decriminalization of drugs canada essay

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Urgent and long overdue: legal reform and drug decriminalization in Canada

Information & authors, metrics & citations, view options, introduction: employing a human rights approach, the impact of covid-19, covid-19: the impact of the pandemic on pwud and harm reduction efforts, roadmap of the report, 1. the legal context of criminal law, 1.1. a brief history of canada's drug laws.

“The approach set out in this guideline directs prosecutors to focus upon the most serious cases raising public safety concerns for prosecution and to otherwise pursue suitable alternative measures and diversion from the criminal justice system for simple possession cases”.

1.2. The purposes of the criminal law

[The] criminal law should be employed to deal only with that conduct for which other means of social control are inadequate or inappropriate, and in a manner which interferes with individual rights and freedoms only to the extent necessarily for the attainment of its purpose.

As the most serious form of social intervention with individual freedoms, the criminal law is to be invoked only where necessary, when the use of other means is clearly inadequate or would depreciate the seriousness of the conduct in question. As well, the Principle suggests that, even after the initial decision has been made to invoke the criminal law, the nature or extent of the response of the criminal justice system should be governed by considerations of economy, necessity and restraint, consonant of course with the need to maintain social order and protect the public.

In the boundary between criminal law and private morality, various concerns have been expressed about either decriminalizing or diverting from criminal prosecution many acts widely considered crimes of “going to Hell in one's own fashion”, such as drug and gambling offences. Some of these offences are considered too minor to be treated with a heavy hand of the criminal law; others are thought to be more effectively dealt with through public education or regulation.

When we take drugs we do so to alter ordinary waking consciousness. The criminal control of a citizen's desire to alter consciousness is unnecessary. We have other at least equally useful and less punitive methods available for control: taxation, prescription, and prohibition of public consumption. But most important, we should confront our own hypocrisy. We can no longer afford the illusion that the alcohol drinkers and tobacco smokers of Canada are engaging in methods of consciousness alteration that are more safe or socially desirable than the sniffing of cocaine, the smoking or drinking of opiates, or the smoking of marijuana.

The answer is not to usher in a new wave of prohibitionist sentiment against all drugs, nor is the answer to allow the free-market promotion of any psychoactive. The middle ground is carefully regulated access to drugs by consenting adults, with no advertising, fully informed consumers, and taxation based on the extent and harm produced by use. There is a need for tolerance, for both tobacco and heroin addicts. And there is a need for control of the settings and social circumstances of drug use. There are no good, or bad, drugs, though some are more toxic, some are more likely to produce dependence, and some are very difficult to use without significant risks…. The task is to dismantle the costly and violent criminal apparatus that we have built around drug use and distribution, mindful that our overriding concern should be public health, not the self-interested morality of Western industrial culture.

1.3. Alternatives to criminalization

To promote alternatives to conviction and punishment in appropriate cases, including the decriminalization of drug possession for personal use, and to promote the principle of proportionality, to address prison overcrowding and overincarceration by people accused of drug crimes, to support implementation of effective criminal justice responses that ensure legal guarantees and due process safeguards pertaining to criminal justice proceedings and ensure timely access to legal aid and the right to a fair trial, and to support practical measures to prohibit arbitrary arrest and detention and torture.

Review and repeal punitive laws that have been proven to have negative health outcomes and that counter established public health evidence. These include laws that criminalize or otherwise prohibit gender expression, same sex conduct, adultery, and other sexual behaviours between consenting adults; adult consensual sex work; drug use or possession of drugs for personal use; sexual and reproductive health care services, including information; and overly broad criminalization of HIV non-disclosure, exposure, or transmission.

Under international law, Canada has both important latitude under the drug control conventions, and important obligations under human rights treaties it has ratified. It can and should use that latitude in the realm of drug control to better respect, protect and fulfil the human rights it has pledged to uphold, and which are also embodied to various degrees in its own constitution.

2. Forms of decriminalization

2.1. distinction between de jure (in law) and de facto (in practice), 2.2. national de jure decriminalization, 2.2.1. portugal, 2.2.2. spain, 2.3. national de facto approaches, 2.3.1. switzerland, 2.3.2. the netherlands, 3. law reform proposals in canada, 3.1. decriminalization efforts in canada, 3.2. law reform proposals, 3.2.1. city of vancouver: the vancouver model, 3.2.2. province of british columbia, 3.2.3. federal law reform proposals, 3.2.4. expert reports and recommendations, 4. constitutional considerations, 4.1. section 7 of the charter : the right to life, liberty, and security of the person, 4.1.1. criminalization and the right to liberty, 4.1.2. criminalization and the right to life and to the security of the person.

… hospitals dispense opioids every day to relieve pain. These drugs are not killing people because the quality of the supply is regulated, the dosages are managed, ingestion is overseen and, should a problem arise, there are trained people on hand who can intervene and who are not made afraid by the spectre of criminalization and stigma. Proponents of harm reduction argue that context matters and shunting drug consumption out of sight while criminalizing and stigmatizing it does the opposite of keeping people safe.

4.1.3. Criminalizing possession for personal use: the principles of fundamental justice

4.2. criminalizing possession: discrimination, 4.2.1. section 4(1) of the cdsa.

There is now copious evidence of the harms of criminalizing simple possession particularly to vulnerable people. Since criminalization of drug possession directly leads to both individual and systemic stigma, it supports discrimination against people who use drugs and prevents people from seeking services. It also undermines the development of health services because needed resources are diverted to the criminal justice system (including correctional facilities) and because people with problematic drug use, when regarded as criminals, are not seen as deserving of services.

4.3. Section 1 of the Charter

The current prohibitionist approach to drug policy has failed to achieve its stated ends: to prevent the growth of illegal drug markets, to curtail use of illegal substances, and to prevent harms associated with the use of these substances. Instead, harms have been magnified through the creation, in reaction to interdiction, of a highly toxic illegal drug supply, and the criminalization, stigmatization, and marginalization of individuals – many of whom have opioid use disorder, a known chronic, relapsing health condition. In addition, massive profits have been generated for violent criminal enterprises involved in the illegal drug market.

5. Ending the harms associated with criminalization

5.1. stigma, 5.2. drug toxicity, 5.3. barriers to harm reduction, 5.4. health and social inequities, 5.5. harms associated with incarceration, 6. decriminalizing to reduce harms, 6.1. recommendations for law reform, 6.1.1. procedural recommendations, 6.1.2. recommended pillars of a canadian decriminalization model, pillar #1: consistent application of uniform requirements across the country, pillar #2: reducing opportunities for discretionary decision-making by police and prosecutors, pillar #3: determining thresholds: setting realistic regulatory policy, pillar #4: addressing “splitting and sharing”, pillar #5: retroactive expungement of criminal records, 6.1.3. implementing a canadian decriminalization model: a staged approach, stage one: immediate policy changes, stage two: regulatory amendments, stage three: introducing a new comprehensive legislative framework, 7. conclusion, legislation a, information, published in.

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• drug policy
• harm reduction
• criminal law
• Integrative Sciences
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Decriminalizing drug use is a necessary step, but it won’t end the opioid overdose crisis

Assistant Professor in the School of Criminology, Simon Fraser University

Disclosure statement

Alissa Greer receives funding from Simon Fraser University and the Social Sciences and Humanities Research Council. Dr. Greer is an assistant professor in the School of Criminology at Simon Fraser University, a research affiliate at the Canadian Institute for Substance Use Research, and a senior associate at Bunyaad Public Affairs.

Simon Fraser University provides funding as a member of The Conversation CA.

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Media, policy-makers, advocates and the public claim that decriminalization will make drug use safer and save lives . But can it?

Decriminalization has been somewhat of a policy buzzword in recent years, with ample media coverage . It comes with both public and government support.

A 2020 survey of more than 5,000 Canadians showed that the majority (59 per cent) favour the decriminalization of drugs . The Canadian Association of Chiefs of Police has also publicly supported decriminalization, along with British Columbia’s chief public health officer .

Such support has also come with action. This year, the City of Vancouver submitted an application to Health Canada for an exemption from Canada’s Controlled Drugs and Substances Act — a policy reform referred to as the Vancouver Model of decriminalization .

An alternative response

In the simplest terms, decriminalization is an alternative response to criminal penalties for simple possession. The most recent data shows there were over 48,000 drug-related offences in Canada in 2019, most of which were for possession for personal use.

The criminalization of drugs results in significant health, social and economic harms , particularly to those who are homeless, experiencing mental health issues, racialized or Indigenous. By eliminating a criminalized response to drug possession, drug policy reform efforts can minimize the contact between people who use drugs and the criminal justice system, and may increase their connection to health and social systems .

However, alongside recognition of the ineffectiveness of criminalization and support for an alternative model, we need to be realistic with our expectations of what decriminalization can do.

Decriminalization versus regulation

Decriminalization does not mean that people can buy cocaine and heroin at the store as they would alcohol and tobacco. Only legal regulation can do that. Legal regulation, which drug policy advocates endorse , includes rules to control who can access what drug and when, as opposed to a free market or full legalization.

An example of legalization is Canada’s Cannabis Act , which provides a legal framework to control the production, sale and possession of cannabis.

Unlike legal frameworks applied to the supply of drugs, decriminalization does not promote a “safer supply” of drugs. The overdose crisis is driven by an unpredictable, illegal drug supply that is marked with adulterants, contaminants and other substances . Decriminalization won’t directly impact this supply of drugs, they will continue to be made in unregulated ways and places.

The illegal drug market will continue to be criminalized, unpredictable and precarious, and people will continue to be unsure of what’s in their drugs (in lieu of better drug checking services or how potent they are. Under a decriminalized model, the overdose risk will inevitably remain high.

That said, decriminalization is still a necessary step in addressing the crisis.

The benefits of decriminalization

Decriminalization changes the way we think about drugs. Drug use will no longer be treated as a criminal issue, but instead a health and social one . This means that instead of addressing drugs through handcuffs, the focus will be on the root causes of drug use, including inequities rooted in housing and health care.

Decriminalization saves governments money. A large proportion of the justice system — police, courts, prisons — are occupied with drug-related crimes . As seen in other decriminalized jurisdictions such as Portugal , it can reduce the demands and costs to this system.

Considering the demonstrated need for addiction and mental health resources, the money saved could be well spent elsewhere, such as community-led responses, health care, housing and social programs.

Decriminalization positively impacts people’s lives. Especially for those targeted by drug law enforcement, namely poor, homeless and racialized people who use drugs, decriminalization can have a positive impact .

For example, eliminating criminal records related to drug possession offences promotes opportunities for people to access employment and housing. Interactions between people who use drugs and police can also be reduced or, better yet, won’t happen at all.

Decriminalization reduces stigma. Negative views towards drugs and people who use them is a major factor in the overdose crisis . By reshaping the way our family, friends and the medical profession think about drugs, drug use can be talked about more openly and honestly.

Reducing stigma can also encourage people who use drugs to talk to their doctors about prescription-based therapies. At the very least, it will help bring drug use out from isolation, where fatal overdoses tend to be the highest .

Decriminalization encourages people to call 911 at the scene of an overdose. Fear of police is currently a barrier to this. Although people cannot be charged with simple possession at the scene of a drug overdose under drug-related Good Samaritan laws , fear of the police is still a deterrent . Legislation that decriminalizes drug possession can reassure people that they will not face criminal penalties. And police will no longer need to respond to calls about overdoses.

