundation. Martin Schechter 
holds a tier I Canada Research Chair in HIV/AIDS and Urban Population 
Health. The study was supported by the US National Institutes of Health 
(grant RO1 DA11591).

We thank Bonnie Devlin, Caitlin Johnston, Robin Brooks, Suzy Coulter, Steve 
Kain, Guillermo Fernandez, John Charette, Will Small, Peter Vann, Thomas 
Kerr and Nancy Laliberte for their research and administrative assistance, 
and all the participants in the VIDUS study.

Competing interests: None declared.

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