Drug Decriminalization: Our Public Health Crisis Requires a Health-Based Response

By: Kayla Beren

      As Portugal is the closest country in Europe to Latin America, it proved to be an optimal entry route for the illegal drug trade in the 20th century.  By the late 90s, Portugal had the highest rate of AIDS related to injection, as well as the second highest precedence of HIV in Europe. This resulted in an influx of comorbid diseases such as hepatitis and tuberculosis, and drug-related arrests more than doubled in a decade.  Over a ten-year span, Portugal’s healthcare and legal system became overwhelmed.  Following years of deliberation, the country decided to drastically alter their conventional approach on drug abuse.  On July 1st, 2001, Portugal decriminalized the personal use and possession of drugs, opened more rehabilitation programs, and began treating substance addiction as a public health issue instead of a criminal one.  Civil penalties replaced criminal charges, meaning that individuals are referred to treatment programs instead of being sent to prisons. 

     Canada is currently in the midst of an opioid crisis. Between January 2016 and December of 2018, more than 11,500 individuals died due to opioid related harms.  Substance use disorder is a complicated biological and social issue, resulting in distorted thinking and behaviour.  Biological factors contributing to sustained problematic drug use include a marked decrease in dopamine production related to a dysfunctional prefrontal cortex, overactivation of reward and motivation circuits in the brain and decreased activation of cognitive control circuits result in inhibited ability to control drives (compulsivity), and a characteristic deprivation of control.  Thus, an important characteristic of substance use disorders is an underlying change in brain circuits, which persists beyond detoxification. External factors leading to addiction are vast, encompassing social and environmental issues such as insecure housing, early childhood trauma, poverty, as well as other social determinants of health.  At a micro level, the stigmatization of substance abuse, over prescription of opioids, and unprescribed usage all contribute to overdoses being at an all-time high within Canada.

​     Substance use disorder being recognized as a multifactorial brain disorder has begun to shift public health and judiciary response.  Canada has recognized that “substance use is a health issue that can be prevented, managed, and treated, and that requires a health focussed response.” Although harm reduction initiatives such as overdose prevention sites, supervised consumption services and methadone clinics have spread across Canada, personal use/possession of drugs is criminalized at all levels, with punishments of jail time, and permanent documentation of incidence on a criminal record. 
In the last 20 years, Portugal’s policy of drug decriminalization has become one of the most successful policies related to substance usage worldwide.  HIV and AIDS in drug users has decreased, deaths from drug overdose is one of the lowest in the European Union, the number of users seeking treatment has increased and drug usage in the most high-risk age group of 15-19-year olds has decreased.  The social costs related to drug use have dropped by 18%.  In contrast, drug prohibition approaches have overall shown overall increases in harm over the past 50 years.  Criminally charging and socially rejecting individuals with substance use disorder simultaneously deters users from seeking treatment and even medical assistance due to worry of penalization. Placing individuals with substance abuse in prisons further increases the likelihood of maintaining or developing addiction, as well as spreading disease in a high-risk environment. When symptoms of a mental disorder are criminalized, regulations in place become barriers to treatment.
     
     In 2016, the British Colombia Provincial Health Officer officially declared illicit drug overdoses a public health emergency.  This has since not been lifted.  Since British Colombia declared an opioid crisis in 2016, 5,000 people have died due to overdoses.   Devastatingly, “this unprecedented public health crisis has decreased life expectancy at birth in the country's most affected provinces of Alberta and British Columbia.”  Following the deaths of 162 citizens of British Colombia in October 2020 alone, Vancouver city council voted to decriminalize all drugs in personal amounts. Currently, British Colombia is attempting to decriminalize personal drug use at a provincial level, through a 56th exemption of the Controlled Drugs and Substances Act under federal law. 