Decriminalization is harm reduction. Although some people fear that decriminalization may increase or encourage drug use, this concern is simply not supported by evidence. We know from dozens of countries, states and cities that have decriminalized drugs that use does not significantly increase . In some places, it has actually decreased .

Decriminalization also lowers overdose and disease rates, while increasing people’s access to social services and health care. In this way, a decriminalization model is a basic harm reduction approach, mitigating the harms experienced by people who use drugs by eliminating or minimizing the source of those harms: criminalization.

A critical step

Overall, the notion of decriminalization is not a panacea or a standalone solution to the harms of drug prohibition — but it is a critical step in the right direction. It will have a positive impact on the lives of so many people who are harmed daily from criminalization.

However, in recognizing the limitations of decriminalization models , governments and other stakeholders can refocus efforts on what does directly impact the overdose crisis: a safer supply. Decriminalization must be paired with greater access to safer pharmaceutical alternatives to the toxic and illegal drug market.

That’s what will save lives.

Caitlin Shane, staff lawyer at Pivot Legal Society, co-authored this article.

• Harm reduction
• Opioid crisis
• Health Canada
• Illegal drugs
• Decriminalization

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The rise and fall of drug decriminalization in the Pacific Northwest

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Keith humphreys and keith humphreys esther ting memorial professor and professor of psychiatry - stanford university vanda felbab-brown vanda felbab-brown director - initiative on nonstate armed actors , co-director - africa security initiative , senior fellow - foreign policy , strobe talbott center for security, strategy, and technology.

September 17, 2024

• Drug decriminalization policies in San Francisco, Oregon, and British Columbia reduced drugs arrests, but spurred public concerns about safety.  
• Different cultural and social contexts shape the designs and outcomes of decriminalization policies.
• Effective drug policy requires a balanced approach, avoiding extremes between harsh criminalization and complete decriminalization.  
• 34 min read

The promise was that harm reduction would at least reduce the harm, but in places like British Columbia, overdoses kept going up. Keith Humphrey's

In this episode, host Vanda Felbab-Brown interviews Stanford professor Keith Humphreys about drug decriminalization in San Francisco, Oregon, and British Columbia. They discuss the origins and motivations for the dramatic policy change in 2020; the design of the policies, including the similarities with and differences from the decriminalization policies in Portugal; and the outcomes in the Northwest, including in terms of drug use, dealing, arrests, and property crime. Humphreys also explains what caused backlash against such policies and, ultimately, policy reversals. Humphreys emphasizes balanced policies, strong community engagement, and evidence-based public health service provision as the way forward.

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FELBAB-BROWN: I am Vanda Felbab-Brown, a senior fellow at the Brookings Institution, and this is The Killing Drugs . With more than 100,000 Americans dying of drug overdoses each year, the fentanyl crisis in North America, already the most lethal drug epidemic ever in human history, remains one of the most significant and critical challenges we face as a nation. In this podcast and its related project, I am collaborating with leading experts on this devastating public health and national security crisis to find policies that can save lives in the United States and around the world.

On today’s episode, I am exploring the criminalization experiences and challenges in San Francisco, Oregon, and British Columbia. My guest is Doctor Keith Humphreys, who is the Esther Ting Memorial Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University. He’s also a senior research scientist at the Veterans Affairs Health Services Research Center in Palo Alto, and an honorary professor of psychiatry at the Institute of Psychiatry, King’s College London. He served on the White House Commission on Drug-Free Communities during the Bush Administration, and as a senior policy adviser in the White House Office of National Drug Control Policy under President Obama. His project paper is titled “The Rise and Fall of Pacific Northwest Drug Policy Reform 2020–2024.”

Keith, thank you for joining me.

HUMPHREYS: Thanks so much for having me, Vanda. I am always delighted to have a chance to talk to you.

FELBAB-BROWN: Well, thanks very much. It’s been terrific collaborating with you over many years. And in this current series, we are delving into the criminalization. And over the past several years, the criminalization has been very significant policy experimentation in the U.S. and Canadian Northwest. At the city level in San Francisco, California, in Vancouver, British Columbia, and at the whole state level in Oregon and Washington. What has that experimentation been about?

HUMPHREYS: It’s been remarkably broad. It certainly involves drug use, but it’s gone well beyond that. And essentially it starts in 2020 just north of me—I live a little bit south of San Francisco—and running up into British Columbia there was a lot of defunding of policing, generally, and sometimes that was cuts, and that was just holding the budget flat.

There was also a pullback of the role police used to have with regulating public space. So, you know, we share a lot of space with each other. We are usually able to sort that out. But in this era, the public’s view much more was that let’s get the police out of that and just kind of let, let people sort it themselves.

And that included people who were using drugs or people who were dealing drugs. That changed the character of these places all up and down the coast and had a whole range of effects, which we try to go into, as you know, in the paper. But what’s been striking to me is how fast it came in and how fast it went straight back out again. So, it’s been extremely dynamic period in drug and crime policy in the Pacific Northwest.

FELBAB-BROWN: Well, and we’ll talk about the significant changes and fluctuations in policy in greater detail on the show. But let me just reiterate the core point that you made. So, the experimentation was about not imprisoning, not penalizing people for using drugs, but also for dealing drugs in local retail markets. And you mentioned that this was part of a broader pullback of police from enforcing various elements of public safety. Did I get it right?

HUMPHREYS: Yes. Yeah, yeah. That’s correct.

FELBAB-BROWN: And so, how did the opioid fentanyl epidemic feed into this? Did it bring about this decriminalization?

HUMPHREYS: We are dealing, as you said with the worst overdose levels we’ve ever seen in the history of the country. Dwarfs things … I I  … when I think early in my career, I thought how bad HIV/AIDS was, that we would never see an epidemic that took that many young lives. And this is this is, in fact, substantially worse than that.

FELBAB-BROWN: It’s worse than the HIV/AIDS epidemic in the 1980s?

HUMPHREYS: Absolutely. Yeah. The rate of acute deaths now from from overdoses is at a half again as high as the very worst year of HIV/AIDS. And again, in both cases, young people.

So, that that has understandably caused many people, including myself, you know, sadness, grief, frustration, despair. And in that environment, you know, more radical solutions often are brought forward because they have to be because, you know, we’re we’re clear that things are not working the way they are.

The second thing is that in all of these places there were very extensive harm reduction policies in place. So, things like needle exchange and naloxone distribution. And the promise for years had been that if we do that, the promise from people who advocate those approaches, maybe we’ll have more drug use, but at least we won’t have so much harm. And here we have these places, particularly British Columbia, which have more harm reduction than any places in the world, and overdoses were going up and up and up.

So, that also fueled a sense of desperation. Let’s try something really different, which was to change the law in terms of how the criminal justice system responded or didn’t respond to people were using drugs in private or in public, and to some extent also how we respond to people who were dealing drugs.

FELBAB-BROWN: And some people are suggesting that the reason why we have so much more focus on harm reduction and even going to decriminalization in the way you have been describing is because the fentanyl opioid epidemic has affected as much white people as minorities. What’s your take on that?

HUMPHREYS: Well, race shapes most areas of social policy in the United States, it just does, whether we like it or not. That’s the way it is. I think it’s definitely the case that even before fentanyl, you could see there was a more, globally speaking, compassionate response to people who were addicted to opioids, like when people started getting addicted in large numbers to prescription opioids in the ‘90s and and the 2000s, both the social reactions, but also like, you know, the news coverage was far less look at this malignant person destroying society and it was much more look at this poor suburban mom who had a bad back and is now addicted to OxyContin.

And part of that is clearly about race. Part of it’s clearly about social class. You know, methamphetamine, which was in the ‘90s, was mostly white people, but they were poor people, and who were treated less sympathetically.

So, I think those things are in the soup. But that’s, that’s actually proceeded fentanyl that, that really, I think is something we’ve seen in the last 20 years.

FELBAB-BROWN: And we speak about methamphetamine on the first episode with Professor Reuter and Professor Midgette, and the super potent meth as well in the mix of dealing with opioids and with fentanyl.

Let’s delve into the specifics of the policies in San Francisco, Oregon, Washington, Vancouver. So, broadly speaking in this Pacific Northwest spanning the two countries, there is decriminalization. But were the policy designs the same, were they different?

HUMPHREYS: Yeah, there were some very important differences. Probably the most similar policies were British Columbia and Oregon, both of which instituted—at the provincial level for British Columbia, state level for Oregon—complete decriminalization of use in, in private and critically in, in public as well, which ended up having a significant effect on how these policies were perceived.

What San Francisco did is it’s a city, so it didn’t really change the law, but just in terms of priorities, it went all in essentially on the harm reduction proposed in terms of spending very little on prevention, a small amount of treatment, but not not a lot. And the police basically pulled back pretty substantially. So, there are enormous open-air markets in San Francisco, like in the Tenderloin, where I is a neighborhood where I volunteer, I walk by, you know, scads of fentanyl dealers everywhere I go who operate with with complete impunity by that being the de facto policy.

And at night there’s there’s literally hundreds of dealers out there, as well as an enormous market of stolen goods, which is part of the surround of these drug scenes as people, you know, mass shoplifting, selling goods, buying drugs and so on like that.

FELBAB-BROWN: And they’re stealing goods in order to pay for the fentanyl they crave?

HUMPHREYS: Correct. Yeah, yeah. And me, and it’s something important to mention. Relative to, you know, heroin when I started my career, somebody who might come into the hospital for treatment to heroin might be using once or twice a day, they might even have a job that can have that much stability. But fentanyl is much more fast acting, and people might be using it 4 or 5, 10, you know, 20 times a day. And so, it’s a much more consuming, no pun intended, consuming activity. But also, you have the constant need for more money to buy the next, next hit of drugs. And that that’s fueled a lot, a lot of this sort of property crime we see connected around fentanyl.

What happened in Washington was unusual, which was it was a court decision that the state’s law on drug possession was in conflict with the Constitution. So, sort of an unusual moment where they just did something that no, no place on Earth has done, courts just said there is no consequences at all. And then the legislature’s like, oh, gosh, now we have no drug laws. And they had a very interesting debate over the next three months. And should we just keep it this way or should we, you know, change things?

And they had previously had felonies as, for possession, which is pretty serious. You could get sent to prison for a felony. And they instead converted it to a very low-level misdemeanor with lots of rules that you had to give treatment options multiple times. The police had to prove that they had done that. So, that’s how it came about really differently. Whereas for example, in Oregon it came out through a popular vote, through an initiative. This was driven in Washington by a court case.

These places also differed in how much services they provided. British Columbia, as I mentioned, it already had a lot of harm reduction services, probably as much as anywhere in the country. San Francisco had a lot of services. Oregon really had very poor services, and that’s part of the story. They have the worst access to care, you know, in the U.S., very little of, you know, a little treatment, a little harm reduction, but not that much, which helped account for why their experiment turned out to be an unhappy one, as I think everybody knows at this point.

FELBAB-BROWN: Yeah. I mean, what is coming across in what you’re explaining to us is a theme that has run across several of the episodes, that the Devil and Angel really are in the details of policy design, but also in the context. And exactly the same designs might have very different outcomes if the cultural or social political context, structural context is different. And in this case also how the changes to laws, how the changes to policies came about, such as through ballot or through a court case.

So, you know, before we speak about the problems, please tell us what have been the successes, the accomplishments of the decriminalization policies.

