Decriminalization

 

Decriminalization is defined by the Canadian Centre on Substance Use and Addiction (CCSA) as, “an evidence-based policy strategy to reduce the harms associated with the criminalization of illicit drugs. […] Decriminalization aims to decrease harm by removing mandatory criminal sanctions, often replacing them with responses that promote access to education and to harm reduction and treatment services.” (CCSA 2018: 2). However, this can cover a broad range of policies, where sanctions can vary in degree. While we provide the legalist definition below, some activists, such as Karen Ward, Zoe Dodd, including members of this group, have argued that only removing all criminal penalties, sanctions and police interaction should be considered decriminalization. We provide the list from the CCSA below, to demonstrate some of the potential alternatives, moving from the most restrictive legal options to the least restrictive (our additions in italics):

 

  • Targeted exemptions (e.g. SCS and prescription maintenance)

  • Court Diversion - outreach through prosecutorial guidance or judicial authority

  • Police Diversion - alternatives to criminal justice responses through outreach at point of arrest (e.g. informal warnings, referrals to treatment (but not forced treatment)

  • Formal sanctions - remove criminal justice sanctions altogether for certain drug-related offenses, and instead sanctions include (1) formal warnings and (2) small fines

  • Personal possession - removing criminal justice sanctions for simple possession (varies by definition of threshold quantity)

 

In the case of Portugal, which decriminalized illicit drugs in 2000, results have shown a drop in the number of overdose deaths, HIV infections and incarceration for drug-related offences, as well as an increase in the number of people voluntarily entering treatment. Given Oregon’s recent move to decriminalize illicit drug possession, which took effect on February 1, 2021 - making Oregon the first state in the US to do so - there is an increased push to make the move in Canada. In November 2020 city councilors in Vancouver, BC unanimously approved a motion to seek decriminalization from Ottawa. On January 27, 2021, Vancouver’s mayor announced that they would be entering into formal discussion with Health Canada about the request. Montreal and the Toronto Board of Health have also made requests to the federal government to decriminalize.

 

 

Countries, such as Portugal, Costa Rica, Germany and Uruguay have removed criminal penalties for drugs. In a recent report by the International Network of People Who Use Drugs (INPUD), they found that even in countries where decriminalization has been implemented, many people who use drugs still have to interact with the legal system, and “full decriminalization without sanctions—would significantly improve the situation overall” (36). Public health bodies in Toronto, Ottawa, Montreal and Vancouver have given their support for a form of decriminalization, but it has yet to be seen which form of decriminalization will be implemented. Vancouver, so far, is the only city that has sought to decriminalize possession using the same exemption process that allows Insite (North America’s first sanctioned supervised consumption site) to operate.

 

 

Punitive, “tough on crime” approaches to substance use, which rely on penalties and sanctions, have been found to be ineffective in deterring drug use. Tough on crime policies escalated during the War on Drugs in the 1980s, with the argument that having harsh penalties for using illicit drugs will act as a deterrent to people using drugs. ‘Tough love’ refers to the idea that punishment through the criminal justice system (and the often forced withdrawal during incarceration) is the best way to show someone the ‘error of their ways.’ These arguments are both paternalistic and based on a set of morals that ignore the evidence that:

  • Exposing PWUD to the criminal justice system does not reduce drug use (see here);

  • Incarceration increases the probability of overdose upon release (see here);

  • Criminalizing addiction is not justice for PWUD

 

 

Additional resource:

 

The organizers of a newly launched Canadian social media campaign (#DecrimDoneRight) have released a statement supporting the proposal for decriminalization in Vancouver, BC, while also outlining a number of concerns on implementation. The 3 major concerns addressed are:

  1. Lack of meaningful and equitable engagement of those directly affected;

  2. Threshold amounts for decriminalized possession, and

  3. Police dictating the parameters of decriminalization

 

You can find the full statement here (English and French)

Legalization

I personally believe that we should be able to buy drugs with all the consumer protection that people get when they buy nicotine or alcohol and that’s how I would like to see it. You know, the fact of, you know, the actual prohibition, is the part that makes everything to be allowed to do anything and everything.