     Understanding substance use disorder as a chronic health issue as opposed to a personal moral failing is an initial step to prevention.  Addiction is currently a heavily stigmatized subject, with copious amounts of blame placed on the individual.  The avoidance of the word “addict” in the DSM-5 reflects the concerns over increased stigmatization of those suffering from this disorder.  This stigma is largely due to an archaic view of addiction.  Research on the etiology of substance use disorder has led to the acknowledgment of the general ineffectiveness of criminalization of personal drug use in addiction prevention.  As more information is gathered, we learn, and policies change.  Currently,  30 countries worldwide have decriminalized personal drug usage to some extent. As the approach to substance abuse reduction changes to a public health perspective, we will hopefully see benefits in the lives of those who live with substance abuse disorder in Canada. 

​     As a final note, although decriminalization is a constructive advancement, it is incredibly important to put emphasis on the significance of social and environmental barriers to health which impact communities as a whole.  The impact of substance use on an individual is very commonly governed by structural factors within their community.  Social and economic determinants may not always figure into the mandate of health care yet are some of the most critical factors in the initiation and trajectory of substance use.  Drug decriminalization is an important step forward but is not a preventative measure; public health dialogue needs to highlight how social inequalities in Canada drive an incredible disparity of substance use and related harms.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
References
 
Russoniello, K. (2013). The Devil (and Drugs) in the Details: Portugal’s Focus on Public Health as a Model for Decriminalization of Drugs in Mexico.  Yale Journal of Health policy, Law, and Ethics, 12(1), 371.
 
Greenwald, G. (2009). Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies. Social Science Research Network. http://dx.doi.org/10.2139/ssrn.1464837
 
Taha, S., Maloney-Hall, B., Buxton, J. (2019). Lessons learned from the opioid crisis across the pillars of the Canadian drugs and substances strategy.  Substance Abuse Treatment, Prevention, and Policy, 14(32). https://doi.org/10.1186/s13011-019-0220-7
 
American Psychiatric Association. (2021). What is a Substance Use Disorder?
Volkow, N. D., Fowler, J. S., Wang, G. (2003). The addicted human brain: insights from imaging studies. Journal of Clinical Investigation, 111(10), 1444-1451. 10.1172/JCI18533
 
DSM-5. (2013). Substance-Related and Addictive Disorder. American Psychiatric Association.
 
Clarke, H., Bao, J., Weinrib, A., Dubin, R. E., Kahan, M. (2019). Canada’s hidden opioid crisis: the health care system’s inability to manage high-dose opioid patients. Official Journal of the College of Family Physicians of Canada, 65(9), 612-614.
 
Health Canada. (2018) Strengthening Canada’s Approach to Substance Use Issues. Government of Canada.
 
Pauly, B., Wallace, B., Pagan, F., Phillips, J., Wilson, M., Hobbs, H., Connolly, J. (2020). Impact of overdose prevention sites during a public health emergency in Victoria, Canada. The Public Library of Science, 15(5). https://doi.org/10.1371/journal.pone.0229208
 
Cabral, T. S. (2017). The 15th anniversary of the Portuguese drug policy: its history, its success and its future. Drug Science, Policy, and law. https://doi.org/10.1177/2050324516683640
 
Domoslawski, A. (2011). Drug Policy in Portugal: The Benefits of Decriminalizing Drug Use. Transnational Institute (TNI). Available online: https://www.tni.org/en
 
Balasingam, V., Suresh, N., Darshan, S., Marek, C. (2018). Decriminalization of drug use. Current Opinion in Psychiatry, 31(4), p. 300-305. 10.1097/YCO.0000000000000429
 
 
Virani, H. N., Haines-Saah, R. J. (2019). Drug Decriminalization: A Matter of Justice and Equity, Not Just Health.  American Journal of Preventative Medicine, 58(1), 161-164. https://doi.org/10.1016/j.amepre.2019.08.012
 
 
Government of Canada. (2021). Controlled Drugs and Substances Act, Part VI. Available online: https://laws-lois.justice.gc.ca/eng/acts/c-38.8/page-12.html
 
 
CirtWideDrugs Crisis Campaign. (2021). Which countries have decriminalized and how? Digital Revolutionists. Available online: https://www.citywide.ie/decriminalisation/countries.html#:~:text=Some%20form%20of%20decriminalisation%20has,differences%20and%20levels%20of%20effectiveness.

Photo: ​https://globalnews.ca/news/5689358/vancouver-coastal-health-safe-drugs-overdose-crisis/