HUMPHREYS: So, you know, when you look at what is, you know, achievements or failures of policy, that’s often in the eye of the beholder. So, the very same outcome might be viewed quite differently. And, you know, a good example of this is so in San Francisco there was a one of the big contractors was funded to create a linkage center, which was sold to the public as this will link people to services like housing, like addiction treatments, like, you know, food banks, and things like that. And the provider just decided on their own initiative that, no, it’s going to be a lounge where people can smoke fentanyl without any penalty. And at the end of that, it turned out that they had linked hardly anybody to addiction treatment at all, but nobody had died from using fentanyl like you’d expect in supervised drug consumption sites.

So, some people would say, well, that was an accomplishment, you know, because they wanted safe consumption sites, and this was clearly one that had succeeded. And other people said, that’s a failure because you were supposed to link people to treatment and you didn’t.

So, all these things are, you know, they’re consequences of policy, but people vary in how they think. And the biggest one, I think is how this sort of arrest environment. So, in places like Oregon, there were dramatic reductions in the number of people who were arrested for using drugs and the number of people who were arrested for dealing drugs. Now, if you have a, you know, a libertarian conception that these are rights that should not be abridged by the state, this is a very good outcome. You know, there was really no better place to use drugs or deal drugs then than than Oregon. On the other hand, of course, some people feel like having those things uncontrolled is bad, so they would view that as a failure. But anyway, that was clearly a consequence as was envisioned in the law. We’re not going to do, that sort of thing.

Property crime and violence went up in Washington and Oregon and San Francisco through this period while dropping in the rest of the country. And I think almost everyone would think that is a bad outcome. You know, people might say we’d like fewer drug arrests, but we don’t like the the violence and and the crime.

In, in terms of some of the mechanics of the policy, there were certainly significant failures just in implementation. So, Oregon had the idea that if you give people a ticket or a fine for up to $100 for say, using fentanyl on a, you know, in a public park, and then but the ticket said, you know, but if you call a, a toll-free hotline, you take a health assessment we’ll waive that fine. And they thought lots of people would then, oh, that they’ll do that and they’ll get in treatment. Well, it turned out over 90 percent of people just threw the ticket away.

And so, that was just clearly like a design failure that did not work. It misunderstood the nature of addiction in thinking that people with such a small incentive would lead people to seek help who had already given up much more profound things in order to use fentanyl.

They had terrible problems, too, just rolling out the money. So, the the measure in Oregon did provide more money for services which were really needed. But rather than work with the addiction, the existing treatment system, the designers essentially tried to set up a new system. This is sort of reflecting the distrust of traditional treatment that was common in this era. And with new people, new faces, and all that reallocated, well, you know, you know, 16 months after it was passed, they hadn’t given out a dollar yet. And so, that was clearly an implementation failure.

The last thing is that one of the key promises was that overdoses would drop. And all of this whole region is experiencing record overdoses that they’ve never seen before. San Francisco, Oregon, Washington, British Columbia. Now, it’s certainly true that part of this has to do with the spread of fentanyl to the West. You know, there, you know, you know, Central California has, you know, their overdose deaths are up by 5%. But but not the sort of 40% increases we saw in places like Oregon and Washington, not the historic levels that you see in British Columbia, which has had fentanyl for a very long time.

So, there’s certainly other factors could matter. It’s also a pandemic obviously, and another thing that would have mattered. It was really hard to sustain in the face of such. Incredible increase in overdoses that these policies were reducing overdose. And in fact, it’s interesting a lot of the advocates just shifted to arguing, well, maybe it hasn’t made things worse, but people didn’t vote for these policies on the theory that maybe they won’t make things worse. They really voted for them in the idea that they would save lives, which they did not do.

FELBAB-BROWN: And that’s even before xylazine has spread to the West. Xylazine, of course, is complicating the most important element of harm reduction right now, which is access to naloxone and the reversal of lethal overdose. And we haven’t seen xylazine yet spread beyond the East Coast and hit the West, hit the Pacific region.

Now, there is another example of decriminalization, and that’s Portugal. About a decade and a half ago, Portugal became the pioneer of decriminalization policies. And the country that implemented harm reduction approaches on a nationwide level. And for several years, Portugal registered significant successes. And many of the jurisdictions that you were speaking about would say that they learned from Portugal. Did they in fact learn? And why were the outcomes in Portugal better than in Oregon, Washington, and San Francisco?

HUMPHREYS: So, you’re right. Portugal is cited as, has been cited for years now in American drug policy, as you know, the example, which is interesting because it’s—I love Portugal, wonderful country—but you never hear it mentioned in any other policy sphere other than this one in the U.S. Portugal, when they removed decriminalization, first off, they never really had much criminalization to begin with. So, it was not a huge shift on the policing side, but it was a huge shift on a health side. So, they had quite extensive services for people—addiction treatment, HIV care, harm reduction services. And let’s not forget that Portugal guarantees the right to health care for all citizens and the United States does not. So, that that is a big difference.

Second thing is Portugal has a different type of drug problem than us. You know, when you see synthetics like nitazenes and fentanyls are now appearing in a couple of European, you know, sites, nothing like what you see in the U.S. and Canada though. So, that was different.

FELBAB-BROWN: So, drugs with much less risk of immediate lethal overdose.

HUMPHREYS: Yeah. So, the modal, you know, opioid users coming into contact with, you know, authorities in Portugal is going to be using, you know, heroin or perhaps a diverted prescription opioid, not a fentanyl or a nitazene, for now at least, I mean maybe the future could be different.

Third thing is the Portuguese had a mechanism which was explicitly rejected by the advocates in the U.S., which is that dissuasion commissions. So, if you are out on the streets using drugs, the police in Portugal can arrest you and say you have to go to a dissuasion commission, which is not a punitive process, but it is a certainly a pretty strong nudge process where you get an assessment from people who are expert in this area and they could say, you know, well, this time we’re going to let it go. We don’t think you have a bad problem. But they can also say, we really think you need to go to treatment. And by the way, you’re a cab driver and we’re not going to let you keep driving your cab until you do.

And it’s it’s a compassionate process, but it is definitely also a pushing process, you know, pushing people towards changing their behavior. And particularly, it was much more libertarian flavored movement in the U.S. and their view was, you know, any kind of pushing is wrong. So that’s, you know, they took it, they took that out. And that may have been a mistake.

FELBAB-BROWN: I just to a little bit elaborate on the pushing element in the Portuguese case. So, people who would be arrested for drug use on the street would be sent to the commission. First of all, what would happen if the person did not show up at the commission? And second, I just want to hit what you are saying, namely that, although people would not be sent to prison, presumably, they could face other penalties like losing public licenses, such as to operate a taxi.

HUMPHREYS: Yeah. That’s right. Yeah, you don’t have any choice but to show up to the commission. It doesn’t mean that anything bad will happen to you if you do. That in fact, the majority of cases, they say, well, you know, you were caught using these drugs. We don’t think you have a problem. You should go and sin no more kind of thing. But you you would can endure a punishment for not showing up. They try very hard not to use carceral penalties. But as you say, they do have these other powers like to fine or place restrictions on people where they can go or what they can do.

So, it is not a free for all, which is a lot of people imagine Portugal is. And it’s interesting when my colleagues who helped design that system have seen cities like San Francisco and Vancouver and Portland, they have been shocked and disgusted at the open drug scene and our tolerance of it. That is not what Lisbon looks like.

And, you know, and that that has been sort of sold to out here, yeah, that’s in Portugal it’s that way. And everyone’s just really comfortable with it. It’s like, no, that’s, that’s absolutely not the way it is. They would intervene in that situation both with the state but also through social networks, which is the other point that’s important to mention is this Portugal has a very different culture than the western coast in North America. It is a country that was a dictatorship in living memory. It is heavily Catholic inflected in its values. It is communitarian. Families are strong. People live in multi-generational neighborhoods where their family has been around for decades. And there’s a lot of love and connection that comes with that. There’s absolutely also some constraint that comes with that.

And this is the opposite of what you see out here. People come to San Francisco or come to the West or come to Portland to get away from all that. There’s plenty of people, like, I didn’t want to live in a small town in Iowa where everyone’s watching what I’m doing. I wanted to be me. I wanted to be a punk musician, I wanted to be an entrepreneur, or, you know, I wanted to express myself.

And so, that’s the culture of the West, which in many ways is magnificent. I mean, that’s why we have Silicon Valley, and we have such arts and music, and we have, you know, gay and lesbian rights, and all those, really things to be cherished.

But it doesn’t work the same way for drugs. When you sort of, you know, and we do have a very powerful drug culture. San Francisco, for example, is one of the heaviest drinking cities in the country. It is the heart of cannabis culture, psychedelic culture. Oregon has a lot of this, too. Seattle as well. Because people aren’t necessarily pursuing their individual good and living their own way, that’s the nature of addiction is people’s ability to make those decisions is not as good. People lose control and people start experiencing harm. And therefore, that ethic of kind of be who you are doesn’t have the same consequences.

And, you know, when you take the law away, which all these places did, the only thing left in societies is the culture. In Portugal, that culture happens to be kind of strong, constraining, and out in the West it isn’t. So, there was really the law was only thing between, you know, left. And when that left, we got what we got, which was an awful lot of drug use and an awful lot of consequences for individuals and for the neighborhoods they lived in.

FELBAB-BROWN: Yeah, and on the episode with Professor Jonathan Caulkins, we were talking about the balance between individual rights and community interests and the complexities and how different times, different societies, different cultures make those judgments. And similarly, on the episode with Professor Harold Pollack and Professor Nicole Gastala, we heard about the important role of communities in helping to reduce demand and encouraging people to access treatment, and the absence of communities having significant effects on the policy effectiveness, a theme that will also come up in our conversation with Philomena Kebec on Native American communities and fentanyl.

So, you know, we talked about some of the accomplishments, we talked about the challenges in the northwest. And you have already mentioned that publics in Oregon, in Washington, in San Francisco soured on many of these policies. When that happened, how have policies changed as well?

HUMPHREYS: We have to put ourselves in the mindset of where people were, you know, when all of this started. So, George Floyd was murdered by police officers, the whole world was appalled, appropriately appalled. And people in the Northwest were particularly so. Some of the most largest, most passionate, and most enduring protests were in that region. So, a huge number of people were sympathetic to the idea of, you know, pulling back on policing of all sorts. Said that would create a better and more just society.

Unfortunately, though, that reality, you know, a year later, two years later, was that they saw there was some cost to that. And this was going to be more, more complicated in, in terms of things like the quality of neighborhoods. And that’s something it’s a very hard thing to quantitatively assess. But I just say as someone who spends a lot of time in San Francisco, I go up to Oregon a lot—we have a lot of research partners up there—I’ve been to Washington, I’ve been to British Columbia, just what it’s like to walk down a street really changed dramatically. You have to remember also there was a pandemic on.

But you think, like, what is it like to be, let’s say, a woman in San Francisco who’s walking to her law firm with a huge number of workers, and there’s three or four men who are using drugs on the side of the sidewalk, and there’s a police officer standing around somewhere. That may just be disturbing, but you don’t feel fearful. Then you have that same situation again where the pandemic has cleared things out. That woman is walking alone. Those three men are there and there’s no policeman anywhere in sight. And you’re kind of in a Wild West situation. Now, there’s no more people using drugs on the streets as before, but something that previously felt sad but not frightening starts to feel frightening.