 

Canada is experiencing an overdose crisis caused by a volatile drug supply. The unpredictability of the market combined with incredibly potent synthetic opioids, primarily fentanyl and fentanyl analogues (eg. carfentanil), but also now isotonitazene and etonitazene, has led to 20,000 overdoses in the past 6 years. Many people who use drugs (PWUD), healthcare professionals, researchers, policy makers and even politicians have advocated for legalization.

 

Legalization of illegal drugs is defined by the CCSA as the removal of criminal sanctions for drug possession*, the production and distribution of drugs for recreational use is regulated by the government. Such examples include, caffeine, alcohol, nicotine and most recently cannabis (e.g. minimum age of purchase, certain standards on production, labelling and marketing). Whereas decriminalization does not regulate the drug market itself, legalization seeks to formally regulate the market. Canada and Uruguay have formally legalized cannabis, and Bolivia has legalized coca (but not cocaine). Outside of these exceptions, legalization for other drugs has yet to be tried since international prohibitionist policies began in the early & mid 20th century. As one CRISM member stated:

 

 

 

Political pushback comes from the same morals-based arguments as decriminalization, but with even stronger vigor. Legalization often brings connotations of the government condoning and enabling the use of drugs, which to many seems too radical. Further, whereas decriminalization is not a violation of international law,  arguably legalization is. That being said, Canada is already violating international law since it has legalized cannabis. Further, there is an option for countries, like Canada, to amend international treaties in order to allow for legalization, known as “inter se modification”. The Transnational Institute has an explanation here:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*A note that youth are still in some ways criminalized under the cannabis act

 

Onsite Harm Reduction Services

The significant increase in overdose deaths over the last 5 years across Canada has spurred the implementation of multiple overdose intervention services, and an expansion of safe consumption sites and services (SCS) and overdose prevention sites (OPS). To date, no one has ever died at either type of facility. During COVID-19, group members indicated that these sites have helped reduce the spread of COVID by implementing public health orders including measures to social distance and providing hand hygiene products - situations that aren’t often possible on the street. 

 

Safe Consumption Sites and Services: How do they work?

At a site a person brings their drugs to a site to consume and depending on the site, drugs are injected, snorted, inhaled or consumed as a pill. Trained staff are available to help if there is an accidental overdose. Other services offered include drug checking (see policy #4 for more info); testing for infectious diseases; education on harm reduction practices; and access to treatment medications. SCS facilities are exempted by Health Canada under section 56 of the Controlled Drugs and Substances Act, so that people can use their own illicit drugs in front of staff without being prosecuted for drug possession.

 

Benefits:

  • reduces risk of accidental overdose because people are not rushing or using alone;

  • connects people to social services (e.g. housing, food banks), healthcare and treatment; and

  • reduces spread of infectious diseases, such as HIV.

Current issues:

  • needs of the community are often not met due to restricted hours of operation for sites and the types of services provided which is typically a result of lack of funding;

  • limited access to SCS outside of major cities, impacting the safety of people who use drugs (PWUD) in rural areas. It is very time consuming to establish a SCS, often taking up to several years to get an approval due to the legal and bureaucratic barriers

 

What are Overdose Prevention Sites?

OPS operate similarly to SCS; people can use their own illicit drugs and access clean equipment, and staff are trained to respond to emergency overdoses. OPS were started as a non-sanctioned, “community-based response to overdose deaths” that are typically run by people with lived and living expertise (PWLE) and tend to be less medicalized compared to SCS (sometimes operating out of tents in public parks).

 

Benefits:

  • Life saving and reduced risk of overdose

  • Significantly fewer barriers to establishing an OPS compared to a SCS – typically operating through temporary province-wide exemptions from the federal government.

  • Connection of PWUD to PWLE who offer expertise and direct experience.

  • A less medicalized setting to better facilitate access for more marginalized populations.