And as other consequences of things are just like, you know, retail theft, housebreaking, vandalism, sort of neighborhoods decaying, get worse and worse. And again, at the time people have said, we don’t want police to do stuff. You know, when when your car’s broken into the tenth time, when, you know, someone has been assaulted, when, when these problems start to spread to bigger and bigger regions, where you see pictures on TV of children having to be literally shepherd by their parents past sometimes, you know, just blocks of people unconscious from drugs, dealing drugs, then the reality sets in. Is, okay, we don’t want to go back to a racist, carceral war on drugs. And also, we’re not satisfied with what’s happening. And we were promised a lot of things that aren’t happening. You know, it’s not easier to get treatment. Deaths are not going down. They’re going up. And our neighborhoods are really decaying.

And so, something that happens that seems sometimes you don’t … you wonder if this ever happens in politics and it did here, is a lot of people change their minds. A lot of people were willing at one moment to try something radically different and see what happened. They got the results of their experiment and they shifted. One of the interesting things about that, by the way, is some of the biggest shifts were among people of color. A lot of this was argued in terms of racial justice. But if you look at the polling against Measure 110, the most hostile people wanted to overturn the most were African Americans.

FELBAB-BROWN: And the please explain to us what is Measure 110?

HUMPHREYS: That was Oregon’s … that was the ballot initiative that Oregon passed to decriminalize all these things, which which, by the way, passed easily at first. It was it was popular. I think it got like 58% of the vote. But, you know, two-and-a-half years later in polling, two-thirds of people said they wanted it repealed in part or in whole. And if you asked people who were Black or people who were Latino, it was three-fourths or even four out of five people were saying that.

And and so, that created a shift that was reflected in politics. In, in San Francisco and in Portland, very sort of defund the police, let’s just accept drugs district attorneys were chucked out of office and replaced by people who promised a much more law-and-order kind of approach. Seattle, you know, you know, I think Joe Biden won Seattle in the 2020 election by something like 50 points. Two years later elected a law-and-order district attorney, who pledge to crack down around drugs and around crime. Vancouver had a complete flipover in their mayoral election. The British Columbian premier, you know, backed off on decriminalization and said in response to the public aspect, said it would no longer be allowing that in public.

FELBAB-BROWN: I want to home in a little on British Columbia and Vancouver, because, you know, other than Portugal, it is often the hallmark, the kind of measure the, the yardstick against which to measure the decriminalization, harm reduction. What are the current policies in Vancouver and British Columbia after the political electoral changes and the the reversal in public acceptance of these policies?

HUMPHREYS: British Columbia has a well-developed network of services that are believed to reduce harms anywhere else. By which I mean, you know, certainly needle exchanges, certainly naloxone, also supervised drug consumption facilities, an enormous number of those, a general sort of tolerance of, of use, and strikingly, what they call safe supply. So, they actually are giving out addictive drugs for unsupervised community use, drugs like hydromorphone, in the hopes that that will reduce addiction. That’s by the way quite for further than Portugal ever went.

FELBAB-BROWN: We learned about this in Jonathan Caulkins’ papers. He gets into the pros and cons and promises and challenges of official supply.

HUMPHREYS: Yes, yes. And we’ll see, you know, we’ll see whether or not that, you know, survives or not. You know, I really don’t I don’t know the answer to that.

But it what it was clear that decriminalization was not politically sustainable in public. When enough people, like, they can’t take their kid to the park anymore because there’s too many needles or it’s just they don’t feel safe because there’s a lot of people are intoxicated, a lot of people are dealing drugs, those communities pushed back. Advocates sued them successfully and said, you cannot restrict the public use of drugs. And, that was even though they won the case, then the premier said, you know,  could tell this was a a political nightmare for his party. And so, he himself said, let’s, let’s not do this anymore.

And interestingly, you know, Ontario had applied to copy the same thing, and the national government said no. So, that that seems to reflect a, a change as well. I don’t think, you know, they will go back to I shouldn’t say go back, I don’t think they’re going to adopt a super punitive criminal justice policy because, you know, they never really had one. You know, neither neither by the way did did did Oregon, you know, for for that point.

But they I do think they want to reclaim public space. I think that’s what a lot of this is about. And I don’t think it’s unreasonable for people to want to have some access to public space. I mean, I, I have spent 35 years telling people that people who use drugs matter. When I go to San Francisco or Portland, I usually have to say people who don’t use drugs matter. And there’s nothing wrong with people wanting, you know, like an elderly couple wanting to be able to walk down the street in the early evening and not have to encounter people using drugs, anyone with a gun stuck in their belt, or that type of thing. That’s just something I get. As you know, I’m a middle-class person. Where I live, that should be the right of everybody and should be sustainable. And that’s why I don’t think the public, the public aspects of this around dealing and use are … just are not sustainable.

FELBAB-BROWN: Well certainly reclaiming public spaces, having access to public spaces is so fundamental to the quality of well-being, social organization, economic life—

HUMPHREYS: —and connection. Yeah.

FELBAB-BROWN: Absolutely. Political life and personal life. So, you know, this all then brings us to, in conclusion, to get your reflections on what is the way forward. How do we avoid the trap of the pendulum swinging from highly racist policies that criminalize users and put them in prison for a long time, which we know is deeply ineffective, deeply counterproductive, and embrace what much more empathy-oriented approaches bring, including saving lives and yet avoid the failures and challenges and problems that we have in the Pacific Northwest?

HUMPHREYS: Yeah. So, the way a lot of people think about policy in general is, is an on/off switch. You know, we can only do we have two choices, and often advocates frame things that way to sort of push a radical solution here. You can only have carceral, awful racist war on drugs or a free for all, when the truth is there’s, you know, these are all dials and, you know, we can turn them at different levels.

It’s interesting that these places like San Francisco, Oregon, like British Columbia, like Washington already had their dial turned pretty low on criminal justice, you know, policies. These are by far, you know, the probably the least punitive states. And what they showed is when you turn it down to zero, you get some qualitatively different effects that you may not have expected.

But there’s a lot of the United States that where those dials are turned up pretty high, where they could probably turn them down to where the Pacific Northwest normally functions and be better off. If you went to Mississippi or Alabama, you would still find people being thrown into, you know, a cell for the use of a drug going through withdrawal horribly, perhaps dying from that, or if not getting out without tolerance and then taking their their normal dose of drugs and dying of an overdose, not having the option of treatment, all those sorts of things.

So, I think that’s where the great reform opportunities are for the states, is the places to learn what, you know, what you can do with modest but not completely absent role for law enforcement.

I think another thing we can observe is having services available matters. And this, by the way, you know one of the sad things about Portugal is that the great success, you know, for a number of years, but things are not going as well now. I mean, I think overdoses are up nine years in a row since the financial crisis. They’ve had a great retrenchment of services.

But I think a lesson is that, you know, the decrim not ends up, you know, not in itself, you know, doing much if you don’t have places for people to go where they can get adequate health care. And so, one thing I’m glad about the bill that replaced Measure 110, and this is a synergy between the people who supported it and the people who repealed it, is it does put a lot of money in into the treatment system, recognizing, you know, that these are, you know, fentanyl addiction is really tough and it’s really, really disabling, disturbing, and obviously potentially deadly condition. So, that seems to me to be, you know, something to take away from, from these experiences.

FELBAB-BROWN: And we delve in great detail into treatment in the episode with Professor Harold Pollack and Professor Nicole Gastala. And, you know, the key takeaways for me from our conversation today is that policy should not be thought of as a pendulum, operating only on the extreme sides or, as you phrased it, an on and off switch, with opportunities to fine tune policies existing across the country, in fact, around the world.

And one of the important opportunities that have come out of the Northwest experiment is learning from experimentation. If we don’t allow local experimentation, we don’t allow local policy innovation, we’ll be just perpetually stuck only in one policy.

So, Professor Humphreys, thank you so much for joining me on the show today. Thank you very much for your tremendous contribution in your paper to the project, and the enormous work that you are doing to help people with drug use and their communities and families.

HUMPHREYS: Thank you so much.

FELBAB-BROWN: The Killing Drugs is a production of the Brookings Podcast Network. Many thanks to all my guests for sharing their time and expertise on this podcast and in this project.

Also, thanks to the team at Brookings who makes this podcast possible, including Kuwilileni Hauwanga, supervising producer; Fred Dews, producer; Gastón Reboredo, audio engineer; Daniel Morales, video editor; and Diana Paz Garcia, senior research assistant in the Strobe Talbott Center for Security, Strategy, and Technology; Natalie Britton, director of operations for the Talbott Center; and the promotions teams in the Office of Communications and the Foreign Policy program at Brookings. Katie Merris designed the compelling logo.

You can find episodes of The Killing Drugs wherever you like to get your podcasts and learn more about the show on our website at Brookings dot edu slash Killing Drugs. 

I am Vanda Felbab-Brown. Thank you for listening.

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To fight the opioid crisis, Canada tests decriminalizing possession

Addicts inject themselves in May 2011 at the Insite supervised injection center in Vancouver, Canada. Laurent Vu The/AFP via Getty Images hide caption

Addicts inject themselves in May 2011 at the Insite supervised injection center in Vancouver, Canada.

In a policy shift aimed at reducing deaths from overdoses, Canada is decriminalizing the possession of small amounts of drugs in the western province of British Columbia.

Drug overdose deaths have risen sharply across Canada over the past five years, with opioid-related deaths linked to fentanyl more than doubling.

British Columbia has been the hardest-hit province— it declared fentanyl a public health crisis six years ago — and provincial officials asked for federal permission to decriminalize the possession of small amounts of opioids, cocaine and methamphetamines.

The experimental policy, which takes effect in January 2023, will last three years.

British Columbia's minister of mental health and addictions, Sheila Malcolmson, says the move will put the focus on health care.

"By decriminalizing people who use drugs, we will break down the stigma that stops people from accessing life-saving support and services," she said in a statement.

New York City allows the nation's 1st supervised consumption sites for illegal drugs

In recent years Canada has introduced a number of health care-focused programs for addressing its overdose epidemic, including setting up supervised injection sites, providing tests to check drugs for fentanyl and making heroin available by prescription for those who haven't found success with other treatments.

But overdose deaths spiked at the start of the pandemic and remained high through 2021, according to the latest data available.

The policy change in British Columbia will apply to individuals 18 and older who are in possession of 2.5 grams or less of illicit drugs.

"We are granting this exemption because our government is committed to using all available tools that reduce stigma, substance use harms, and continuing to work with jurisdictions, to save lives and end this crisis," said Carolyn Bennett, Canada's federal minister of mental health and addictions.

The War On Drugs: 50 Years Later

Oregon's pioneering drug decriminalization experiment is now facing the hard test.

In the U.S., voters in the state of Oregon approved a similar policy in 2020, decriminalizing personal use quantities of most illicit drugs under state law. That change was made without approval from the federal government.

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Original research

Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review, ayden i scheim.

1 Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA

2 Centre on Drug Policy Evaluation, St Michael's Hospital, Toronto, Ontario, Canada

Nazlee Maghsoudi

3 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

Zack Marshall

4 Social Work, McGill University, Montreal, Quebec, Canada

Siobhan Churchill

5 Epidemiology and Biostatistics, Western University, London, Ontario, Canada

Carolyn Ziegler

6 Library Services, Unity Health Toronto, Toronto, Ontario, Canada

7 Medicine, University of California San Diego, La Jolla, California, USA

Associated Data

bmjopen-2019-035148supp001.pdf

bmjopen-2019-035148supp002.pdf

bmjopen-2019-035148supp003.pdf

To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally.

Systematic review with narrative synthesis.

Data sources

We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018.

Inclusion criteria

Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation.

Data extraction and synthesis

Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest.

We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use.

Conclusions

Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.

Strengths and limitations of this study

• This is the first study to review all literature on the health and social impacts of decriminalisation or legal regulation of drugs.
• We systematically searched 10 databases over a 38-year period, without language restrictions.
• The review was limited to study designs appropriate for evaluating interventions, nevertheless, most included studies used relatively weak evaluation designs.
• Included outcomes were heterogeneous and not quantitatively synthesised.
• Heterogeneity in the details and implementation of decriminalisation or legal regulation policies was not considered in this review.

Introduction

An estimated 271 million people used an internationally scheduled (‘illicit’) drug in 2017, corresponding to 5.5% of the global population aged 15 to 64. 1 Despite decades of investment, policies aimed at reducing supply and demand have demonstrated limited effectiveness. 2 3 Moreover, prohibitive and punitive drug policies have had counterproductive effects by contributing to HIV and hepatitis C transmission, 4 5 fatal overdose, 6 mass incarceration and other human rights violations 7 8 and drug market violence. 9 As a result, there have been growing calls for drug law reform 10–12 and in 2019, the United Nations Chief Executives Board endorsed decriminalisation of drug use and possession. 13 Against this backdrop, as of 2017 approximately 23 countries had implemented de jure decriminalisation or legal regulation of one or more previously illegal drugs. 14–16

A wide range of health and social outcomes are affected by psychoactive drug production, sales and use, and thus are potentially impacted by drug law reform. Nutt and colleagues have categorised these as physical harms (eg, drug-related morbidity and mortality to users, injury to non-users), psychological harms (eg, dependence) and social harms (eg, loss of tangibles, environmental damage). 17 18 Concomitantly, a diverse and sometimes competing set of goals motivate drug policy development, including ameliorating the poor health and social marginalisation experienced by people who use drugs problematically, shifting patterns of use to less harmful products or modes of administration, curtailing illegal markets and drug-related crime and reducing the economic burden of drug-related harms. 19

Given ongoing interest by states in drug law reform, as well as the recent position statement by the United Nations Chief Executives Board endorsing drug decriminalisation, 13 a comprehensive understanding of their impacts to date is required. However, the scientific literature has not been well-characterised, and thus the state of the evidence related to these heterogeneous policy targets remains largely unclear. Systematic reviews, including two meta-analyses, are narrowly focussed on adolescent cannabis use. Dirisu et al found no conclusive evidence that cannabis legalisation for medical or recreational purposes increases cannabis use by young people. 20 In the two meta-analyses, Sarvet et al found that the implementation of medical cannabis policies in the USA did not lead to increases in the prevalence of past-month cannabis use among adolescents 21 and Melchior et al found a small increase in use following recreational legalisation that was reported only among lower-quality studies. 22

Given increasing interest in quantifying the impact of drug law reform, as well as a lack of systematic assessment of outcomes beyond adolescent cannabis use to date, we conducted a systematic review of original peer-reviewed research evaluating the impacts of (a) legal regulation and (b) drug decriminalisation on drug availability, use or related health and social harms. Our primary aim is to characterise studies with respect to metrics and indicators used. The secondary aim is to summarise the findings and methodological quality of studies to date.

Consistent with our aim of synthesising evidence on the impacts of decriminalisation and legal regulation across the spectrum of potential health and social effects, we conducted a systematic review using narrative synthesis 23 without meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in preparing this manuscript. 24 The review protocol was registered in PROSPERO (CRD42017079681) and can be found online at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=79681 .

Search strategy and selection criteria

The review team developed, piloted and refined the search strategy in consultation with a research librarian and content experts. We searched MEDLINE, Embase, PsycINFO, Web of Science, Criminal Justice Abstracts, Applied Social Sciences Index & Abstracts, International Bibliography of the Social Sciences, PAIS Index, Policy File Index and Sociological Abstracts for publications from 1 January 1970 through 4 October 2018. We used MeSH (Medical Subject Headings) terms and keywords related to (a) scheduled psychoactive drugs, (b) legal regulation or decriminalisation policies and (c) quantitative study designs. Search terms specific to health and social outcomes were not employed so that the search would capture the broad range of outcomes of interest. See online supplemental appendix A for the final MEDLINE search strategy. For conference abstracts, we contacted authors for additional information on study methods and to identify subsequent relevant publications.

Supplementary data

We included peer-reviewed journal articles or conference abstracts reporting on original quantitative studies that collected data both before and after the implementation of drug decriminalisation or legal regulation. We did not consider as original research studies that reproduced secondary data without conducting original statistical analyses of the data. We defined decriminalisation as the removal of criminal penalties for drug use and/or possession (allowing for civil or administrative sanctions) and legal regulation as the development of a legal regulatory framework for the use, production and sale of formerly illegal psychoactive drugs. Studies were excluded if they evaluated de facto (eg, changes in enforcement practices) rather than de jure decriminalisation or legal regulation (changes to the law). This exclusion applied to studies analysing changes in outcomes following the US Justice Department 2009 memo deprioritising prosecution of cannabis-related offences legal under state medical cannabis laws. Eligible studies included outcome measures pertaining to drug availability, use or related health and social harms. We used the schema developed by Nutt and colleagues to conceptualise health and social harms, including those to users (physical, psychological and social) and to others (injury or social harm). 18

Both observational studies and randomised controlled trials were eligible in principle, but no trials were identified. There were no geographical or language restrictions; titles, abstracts and full-texts were translated on an as-needed basis for screening and data extraction. We excluded cross-sectional studies (unless they were repeated) and studies lacking pre-implementation and post-implementation data collection because such designs are inappropriate for evaluating intervention effects.

Data analysis

Screening and data extraction were conducted in DistillerSR (Evidence Partners, Ottawa, Ontario). We began with title-only screening to identify potentially relevant titles. Two reviewers screened each title. Unless both reviewers independently decided a title should be excluded, it was advanced to the next stage. Next, two reviewers independently screened each potentially eligible abstract. Inter-rater reliability was good (weighted Kappa at the question level=0.75). At this stage, we retrieved full-text copies of all remaining references, which were screened independently by two reviewers. Disagreements on inclusion were resolved through discussion with the first author. Finally, one reviewer extracted data from each included publication using a standardised, pre-piloted form and performed quality appraisal. A second reviewer double-checked data extraction and quality appraisal for every publication, and the first author resolved any discrepancies.

The data extraction form included information on study characteristics (author, title, year, geographical location), type of legal change studied and drug(s) impacted, details and timing of the legal change (eg, medical vs recreational cannabis regulation), study design, sampling approach, sample characteristics (size, age range, proportion female) and quantitative estimates of association. We coded each study-level outcome measure into one metric grouping, using 24 pre-specified categories and a free-text field (see figure 1 for full list). Examples of metrics include: prevalence of use of the decriminalised or regulated drug, overdose or poisoning and non-drug crime.

Metrics examined by included studies. excl., excluding.

We also categorised the estimated direction of association of the legal change on outcome measure(s) of interest (beneficial, harmful, mixed or null). These associations were coded at the outcome (not study) level and classified as beneficial if a statistically significant increase in a positive outcome (eg, educational attainment) or decrease in a negative outcome (eg, substance use disorder) was attributed to implementation of decriminalisation or legal regulation, and vice versa for harmful associations. The association was categorised as mixed if associations were both harmful and beneficial across participant subgroups, exposure definitions (eg, loosely vs tightly regulated medical cannabis access) or timeframes. Although any use of cannabis and other psychoactive drugs need not be problematic at the individual level, we categorised drug use as a negative outcome given that population-level increases in use may correspond to increases in negative consequences; we thought that this cautious approach to categorisation was appropriate given that such increases are generally conceptualised as negative within the scientific literature. For outcomes that are not unambiguously negative or positive, the coding approach was predetermined taking a societal perspective. For example, increased healthcare utilisation (eg, hospital visits due to cannabis use) was coded as negative because of the increased burden placed on healthcare systems. The association was categorised as null if no statistically significant changes following implementation of drug decriminalisation or legal regulation were detected. We set statistical significance at a= 0.05, including in cases where authors used more liberal criteria.

Quality assessment at the study level was conducted for each full-length article using a modified version of the Downs and Black checklist 25 for observational studies ( online supplemental appendix B ), which assesses internal validity (bias), external validity and reporting. Each study could receive up to 18 points, with higher scores indicating more methodologically rigorous studies. Conference abstracts were not subjected to quality assessment due to limited methodological details.

Patient and public involvement

This systematic review of existing studies did not include patient or public involvement.

Study characteristics

As shown in the PRISMA flow diagram ( figure 2 ), we screened 4860 titles and abstracts and 213 full-texts, with 114 articles meeting inclusion criteria ( online supplemental appendix C ). Key reasons for exclusion at the full-text screening stage were that the article did not report on original quantitative research (n=59) or did not evaluate decriminalisation or legal regulation as defined herein (n=23). Details of each included study are presented in online supplemental table 1 . Included studies had final publication dates from 1976 to 2019; 44.7% (n=51) were first published in 2017 to 2018, 43.9% (n=50) were published in 2014 to 2016 and 11.4% (n=13) were published before 2014.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.

Characteristics of included studies are described in table 1 , both overall and stratified by whether they evaluated decriminalisation (n=19) or legalisation (n=96) policies (one study evaluated both policies). Most studies (n=104, 91.2%) were from the USA and examined impacts of liberalising cannabis laws (n=109, 95.6%). Countries represented in non-US studies included Australia, Belgium, China, Czech Republic, Mexico and Portugal. The most common study designs were repeated cross-sectional (n=74, 64.9%) or controlled before-and-after (n=26, 22.8%) studies and the majority of studies (n=87, 76.3%) used population-based sampling methods. Figure 3 illustrates the geographical distribution of studies among countries where national or subnational governments had decriminalised or legally regulated one or more drugs by 2017.

Characteristics of studies evaluating drug decriminalisation or legal regulation, 1970 to 2018

*Combined total exceeds number of studies because some evaluated both decriminalisation and legal regulation.

†One global study and one multi-country European study including Belgium and Portugal.

Number of included studies from countries that implemented decriminalisation or legal regulation by 2017. Note: Policy changes were classified, following the review inclusion criteria, based on the implementation of a change to national or subnational law to decriminalise drug use and/or possession or to legalise at least one class of drugs. We did not evaluate the extent to which legal changes were reflected in policing and criminal justice practice. Implementation of cannabis legalisation for medical purposes only is not reflected in this map.

Study quality

Quality assessment was performed for the 93 full-length articles included in the review, excluding 21 conference abstracts ( online supplemental table 1 ). Scores ranged from 7 to 18 of 18 possible points, with a mean of 14.4 (SD=2.56). Quality scores were similar comparing US to non-US-based studies ( X =14.4 and 13.7, respectively, p=0.386) but higher for studies evaluating legal regulation ( X =14.8) versus decriminalisation ( X =12.8) (p=0.003). Study quality differed significantly (p<0.001) by the direction of the association with the outcome of interest, with higher quality scores among studies estimating mixed ( X =15.4) or beneficial ( X =15.2) versus null ( X =14.2) or harmful ( X =13.1) effects of legal change on the outcome of interest. Study quality did not appear to increase over time (eg, X =14.0 in 2014 and 14.4 in 2018).