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 Current issues:

  • Since these sites are more informal than SCS and are typically operated by PWLE, there is often a lack of support by municipalities and Health Authorities.

  • As they were initially developed as an emergency response to overdose crises, their permanency is unclear.  

 

Both SCS and OPS have received significant political pushback. Many see OPS and SCS as “enabling addiction,” and argue that the public shouldn’t be spending tax dollars supporting drug use. Again, this is a significantly outdated point of view that doesn’t take into account the positive impacts of these sites.

 

Another harm reduction service that can be either combined with OPS/SCS or operate as a standalone service is drug checking. ‘Drug checking’ refers to a series of different techniques where people can come and get their drugs tested to determine either the contents or purity. As one of our members noted:

 

 

Drug checking, OPS/SCS are some of the many services that exist in Canada that are able to reduce the risks associated with drug consumption in poisoned drug supply. They are, however, not substitutes for safe supply, which would replace the volatile drug market with pharmaceutical grade alternatives.

“I’m not saying we won’t get an overdose but the chances are much lower. It’s a lower chance of an overdose... because you know, like people don’t know what they’re buying. You know, they’re paying money and they don’t know what they’re getting. When you look at all the difference in the drug supply, it is too poisonous and it’s too toxic. So for that, as a result of that, people are very angry.”

 

Improving access to OAT: increasing the number of prescribers

One significant barrier to accessing medications to support non-toxic substance and/or to treat opioid use disorder - called opioid agonist therapies or OAT - is the insufficient number of prescribers. This causes long waitlists to see a prescriber, which may deter patients from starting treatment. Some patients who live in rural, remote and northern regions travel hours to receive dosages of OAT. Group members identified the need for prescribers as a crucial aspect of reducing the overdose crisis.

 

 

 

 

 

“[We need to] remove some of these barriers and get more doctors and nurse practitioners to prescribe, to prescribe the people what they need. If they can, if they, you know, and doing so, you know, people will be, we wouldn’t have so many overdoses.”

 

There are many reasons why there aren’t more doctors and nurse practitioners (NPs) prescribing OAT, including:

 

  • Doctors who are paid by fee-for-service, meaning they won’t be paid if a patient does not show up. These doctors may be hesitant to take on patients requiring OAT due to the perception that people who use drugs (PWUD) aren’t reliable in showing up for appointments

  • Practitioner concerns that they do not have sufficient education/training to provide OAT

  • Primary care physicians and NPs are often not provided substance use disorder education/training as an entry-level competency

  • Unaware of Health Canada and physician regulatory college policies re: prescribing OAT

 

There’s also the issue of the overall number of doctors and NPs in Canada which is less than 100,000, and the vast majority are concentrated in urban areas. Meanwhile, Canada has over 300,000 registered nurses (RNs) who, with the right education and training, could have the competencies to prescribe OAT. However, this would require authorization by the federal government, as well as RNs’ respective provincial regulatory bodies and employers. British Columbia (BC) is trying to change that.

 

As of July 2020, in response to the record high number of reported opioid-related overdoses and overdose-related deaths throughout the COVID-19 pandemic, RNs and RPNs in BC have been given temporary authority to prescribe buprenorphine/naloxone to treat opioid use until September 2021. These exemptions are temporary and will be rescinded on the date that the emergency related to toxic, illegally produced opioids and the increase in people overdosing and dying “has passed.” At the time of writing, RNs and RPNs in BC are only authorized to prescribe buprenorphine/naloxone, as the additional required supports and resources in order to prescribe all other OAT medications are under development.

 

While there has been improvement over the years with a push to educate more practitioners about OAT in school and after, there is still a long way to go.

“We don’t only want a handful of doctors or nurse practitioners to write that script.

We want all doctors, all nurse practitioners to write that script.”

I personally believe that we should be able to buy drugs with all the consumer protection that people get when they buy nicotine or alcohol and that’s how I would like to see it. You know, the fact of, you know, the actual prohibition, is the part that makes everything to be allowed to do anything and everything.