Study outcome measures and metrics

Across 114 studies we extracted 224 outcome measures, which were coded into 32 metrics ( figure 1 ). The most common metric employed by studies was the prevalence of use of the decriminalised or legally regulated drug, which was examined in 39.5% of studies (n=45) and represented 22.3% of outcome measures (n=50). Of these studies, 13 (28.9%; 8 full-length articles and 5 abstracts) did not report any other metric 26–38 and an additional 6 studies (13.3%) reported on the prevalence of use in addition to a single drug-related perception metric (either harmfulness or availability). 39–44 The second most common metric was the frequency of use of the decriminalised or legally regulated drug (14.0% of studies, n=16) and the third was the prevalence or frequency of use of tobacco, alcohol or drugs that remained illegal (12.3% of studies, n=14). The fourth most commonly employed metric was any change in the perceived health harmfulness of using the decriminalised or regulated drug (10.5% of studies, n=12), which was assessed among adolescents or young adults in all studies except for one that assessed this metric among parents. 45

All other metrics were assessed in <10% of included studies. Health service utilisation was evaluated in 7.9% of studies (n=9) using 12 outcome measures, primarily related to emergency department visits and/or hospitalisations. Prescribed (primarily opioid) drug use and perceived availability of the decriminalised or legally regulated drug were reported in 7.0% of studies each (n=8). Overdose or poisoning by the decriminalised or regulated drug, and by other drugs (predominantly opioids), were examined in 5.3% (n=6) and 6.1% of studies (n=7), respectively. Driving while under the influence or with detectable concentrations of the decriminalised or regulated drug (cannabis) was examined in seven studies (6.1%) inclusive of eight outcome measures. Notably, one study assessed self-reported impaired driving, 46 while others assessed the proportion of fatally injured drivers screening cannabis-positive or the overall prevalence of driving with detectable tetrahydrocannabinol (THC) concentrations in blood. Remaining metrics were measured in less than 5% of studies ( figure 1 ). Some pre-specified metrics were not represented in any of the articles, including infectious disease incidence (eg, HIV, hepatitis C), environmental impacts (eg, drug production waste, discarded needles) and labour market participation.

Studies outside the US

Of the 10 studies conducted outside the USA, 6 focussed on cannabis decriminalisation. All three studies from Australia examined the prevalence of cannabis use post-decriminalisation, 31 34 47 while one also measured perceived cannabis availability. 47 Following cannabis decriminalisation, one European multi-country study including Belgium and Portugal examined the prevalence of cannabis use and uptake of cannabis-related addictions treatment 48 and one Czech study considered the age of first cannabis use. 49 An international study using United Nations Office on Drugs and Crime data from 102 countries compared availability, as reflected by cannabis seizures and plant eradication, in countries that had decriminalised cannabis versus those that had not. 50 Three non-US studies evaluated decriminalisation of all psychoactive drugs. Two studies from Portugal examined healthcare and non-healthcare costs and psychoactive drug prices, respectively. 51 52 One study from Mexico examined drug-related criminal justice involvement (arrests) and (violent) crimes. 53 Finally, a study of historic opium legalisation in China (1801 to 1902) measured the price and availability (quantity of exports) of opium before and after legalisation. 54

Impacts of decriminalisation and legal regulation

Results of individual studies are provided in online supplemental table 1 . Online supplemental table 2 tallies findings and average quality scores for each of the metrics; here we summarise findings for metrics examined in more than 5% of studies, in descending order based on the number of datapoints. Across all three substance use metrics (prevalence of use, frequency of use and use of other alcohol or drugs), drug law reform was most often not associated with use (with null findings for 48.0% to 52.4% of outcome measures falling under these metrics). With respect to change in perceived harmfulness of the decriminalised or regulated drug, mixed results were found in half of cases, with heterogeneity detected on the basis of age, gender and state. 39 43 55–57 For example, legal regulation of cannabis for medical use was associated with greater perceived harmfulness of cannabis among eighth graders but not older students in an analysis of US Monitoring the Future data 39 while a study employing US National Survey on Drug Use and Health data found greater perceived harmfulness of cannabis among young adults aged 18 to 25 but not adolescents aged 12 to 17. 57

Among nine studies that employed health service utilisation metrics, harmful effects were reported for 6 of 12 outcome measures, with increases in emergency department visits and/or hospitalisations attributed to decriminalisation or legal regulation. 58–63 However, all but one of those studies 58 assessed change over time in one jurisdiction, without a control group. Further, two studies that also examined changes in acute care use for non-cannabis drugs found reductions in those visits or admissions following cannabis decriminalisation or legal regulation. 60 64 In contrast, six of nine prescription drug use associations were beneficial, with reductions observed in rates of opioid 65–69 and other drug prescribing 70 71 attributed to legal regulation of cannabis for medical use; outcomes in this category came from studies of higher average quality ( X =16.3). Perceived availability of the decriminalised or regulated drug appeared largely unaffected by decriminalisation (null associations for five of nine outcome measures) but two studies indicated increased perceived availability of cannabis among Colorado, US, adolescents following legal regulation for adult use 72 and among adults in US states with legal regulation for medical use. 44 Across the subset of seven outcome measures for overdose or poisoning by the decriminalised or regulated drug (cannabis), in all cases an increase in calls to poison control centres or unintentional paediatric exposures was reported. 59 73–77 However, studies assessing the impacts of cannabis regulation on overdose or poisoning by drugs other than cannabis concluded that the effects were either beneficial (four outcome measures 64 76 78 79 ) or mixed/null (three outcome measures 80–82 ). Driving with detectable concentrations of THC was most often found to increase following decriminalisation or legal regulation (five of eight outcome measures; 83–87 ), but these studies were of lower average quality ( X =12.0).

Impacts of decriminalisation

Of the 19 studies evaluating impacts of decriminalisation, six measured the prevalence of use of the decriminalised drug with eight unique outcome measures. No association was detected for all but three outcomes; following cannabis decriminalisation lifetime use increased among adults in South Australia, 31 while past-month use increased among 12 th graders but not younger students in California, 56 relative to the rest of the country in both cases. After peyote use for ceremonial purposes was decriminalised in the USA in 1994, self-reported use increased among American Indians. 88 Three studies evaluated relationships between decriminalisation and drug-related criminal justice involvement in Mexico and the USA. One high-quality study found that decriminalisation positively influenced criminal justice involvement: in five US states, arrests for cannabis possession decreased among youth and adults. 89 When possession of small amounts of cannabis was decriminalised in the 1970s in Nebraska, however, the mean monthly number of arrests did not change, while cannabis-related prosecutions increased among youth. 90 In Tijuana, Mexico, decriminalisation of all drugs had no apparent impact on the number of drug possession arrests. 53 Two historical and one recent study measured healthcare utilisation. US states that decriminalised cannabis in the 1970s saw greater emergency department visits related to cannabis, but decreased visits related to other drugs. 60 In Colorado, US, decriminalisation was associated with increased emergency department visits for cyclic vomiting. 62 Addiction treatment utilisation, healthcare and non-healthcare costs, driving after use, price of drugs, availability of drugs, frequency of use, attitudes towards use and perceived harmfulness were each evaluated in only one or two studies of decriminalisation.

This systematic review identified 114 peer-reviewed publications and conference abstracts evaluating the impacts of drug decriminalisation or legal regulation from 1970 to 2018. Within this search period, 88.6% were published in 2014 or later. This rapid growth in scholarship was driven by the implementation and subsequent evaluation of cannabis legalisation in a number of US states beginning in 2012, and knowledge production will surely continue to accelerate as longer-term data become available and as other jurisdictions (eg, Canada and Uruguay) analyse the effects of recently implemented cannabis legalisation. Indeed, a first study on the impacts of cannabis legalisation on adolescent use in Uruguay was published in May 2020 (finding no impact on risk of use 91 ). The present study provides an overview of the emerging literature based on our systematic review and suggests three key patterns.

First, peer-reviewed longitudinal evaluations of drug decriminalisation and legal regulation are overwhelmingly geographically concentrated in the US and focussed on cannabis legalisation. Importantly, the lack of non-US studies evaluating legal regulation of cannabis for medical use may reflect the more tightly controlled nature of medical cannabis regulation in other countries, and thus the more limited potential for population-level effects. It is notable that decriminalisation in the absence of legal regulation was evaluated in only 18 studies (15.8%), despite being far more common globally than legal regulation. These gaps may hamper evidence-based drug law reform in countries that are less well-developed, that play a substantial role in drug production and transit or that have different baseline levels of substance (mis)use as compared with the US.

Second, prevalence of use was the predominant metric used to assess the impact of drug law reform, despite its limited clinical significance (eg, much cannabis use is non-problematic) and limited responsiveness to drug policy. This is because ecological analyses have indicated little relationship between drug policies and prevalence of use, 52 as have studies assessing within-state change in use related to legal regulation. 21 These findings are supported by the preponderance of evidence synthesised in this review, although some variation is evident in relation to the specific provisions of legal reforms (eg, liberal vs tightly regulated medical markets 92 ). Impacts of legal cannabis regulation on prevalence and frequency of use continue to be evaluated, with recent data suggesting small increases among adults, but not youth. 93 Drug policies may be more able to influence the types of drugs that people use, drug-related risk behaviours and modes of drug consumption. 94 Metrics to assess these outcomes, however, were lacking in the reviewed literature. For example, only one study (0.8%) investigated whether legal regulation of cannabis was associated with changes in the mode of cannabis consumption. 72 Although the prevalence of use was often measured alongside more clinically or socially significant metrics (eg, prevalence of substance use disorders, educational outcomes among young adults), 42.2% of studies assessing substance use prevalence included that metric alone or in combination with a single drug-related attitude metric.

Third, there was a lack of alignment between the stated policy objectives of drug law reform and the metrics used to assess its impact in the scientific literature. For instance, removal of criminal sanctions to prevent their negative sequelae is a key rationale for decriminalisation and legal regulation, 12 13 95 but only four studies (3.5%) evaluated changes in drug-related criminal justice involvement following drug law reform. Similarly. improving the physical and mental health of people who (already) use drugs is a motivation for drug policy reform but no included studies examined mental or physical health outcomes (aside from substance use disorders) in this population. As a result, there is a risk that decisions on drug policy may be informed by inappropriate metrics. Promisingly, in recent months, additional studies assessing legal regulation that employ a range of criminal justice metrics have been published. 96–98 Finally, despite ample evidence of the impact of criminalisation on infectious disease transmission and acquisition risks, 5 we found no studies evaluating the impact of decriminalisation on these outcomes.

Both the included studies and our systematic review have important strengths and limitations. To our knowledge, we conducted the first review of all global literature on decriminalisation and legal regulation and applied no language restrictions. All eligible articles identified were published in English; this may reflect a paucity of evaluation research published in other languages and/or limitations of our search strategy (eg, some non-English journals may not be indexed in the 10 databases searched). In addition, we excluded grey literature, non-original research and study designs that are not suited to evaluating policy effects (eg, cross-sectional studies), but these restrictions narrowed the geographical scope of included studies. For example, two articles on Portugal were excluded as non-original research, but nevertheless provide important insight on impacts of decriminalisation. 99 100 Despite restricting eligibility to more rigorous study designs, most included studies used relatively weaker eligible designs that are known to be vulnerable to pre-existing trends and confounding; only 22.8% and 5.3%, respectively, used controlled before-and-after or interrupted time series designs to address these threats to validity. The use of these study designs may be related to limited resources for prospective drug policy evaluations, with many studies relying on publicly available, routinely collected data. That the US is unique in the extent to which data on drug use and related harms are routinely collected helps to explain its over-representation in our review. Scoping reviews inclusive of grey literature and cross-sectional designs would be valuable for describing the full range of evaluations that have been conducted globally.

While beyond the scope of our high-level synthesis, the implementation and specific provisions of drug policies vary widely. Decriminalisation policies vary in their definitions of quantities for personal use, application of administrative penalties and the extent to which the law ‘on the books’ is reflected in policing and criminal justice practice. Indeed, in some jurisdictions with nominal decriminalisation, arrests for possession of small quantities of the decriminalised drugs remain routine. 53 Legal regulation models for cannabis are also heterogeneous. For example, policies legally regulating cannabis for medical use may or may not allow for legal dispensaries, and this provision has been shown to substantially modify the impact of legal regulation on cannabis use. 101 To the extent that individual studies employed crude exposure measures (eg, presence vs absence of a law), they may have obscured context-dependent effects of drug law liberalisation. Further, the impact of drug laws on drug use and related outcomes may be limited by a lack of public awareness of the details of local laws. 102

Our use of vote-counting in this synthesis (ie, categorising individual outcome measures as indicating beneficial, harmful, mixed/subgroup-specific or no statistically significant associations) is subject to the same limitation. Vote-counting should also be interpreted with caution in light of the heterogeneity of outcome definitions, the inherent arbitrariness of statistical significance thresholds and the key distinction between statistical and clinical significance. In addition, many included studies are evaluating the same policies (eg, cannabis legalisation in western US states), sometimes using overlapping data but drawing different conclusions based on analytical choices and timeframes. The existence of multiple datapoints for a particular outcome does not imply that the outcome has been well-studied across diverse contexts such that scientific consensus on its effects has been reached. Moreover, as illustrated by a recently published extension of the included article by Bachhuber et al , 79 multiple high-quality studies may generate results that are later revealed to be spurious as additional follow-up data become availability. Specifically, Shover et al demonstrated that the positive association reported between medical cannabis legalisation and opioid overdose mortality in 1999 to 2010 reversed direction in later years, suggesting that earlier findings of a protective effect should not be given causal interpretations. 103 This was foreshadowed in the included article by Powell et al , which found that the purportedly positive effect of medical cannabis legalisation was attenuated in 2010 to 2013. 82 This scientific back-and-forth can be expected given that most included articles are evaluating legal changes introduced rather recently, and thus are examining early impacts with limited years of follow-up. Longer-term impacts of non-medical cannabis legalisation, and how they might be influenced by increased commercialisation, are yet to be seen. 104

The findings of this review indicate a need for a broadening of the metrics used to assess the impacts of drug decriminalisation and legal regulation. Given the growing number of jurisdictions considering decriminalisation or legal regulation of psychoactive drugs, 14–16 the disproportionate emphasis on metrics assessing drug use prevalence, as well as the limited geo-cultural diversity in evaluations, are concerning. Experts have called for a more fulsome approach to evaluating drug policies in line with public health and the United Nations Sustainable Development Goals, with attention to the full breath of health and social domains potentially impacted, including human rights and social inclusion (eg, stigma), peace and security (eg, drug market violence), development (eg, labour market participation), drug market regulation (eg, safety of the drug supply) and clinically-significant health metrics (eg, drug-related morbidity). 105 Drawing on methods such as multi-criterion decision analysis, 19 the engagement of both scientists and policymakers in priority-setting may help to produce evidence that provides a more comprehensive understanding of the breadth of impacts that should be anticipated with drug law reform efforts. Funding will also be required to support rigorous prospective evaluations of legal reforms.

Supplementary Material

Acknowledgments.

The authors would like to thank Gelareh Ghaderi for assistance with screening and data extraction.

Twitter: @aydenisaac

Presented at: Presented at the International Society for the Study of Drug Policy (May 22, 2019) and the International Harm Reduction Conference (April 29, 2019).

Contributors: DW and AIS conceptualised and supervised the review. CZ designed and conducted the literature searches. AIS drafted the manuscript. SC, ZM and AIS conducted screening and data extraction. NM contributed to drafting the manuscript and developing figures. All authors contributed to interpretation of findings and revising the manuscript for important intellectual content.

Funding: This review was supported by the Canadian Institutes of Health Research (CIHR) via the Canadian Research Initiative on Substance Misuse (SMN-139150), the MAC AIDS Foundation, and the Open Society Foundations. Ayden Scheim was supported by a Canadian Institutes of Health Research Postdoctoral Fellowship. Nazlee Maghsoudi is supported by a CIHR Vanier Canada Graduate Scholarship. Dan Werb is supported by a US National Institute on Drug Abuse Avenir Award (DP2- DA040256), a CIHR New Investigator Award, an Early Researcher Award from the Ontario Ministry of Research, Innovation and Science and the St Michael’s Hospital Foundation.

Map disclaimer: The depiction of boundaries on the map(s) in this article does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: All relevant data are contained within the article and supplementary materials.

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Canadians’ knowledge and attitudes around drug decriminalization: Results from a public opinion research survey

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Background on the exemption in british columbia related to personal possession of certain illegal drugs, approach to monitoring attitudes around drug decriminalization, about the public opinion research (por) survey, key highlights from the por survey results.

At the request of the Government of British Columbia, an exemption related to personal possession of certain illegal drugs has been granted for adults 18 years of age and older in the province. British Columbia (BC) refers to this exemption as a form of decriminalization.

From January 31, 2023 to January 31, 2026, adults are no longer subject to criminal charges or drug seizure if they're found in personal possession of up to 2.5 grams total of any combination of:

• methamphetamine

Instead, they are offered information about health and social supports. This includes support with referrals to local treatment and recovery services, if requested.

Health Canada is collecting data at a national level on Canadians' attitudes towards, and knowledge of, drug decriminalization. To do this, Health Canada has identified a set of indicators to monitor changes related to:

• attitudes towards drug use
• perceptions of public safety

A key source of data for this work will be information gathered from public opinion research (POR).

The POR survey was conducted by the Privy Council Office (PCO). It used 2 separate random samples of 2,000 Canadian adults aged 18 and older. Questions on attitudes towards people who use drugs and decriminalization were run between February 27 and March 12, 2023. Questions on knowledge of decriminalization were run between April 17 and April 30, 2023. Respondents were randomly sampled with proportional representation from across Canada. Unless otherwise noted, results shown in this report are expressed as percentages and may not add up to 100% due to rounding or a "not sure" response to a given question.

Questions focused on both attitudes and knowledge about:

• preferences for approaches to addressing substance use, including a focus on health and social services versus police enforcement
• general attitudes around empathy for people struggling with substance use
• general attitudes around level of comfort in talking to friends and family members about their substance use
• perceived benefits and disadvantages of decriminalization
• This included a focus on improved access to relevant health and social services, reduced stigma, increased harms, and reduced community safety

The POR survey also included 4 true-or-false questions to test respondents' knowledge of the details of BC's exemption for personal possession.

To address substance use, 49% of Canadians preferred a focus on access to health and social services rather than police enforcement, which represented 7% of respondents (Figure 1). However, 35% felt that both approaches were equally appropriate while 6% felt that neither approach was appropriate.

Women, those with higher education and income levels, and Canadian-born respondents were more likely to prefer a focus on access to health and social services to address substance use (Figure 2a).

Although few Canadians prefer a police enforcement approach to address substance use, men and those with lower income and education levels were more likely than others to favour police enforcement (Figure 2b). Men, those with trade or college education, and immigrants were more likely to feel that both approaches were equally appropriate to address substance use (Figure 2c).

88% of Canadians responded that they would like their friends or family members who use drugs to feel comfortable talking to them about it and 81% had empathy for people struggling with substance use (Figure 3). Canadians with lower income and education levels were more likely to think decriminalization would increase harms associated with substance use and make their community less safe. Although 62% of Canadians felt that decriminalization would make it easier to access health and social services, 51% also thought it would increase harms associated with substance use such as overdoses.

Question: Which of the following approaches do you feel is more appropriate to address substance use among people who use drugs?

Source: PCO Survey on Current Issues, February 27 to March 12, 2023

Base: All respondents (Canada: n= 2,000)

Figure 2: Attitudes towards approaches to address substance use among people who use drugs for specific populations

Question: To what extent do you agree or disagree with the following statements?

Questions testing Canadians' knowledge of the exemption in BC focused on:

• differences between the exemption and legalization
• the role of police in enforcing the exemption
• details about which activities involving drugs are covered by the exemption in BC

57% to 62% of Canadians, depending on the question, were able to correctly identify details of BC's exemption (Figure 4). However, 18% to 24% of respondents answered incorrectly and 15% to 19% were unsure of the answer.

Increased knowledge of the details of BC's exemption were shown by (Figure 5):

• BC respondents
• those aged 18 to 34 years
• those with higher education and income levels
• Canadian-born respondents

Question: Based on your understanding of the decriminalization of personal possession of drugs being implemented in British Columbia, are the following statements true or false? (Correct answers are highlighted in darker cells)

Source: PCO Survey on Current Issues, April 17 to 30, 2023

BC's exemption understanding index: Respondents get 25 points for each correct answer. A respondent who answers all four questions correctly gets a score of 100 (range: 0-100)

The results from this survey reflect the knowledge and attitudes of Canadian adults around drug decriminalization and the exemption in BC. These results will serve as a baseline to monitor key outcomes of the exemption, particularly public awareness and understanding of the details of the exemption and substance use. Health Canada's work will continue to compliment monitoring and evaluation work being led by the BC Ministry of Mental Health and Addictions and the Canadian Institutes of Health Research.

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Why Decriminalize Drugs?

On Thursday, May 24 th the Canadian Drug Policy Coalition released a report on Canadian drug policy. The report calls for the replacement of Canada’s National Anti-Drug Strategy with one focused on health and human rights, the scale-up of comprehensive health and social services, including housing and treatment services that engage people with drug problems; more robust educational programs about safer drug use, the decriminalization of all drugs for personal use and the creation of a regulatory system for adult cannabis use.

The Canadian media responded quickly to our recommendation to decriminalize personal possession of drugs with questions about how this approach would work, especially when it comes to drugs like heroin and cocaine. Canada’s Conservative government also reacted swiftly to media coverage of our report and publicly dismissed our proposal to decriminalize the personal use of all other drugs.

Let’s be very clear about what the Canadian Drug Policy Coalition is recommending: the full legal regulation of cannabis for adult use and the decriminalization of possession of small quantities of all other drugs for personal use. We do not at this time recommend full legal regulation of drugs other than cannabis; nor do we suggest that all currently illegal drugs should become widely available. Decriminalization of possession of these drugs will not address the harms associated with an underground market. But it is a first step towards a more effective policy. Decriminalization, a strategy currently in use by up to 30 countries world-wide, has been quietly adopted in the wake of the escalating costs of prohibition and its failure to stem the tide of drug use and eliminate drug markets.

Politicians still insist that decriminalizing drug use would send the “wrong message”. This idea is grounded in the false belief that criminalizing drugs keeps people from using them and lessening penalties for drug use will in fact result in higher rates of drug use.  But in countries and regions where decriminalization has been implemented, this has just not been the case. As the Global Commission on Drug Policy suggested in 2011,

“A key idea behind the ‘war on drugs’ approach was that the threat of arrest and harsh punishment would deter people from using drugs. In practice, this hypothesis has been disproved – many countries that have enacted harsh laws and implemented widespread arrest and imprisonment of drug users and low-level dealers have higher levels of drug use and related problems than countries with more tolerant approaches. Similarly, countries that have introduced decriminalization, or other forms of reduction in arrest or punishment, have not seen the rises in drug use or dependence rates that had been feared.”

International comparisons also show us that there is no correlation between the harshness of enforcement and the prevalence of drug use. Even in states that have decriminalized all drugs, the sky has not fallen. In 2000, Portugal moved to decriminalize all drugs, including cocaine and heroin, at the same time as it scaled up the availability of services to address drug use problems. By moving personal possession away from law enforcement, drug use did not rise significantly, especially when compared with neighbouring countries. Portugal has also seen a reduction in illegal drug use among problematic drug users and teens, a reduced burden on the criminal justice system, and a significant drop in HIV infections and drug-related deaths.

Prohibition has failed. Drug use is still high, incarceration for drug offenses is increasing and despite billions of dollars spent over the years, law enforcement has failed to meet its objectives of protecting public health and public safety.

One of the drugs that causes the most health and public safety harms – alcohol — is completely legal and widely available yet other drugs with a relatively small public health footprint remain completely illegal. Using the criminal law to discourage a behaviour like drug use only throws the law into disrepute because a complex phenomena like harmful drug use is the result of many factors, none of which the law, police, courts or prisons are prepared to address.

In preparing our report, we talked to people across the country – service providers, family members, people who use drugs — and they told us again and again that Canada’s outdated approach to drug policy is hurting our citizens. In fact, using law enforcement to curb drug use increases its harms by driving it into the shadows. The criminalization of drug use also makes it more difficult to engage people in vital and life-saving health care services.

We need to overhaul our approach to drugs. Globally, the current system of drug control is under considerable pressure to change. Some national governments have begun to chart their own paths when it comes to drug control, including experimenting with decriminalization. It’s time to follow suit, and modernise Canada’s legislative, policy and regulatory frameworks that address drugs.

The Canadian Drug Policy Coalition is based out of Simon Fraser University’s Faculty of Health Sciences.

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1 (866) 324-7093, call us now, understanding decriminalization and the steps to ending the opioid crisis.

Aug 3, 2021

Opinion: Decriminalization is a critical step in curbing the opioid crisis

A recent opinion article published in The Conversation examines the benefits of drug decriminalization, as well as its potential impact in fighting the ongoing opioid crisis. The article, co-authored by Alissa Greer, Assistant Professor in the School of Criminology, Simon Fraser University and Caitlin Shane, staff lawyer at Pivot Legal Society, also critically examines drug decriminalization compared to regulation, as well as its effects on drug-related harms.

According to a survey conducted in 2020, 59% of respondents favour the decriminalization of drugs. The Canadian Association of Chiefs of Police has also recently publicly supported decriminalization, in addition to British Columbia’s chief public health officer.

Earlier in 2021, the City of Vancouver submitted an application to Health Canada for an exemption from Canada’s Controlled Drugs and Substances Act — a policy reform referred to as the Vancouver Model of decriminalization.

What is drug decriminalization?

Drug decriminalization refers to the implementation of an alternative response to criminal penalties for simple possession. It has been shown that criminalization of drugs has resulted in significant health, social and economic harms to vulnerable populations, including individuals who are homeless, have mental health issues, and Indigenous individuals.

In addition, drug decriminalization aims to “minimize the contact between people who use drugs and the criminal justice system and may increase their connection to health and social systems,” according to the authors of the opinion article.

Decriminalization vs. regulation

Legal regulation of drugs involves rules to control access to drugs, in contrast to a free market or full legalization.

Since decriminalization does not promote a “safer supply” of drugs, it will not affect the illegal supply of drugs containing toxic adulterants. Finally, the illegal drug market will continue to be criminalized following the implementation of decriminalization. According to the authors of the opinion article, the overdose risk will, nevertheless, remain high.

Advantages of drug decriminalization

One of the main benefits of drug decriminalization is that it will help to address drug use as a health and social issue in contrast to a criminal one; this would reduce the workload for the legal system, as well as the costs involved. Drug decriminalization also creates a positive impact in people’s lives, promoting their opportunities to access employment and housing. Furthermore, it reduces the stigma associated with drug use, and can serve as an effective harm reduction measure. Finally, implementation of drug decriminalization can encourage people to contact emergency services following an overdose, since fear of police can act as a deterrent in some situations.

Ontario’s mayors have called for decriminalization

Ontario’s Big City Mayors (OBCM) have been calling for the decriminalization of illicit drugs, in addition to continued funding and development of mental health crisis response units.

“While the provincial government is responsible for funding and coordinating mental health and addictions supports, all levels of government have a role to play in improving services for our residents,” OBCM said.

“The war on drugs isn’t working,” said Barrie Mayor Jeff Lehman. “We need to start understanding that this is a public health crisis for people who are addicted and to take a health approach to the people who are using drugs rather than policing.”

Decriminalization as a critical step, but not a solution to opioid crisis

According to the authors of the opinion article, decriminalization is not “a standalone solution to the harms of drug prohibition.” However, it can serve as a critical step in the right direction, since it will exert a positive impact on the lives of numerous people who are harmed daily from criminalization.

The authors maintain that it is important to be aware of the limitations of decriminalization models, so that governments and other stakeholders can refocus efforts on creating a safer drug supply. The authors also emphasize the fact that decriminalization must be coupled with greater access to safer pharmaceutical alternatives to the toxic and illegal drug market.

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Prominent mental health teaching hospital joins calls to decriminalize all illicit drugs.

The push to decriminalize drugs in Canada

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As overdose deaths keep surging in Canada, the movement to decriminalize illicit drugs is gaining steam, with one of the country's largest mental health facilities joining national advocates and several major cities in putting pressure on the federal government to act.

Earlier this summer, mayors from across B.C. signed a letter in support of Vancouver city officials who are seeking Health Canada's approval to  decriminalize the possession  of small amounts of illegal drugs. 

Toronto is gearing up to submit a similar request , a move which follows the city recently hitting its highest one-day opioid overdose count in late July .

Now, the country's largest mental health teaching hospital, the Centre for Addiction and Mental Health (CAMH) in Toronto, is for the first time formally pushing for countrywide drug decriminalization as well, CBC News has learned.

In a new policy statement being released publicly on Wednesday, the hospital is calling on the federal government to decriminalize all drugs while working with the provinces to ramp up treatment and harm-reduction services and replace the "unregulated, toxic drug supply."

"The driving factor behind the shift has been the harms we're seeing," said Dr. Leslie Buckley, chief of the addictions division at CAMH, during an interview.

Buckley says the legal framework around substance use hasn't been successful at curbing drug use, and instead causes social harms which disproportionately affect racialized communities.

"We should be thinking about substance use through a health lens," Buckley said, "and focusing on how to help people be well, rather than face criminal penalties."

CAMH is specifically calling on the federal government to "ensure decriminalization applies across the country and to all currently illicit drugs" — rather than a piecemeal approach relying on regional or substance-specific exemptions — with no fines or other administrative penalties. 

The push comes as overdose deaths are hitting new highs in much of the country, in part fuelled by an increasingly toxic illegal drug supply and, advocates say, by the social isolation and stress sparked by the ongoing COVID-19 pandemic. 

Federal data shows there were nearly 7,000 apparent opioid toxicity deaths reported in Canada between April 2020 and March 2021 — an 88 per cent increase from the same time period prior to the pandemic — with the bulk of the most recent deaths reported in British Columbia, Alberta and Ontario.

"We have not seen a commensurate response in prevention that signifies that there is urgency," said Angela Robertson, executive director of the Parkdale Queen West Community Health Centre, which operates sites for safer, monitored drug use in Toronto. 

"Here is a public health crisis that warrants a public health crisis response."

There were some signals on the campaign trail that the Trudeau government may be open to exploring new avenues to tackle overdose-related deaths.

Although the Liberal platform didn't mention decriminalization specifically, or offer a commitment to providing a safe drug supply — approaches which were backed by other parties  — Prime Minister Justin Trudeau has expressed a willingness to work with groups pursuing those solutions. 

"We've seen a number of provinces, particularly British Columbia, very interested in moving forward on some forms of decriminalization and we are absolutely open to working with them," Trudeau said during an announcement on mental health commitments.

Fewer Canadians are also being charged with drug possession in recent years, with the number of people facing charges dropping from more than 35,000 people in 2015 to roughly 18,000 in 2019, the latest available Statistics Canada data show.

'People are really listening now'

It's a shift not lost on advocates like Arlene Last-Kolb, who lost her 24-year-old son Jesse to fentanyl poisoning in July 2014.

The Manitoba mother has since been calling for changes in how Canada handles the opioid crisis.

"We talk about decriminalization for people that have no choice but to go to the streets to get what they need, and they're most likely going to die from that," said Last-Kolb, who is a board member of the advocacy group Moms Stop the Harm and co-founder of Overdose Awareness Manitoba.

"Why are we not talking about making it safer?"

Recently, there's been growing momentum around those kinds of harm-reduction approaches, she said. "What is new is that people are really listening now — and they're really starting to understand it."

Yet drug use policies remain a patchwork across the country, with varying levels of support and access to facilities like supervised injection sites, even as deaths have surged in recent years.

In Edmonton, daily drug poisonings are now putting extra strain on a health system that's also being overwhelmed by patients battling COVID-19, said family physician Dr. Ginetta Salvalaggio, an associate professor at the University of Alberta.

As co-chair of the Edmonton Zone Medical Staff Association's opioid poisoning committee, Salvalaggio is part of a group advocating for the urgent expansion of new overdose prevention sites in all of Alberta's major cities and broader access to a safer drug supply to tackle the current crisis — and she said longer-term, decriminalization needs to remain part of the conversation.

• Toronto seeks federal exemption to decriminalize drug use as opioid overdoses rise
• Police commissioners discuss drug decriminalization to address overdose crisis

"The drug supply that is currently circulating is, if anything, just getting from bad to worse, and that's not going to get solved by trying to take what's currently on the street off," Salvalaggio added. "So we need a much more comprehensive approach."

According to Buckley, the physician from CAMH, curbing the overdose crisis in both the short and long term requires a slate of tactics — including decriminalizing drugs, improving access to a safer drug supply and addiction treatments, and educating Canadians on the potential harms of drug use.

"We know that there is a possibility that we can be normalizing substance use, which we know can lead to people thinking it's less harmful," she acknowledged.

"Today's substances are not your parent's substances. The context has really changed."

• 'Harm is happening right now' as overdoses increase in Regina, says Regina police chief
• Video More than 7,000 lives lost to toxic drugs in 5 years — and this B.C. health crisis is only getting worse

Last-Kolb stresses that people like her late son have long used illegal drugs for a variety of reasons, and she maintains they deserve safer, legal options — just like those available to Canadians who choose to drink alcohol or smoke cannabis.

"My son would be married now with children. That's what I want for other people. I want people to be safe, I want our children to be safe," she said.

"And I don't want them to have to go to the streets and get something illegal that will most likely kill them."

ABOUT THE AUTHOR

Senior Health & Medical Reporter

Lauren Pelley covers the global spread of infectious diseases, pandemic preparedness and the crucial intersection between health and climate change for CBC. She's a two-time Registered Nurses' Association of Ontario Media Award winner for in-depth health reporting in 2020 and 2022 and a silver medallist for best editorial newsletter at the 2024 Digital Publishing Awards for CBC Health's Second Opinion. Contact her at: [email protected]

• @LaurenPelley